Palmar arthroplasty for the treatment of the stiff swan-neck deformity

Palmar arthroplasty for the treatment of the stiff swan-neck deformity in rheumatoid arthritis is designed to correct the mechanical block to flexion that is caused by palmar plate adhesions (which obliterate the retrocondylar recess) and by collateral ligament contracture and adhesions. This procedure can be performed at the same time as correction of the primary cause of proximal interphalangeal joint (PIP) hyperextension (e.g., intrinsic tightness or flexor tenosynovitis) and can also be supplemented with superficialis tenodesis to minimize recurrent hyperextension. Postoperative flexor dynamic traction, which is started at 24 to 48 hours and continued for a minimum of 3 to 4 weeks, is critical to the maintenance of motion. Arthroplasty in 47 PIP joints in 14 hands of 9 patients demonstrate an increase in motion from +20 degrees hyperextension and 9.5 degrees flexion to -7 degrees extension and 72 degrees flexion postoperatively.     

Surgical treatment of swan-neck deformity in hemiplegic cerebral palsy

PURPOSE: Previously described surgical treatments for dynamic swan-neck deformity in cerebral palsy are technically difficult and time consuming. Typically only a few fingers could be addressed at one sitting, and postoperative swelling and stiffness were often incurred. An easy procedure of central slip tenotomy is described that allows for multiple fingers to be addressed, with minimal postoperative morbidity. METHODS: Fifteen patients (33 fingers) with hemiplegic cerebral palsy and dynamic swan-neck deformities of their fingers were treated. Only swan-neck deformities of greater than 20 degrees were considered for treatment. Pre- and postoperative measurements of swan-neck deformity were recorded. A central slip tenotomy was performed through a transverse incision proximal to the proximal interphalangeal joint. The joint was pinned in 10 degrees of flexion for 4 weeks, and then active extension was allowed to 10 degrees short of full extension and blocked with an oval-8 splint. Average patient age was 16 years (range 5-44 years). All patients had concurrent procedures performed on the extremity. Average follow-up evaluation was 23 months (+/-12 months). RESULTS: Improvement in dynamic swan-neck deformity averaged 32 degrees . Preoperative swan-neck deformity averaged 38 degrees and postoperative swan-neck deformity averaged 6 degrees . No swan-neck deformity was worse than its preoperative state, and no patient developed boutonniere deformity. No patient lost active or passive flexion after the procedure. All patients would repeat the procedure. CONCLUSION: Central slip tenotomy is a reliable treatment for dynamic swan-neck deformity in cerebral palsy in patients without dynamic metacarpophalangeal flexion deformity. Because of the simplicity of the procedure, it can easily be added to the treatment of the entire upper extremity in cerebral palsy.     

Correction of swan neck deformity in rheumatoid arthritis using a new lateral extensor band technique

Swan neck deformity is a progressive and disabling condition that commonly affects rheumatoid arthritic hands. During a 4-year period, 101 fingers in 43 patients had this deformity corrected using a new procedure combining the distally based extensor lateral band technique described by Littler and the flexor digitorum superficialis (FDS)-palmar plate pulley introduced by Zancolli. The ranges of motion of the metacarpophalangeal, proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints were assessed pre-operatively and 12 months after surgery. An average PIP joint hyperextension of -13.3 degrees was converted to +13.4 degrees . The ranges of motion of the proximal and DIP joints were significantly different (Student's t-test). No patient suffered recurrence of the deformity during an average follow-up of 20 months. This new technique improves some unappealing aspects of previous techniques and provides a stable and reliable correction of swan neck deformity.     

Lateral band translocation for swan-neck deformity.

Lateral band translocation involves transfer of the dorsally subluxed radial lateral band to the palmar aspect of the joint where it is maintained by a sling created between the flexor superficialis tendon and the palmar plate. Thirty fingers with swan-neck deformity of differing causes and a preoperative hyperextension deformity averaging 16 degrees were treated. After operation all swan-neck deformities were corrected and the average flexion contracture was 11 degrees. The range of preoperative flexion was either regained or improved. There were no recurrences and no complications. This relatively simple procedure is an effective treatment of swan-neck deformity and an attractive alternative to previously described procedures.     

Soft tissue reconstruction for rheumatoid swan-neck and boutonniere deformities: Long-term results

Ninety-two fingers with rheumatoid swan-neck deformity were treated with dorsal capsulotomy and lateral band mobilization. An initial increase of 55° of motion into flexion was noted, but this proximal interphalangeal motion deteriorated over time. Of 15 fingers followed at 3 and 12 months, there was a mean loss of 17° of the early postoperative flexion. Nineteen fingers with rheumatoid boutonniere deformity were treated with central slip reconstruction. The results were unpredictable, with only modest improvement in the proximal interphalangeal extension, which deteriorated over time. The authors now recommend arthrodesis for most severe rheumatoid boutonniere deformities.     

The rheumatoid swan-neck deformity

It is important to evaluate each swan-neck deformity to determine the mobility and radiographic condition of the PIP joint. This information forms a basis for logical treatment. In those fingers with little or no loss of motion, the treatment alternatives include DIP joint fusions, dermadesis, or flexor tenodesis. With significant loss of PIP joint motion, an attempt is made to first restore passive motion by manipulation and lateral band or skin releases. It then becomes essential to restore flexor tendon excursion. In those patients with destroyed joint surfaces the salvage procedures of fusion and arthroplasty are the treatments of choice.     

The terminal tendon of the digital extensor mechanism: Part II, kinematic study

PURPOSE: To conduct kinematic analyses of both intact and sectioned terminal tendon (TT) of multiple fingers in the hand. METHODS: The TTs of 36 fresh-frozen cadaveric digits were used in this study. TT excursion was assessed along with the influence on proximal joint motion. The influence of TT lengthening and shortening on distal interphalangeal (DIP) joint motion were investigated. RESULTS: TT excursion averaged 1 mm at the DIP joint and was influenced by the proximal interphalangeal (PIP) joint but not the position of other joints in the hand and wrist. The greatest degree of DIP joint motion averaged 86 degrees when the PIP joint was in full flexion, whereas the least motion averaged 45 degrees when this joint was in neutral position. Lengthening of the TT resulted in angular deformity at the DIP joint. Average flexion deformities reached 25 degrees at 1 mm, 36 degrees at 2 mm, 49 degrees at 3 mm, and 63 degrees at 4 mm of lengthening. The middle finger showed the greatest flexion deformity, followed by the ring, small, and index fingers. Shortening the TT by as little as 1 mm resulted in difficult tendon repair because of excessive tension and minimal or no DIP joint flexion was obtained. CONCLUSION: Only DIP and PIP joints affect TT excursion; hence these are the main joints to be immobilized to protect TT repair. The middle finger TT showed the least tolerance to lengthening with potential for mallet deformity. Joint flexion deformity is proportional to tendon lengthening. Only 1 mm of TT lengthening results in approximately 25 degrees of DIP joint extension lag, and 4 mm of TT lengthening results in DIP joint flexion deformity greater than 60 degrees . Even 1 mm of TT shortening will seriously restrict DIP joint flexion.     

Die Littler-Tenodese zur Behandlung der rheumatischen Schwanenhalsdeformit?t

Objective

Correction of swan neck deformity at the PIP and DIP joint by reconstruction of the oblique retinacular ligament through palmar transposition of one distally pedicled lateral band (oblique retinacular ligament reconstruction (ORL)?=?Littler?II).

Indications

Rheumatoid swan neck deformity Nalebuff stages?I?CIII (dynamic, partially contracted, contracted). The swan neck deformity should be of articular origin.

Contraindications

Advanced radiologic changes of the PIP joint (Larsen?3?C4) [12]. Extrinsic and intrinsic causes of swan neck deformity. Flexor tendon synovitis.

Surgical technique

Dorsal approach to the PIP joint. One lateral band is sectioned proximally at the level of the musculotendinous junction. It is then isolated from the extensor apparatus and left pedicled distal at the insertion. The isolated lateral band is then passed underneath the Cleland ligament from distal to proximal and is sutured to the distal edge of the A2?pulley. The correct tension of the tenodesis achieves flexion at the PIP joint and extension at the DIP joint. In contracted and partially contracted joints, the PIP joint is temporarily transfixed. Depending on the clinical findings, a synovectomy or dorsal arthrolysis of the PIP joint must be performed.

Postoperative management

Immediate postoperative mobilization of the PIP joint for flexion. A figure-of-eight finger splint has to be worn for 12?weeks. The splint must allow full PIP flexion and limit extension over 20?C30° of flexion. In case of temporary transfixation of the PIP joint, wire removal after 4?C6?weeks and start of mobilization. Passive extension over 20?C30° of flexion only after 12?weeks.

Results

From 2004?C2007, 30?PIP joints in 20?rheumatoid patients were treated for swan neck deformity. In all cases, the original method as described by Littler was used. A change of the procedure due to insufficiency of the Cleland ligament or the A2?pulley was not necessary in any of the cases. After a mean of 22?months, 26?PIP joints in 17?patients could be followed up. In 12?PIP joints, the deformity was partially contracted, in two joints contracted. In 10?joints, a dorsal arthrolysis had to be performed, while a lengthening of the medial band was performed in 1?patient. The swan neck deformity could be compensated in all cases. Preoperative hyperextension of a mean 21° could be reduced to a mean 24° of flexion postoperatively. The ROM did not change much but was shifted from the extension sector to the flexion sector of the PIP joint. In no case were complications or recurrence of the deformity noted. Pain could be reduced in all patients except one. The radiologic joint situation was Larsen stage 2.2 preoperatively and 2.3 postoperatively.     

Pyrolytic carbon proximal interphalangeal joint arthroplasty: results with minimum two-year follow-up evaluation

PURPOSE: To retrospectively review the surgical technique, postoperative therapy/splinting protocols, and clinical and radiographic outcomes of patients who had pyrolytic carbon proximal interphalangeal (PIP) joint arthroplasty. METHODS: A total of 50 PIP joint replacements in 35 patients were performed with a minimum follow-up period of 27 months. Indications for surgery included pain, decreased range of motion, instability, and/or deformity. The preoperative diagnosis was osteoarthritis in 14, rheumatoid arthritis in 11, and posttraumatic arthritis in 10. There were 20 women and 15 men affected. The average age at the time of surgery was 53 years. The fingers replaced included the index (15), middle (18), ring (10), and small (7). The preoperative arc of motion averaged 40 degrees (0 degrees-60 degrees ), and the pinch and grip measurements averaged 3 and 19 kg, respectively. The preoperative pain scores averaged 6 (scale, of 0-10) on a visual analog space scale. RESULTS: The arc of motion was 47 degrees after surgery, and the average pinch and grip measurements were 4 and 25 kg, respectively. Pain scores improved to 1. At the final follow-up evaluation the overall patient satisfaction was nearly 80%. The results of index finger PIP replacements are compatible with other digits. Fourteen joints (in 14 patients) to date have required additional procedures to improve or maintain joint motion/function or pain; 5 for minor reasons and 9 for major complications. The revision arthroplasty rate was 8%. No infections were noted. Although not medically necessary, 2 patients requested and had an amputation. Radiographic subsidence and subsequent settling (in accordance with Wolff's law) without apparent loosening occurred in 20 joints. CONCLUSIONS: Our 2-year minimum follow-up evaluation of pyrolytic carbon implant arthroplasty showed improved pain relief and good overall patient satisfaction. Twenty-eight percent of patients required a second procedure and 8% required a revision arthroplasty. Radiographs showed gross changes in implant and eventual settling to a stable position in 40% of the joints. A longer follow-up period will help to better determine the efficacy of this implant. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Flexor digitorum superficialis tendon transfer for intrinsic replacement : Long-term results and the effect on donor fingers

This study is a review of 127 hands in 100 patients in whom one or two FDS tendons were used to correct claw-hand deformity and/or loss of opposition of the thumb. In lumbrical replacement the results were graded as excellent in 16 hands (21%) and good in 43 hands (57%). For opponensplasty the results were excellent in 26 hands (32%) and good in 42 hands (51%). Possible defects that can develop in the donor finger are: swan-neck deformity, flexion posture of the DIP joint, not as part of the swan-neck deformity, check-rein deformity or flexion contracture, and insufficient finger flexion. Of the 158 fingers swan-neck deformity was seen in 15%, DIP flexion in 29%, check-rein deformity in 26% and insufficient finger flexion in 18%. The latter occurred with another defect. In 48 fingers (30%) no defects were observed.     

Metacarpal rotational osteotomy

Maximum metacarpal rotation and corresponding phalangeal correction were measured in 80 fingers of 40 cadaver hands. Total metacarpal rotation averaged 50 degrees to 52 degrees in the index, long, and ring fingers and 69 degrees in the small finger. Phalangeal correction averaged 36 degrees to 37 degrees in the index, long, and ring fingers and 50 degrees in the small finger (70% of rotation in the metacarpal). The orientation of the metacarpophalangeal joint was not a significant limiting factor. However, the deep transverse metacarpal ligament did limit maximum rotation at the metacarpal and the phalanx. The advantages of basal metacarpal osteotomy make this technique the procedure of choice for correcting malrotation of up to an average of 18 degrees to 19 degrees for the index, long, and ring fingers. For the small finger, 20 degrees to 30 degrees of correction is possible, depending on the direction of rotation. A table has been devised to predict the correction for individual digits.     

The dorsal approach to silicone implant arthroplasty of the proximal interphalangeal joint

Silicone implant arthroplasty (SIA) has been an effective alternative in the treatment of arthritic conditions of the proximal interphalangeal (PIP) joints since its introduction into surgical practice in the early 1960s. Patients with post-traumatic, degenerative, and rheumatoid arthritis all may be candidates for PIP joint SIA. The indications for SIA of the PIP joint include pain, limited joint mobility, and angular deformity of the joint with underlying articular destruction. Contraindications include ankylosis of the joint due to bony or soft-tissue restrictions, infection, inadequate soft-tissue support for coverage, absence of flexor and/or extensor tendon function, and considerable periarticular bone loss in the proximal and middle phalanges. Proximal interphalangeal joint SIA can be accomplished by dorsal, volar, or midaxial approaches. The dorsal approach has the advantages of relative technical ease, excellent visibility of the articular surfaces for preparation of the implant canals, access to the extensor mechanism for correction of central slip abnormalities, and preservation of the collateral ligaments. The surgical technique is outlined and includes handling of the extensor mechanism and central slip attachment, mobilization of the collateral ligaments, joint surface resection, preparation of the bony canals, implant sizing, implant insertion, and repair of the soft tissues. Pearls and pitfalls of the technique are outlined. Early postoperative mobilization with hand therapy is essential but must include protection of the repaired extensor apparatus. Complications include bony changes, implant failure, recurrent angular deviation or swan-neck deformity, particulate synovitis, and rarely, infection. Complications related to implant failure are most often managed with implant replacement or arthrodesis; those related to poor mobility, angular deformity and tendon imbalance, pain, or infection are managed by arthrodesis. Although SIA of the PIP joint has a relatively high degree of success when measured both subjectively and objectively, careful patient selection is important for achieving desirable results.     

Alumina ceramic prosthesis arthroplasty of the metacarpophalangeal joint in the rheumatoid hand. A 2-4-year follow-up study

Swanson's finger implant is being widely used to improve deformity of the thumb and finger and to restore function in the rheumatoid hand. Breakage of the implant and implant synovitis have been the most troublesome complications. The authors developed an alumina ceramic finger prosthesis to lessen these complications. This prosthesis was used for the metacarpophalangeal joint in 5 cases of flexion deformity of the thumb and in 21 cases (82 digits) with ulnar drift deformity. These cases were followed for 24-62 months (average, 38 months). Postoperative extension of the thumb was limited to 18 degrees and flexion was 48 degrees, on average. Postoperative range of motion was 30 degrees. The average limitation of extension of all digits was 18 degrees, and the average flexion was 54.5 degrees. The average range of motion was 36.5 degrees. Flexion deformity of the metacarpophalangeal joint of the thumb disappeared after operation, and ulnar drift was reduced to less than 10 degrees deviation in 87.8%. No dislocation or fracture of the prosthesis has been found on roentgenologic examination during short-term follow-up study. This prosthesis is useful for reducing deformity of the thumb and the finger in the rheumatoid hand. Postoperative extension of the metacarpophalangeal joint, however, has been unsatisfactory. The design of the prosthesis should be improved so that the rotational center of the metacarpophalangeal joint is located palmarly.     

Arthrodesis of small joint of the hand: a rapid and effective technique

Seventy-six patients underwent 103 arthrodeses of digital joints of the hand to treat deformity, pain, or instability. Each fusion was done by means of a surgical technique that allowed for proper positioning with minimal shortening. No bone graft was used. Only one joint failed to fuse. Bony union was present in 10 weeks or less in 86% of the digits. External immobilization was not used in one third of the joints, primarily low-demand patients with rheumatoid arthritis. There were two superficial pin tract infections that healed after pin removal and a course of oral antibiotics. This surgical technique proved to be technically simple and allowed for easily adjusted positioning of each joint without multiple osteotomies or excess shortening.     

Silicone interpositional arthroplasty of the distal interphalangeal joint

Twenty-three female patients had silicone interpositional arthroplasty of the distal interphalangeal joint in 38 digits. The operative indications were pain and deformity of the distal interphalangeal joint. The underlying diagnosis was osteoarthritis in all but one patient who had rheumatoid arthritis. The average age at the time of operation was 58.3 years. The implants have been in place for a mean period of 72.2 months (range, 12.6 to 123.1 months). At follow-up, extension lag averaged 12.7 degrees and the range of motion of the distal interphalangeal joint had a mean value of 33.2 degrees. Compared with arthrodesis, silicone interpositional arthroplasty offers the advantage of retained motion while preserving stability.     

Double lateral band transfer for treatment of traumatic hyperextension instability of the proximal interphalangeal joint: a report of two cases

Post-traumatic hyperextension instability of the proximal interphalangeal joint may lead to pain, difficulty with initiating finger flexion, and a swan-neck deformity. Most techniques to correct a traumatic hyperextension deformity of the proximal interphalangeal joint require a window in the flexor retinaculum, retraction of the flexor tendons, and manipulation of the joint capsule with a conceivable potential for joint stiffness, tendon adhesions, and tendon bowstringing. We describe an extra-articular lateral band transfer technique that utilizes strips of both lateral bands and preserves the functional integrity of the flexor tendon sheath.     

Behandlung der posttraumatischen Schwanenhalsdeformität

Swan-neck deformity of the finger, defined as hyperflexion of the distal interphalangeal (DIP) joint and hyperextension of the proximal interphalangeal (PIP) joint, can significantly limit hand function. Axial trauma to the finger is a typical injury during ball sports with hyperextension of the proximal interphalangeal (PIP) joint. Treatment is conservative with fingersplint (anti-swan-neck-splint). The established deformity can also thus be treated. However, surgical correction is often desired. In the case of long standing swan-neck deformities where flexion deformity of the DIP is marked, good results can be reliably achieved with Littler-II tenodesis. In mild flexion deformity of the DIP refixation of the palmar plate or superficial tenodesis (Littler I tenodesis) is indicated.     

Congenital flexion deformity of the middle finger and sagittal band hypoplasia

PURPOSE: To report a congenital anomaly of the middle finger. METHOD: Nine patients (16 digits) are reported with congenital flexion deformity of the metacarpophalangeal (MCP) joint of the middle finger. Three patients (4 digits) had isolated deformities to the middle finger and in 6 the deformity was part of congenital ulnar drift (CUD) of the hand. Three patients had Freeman-Sheldon syndrome, 2 had nonsyndromic CUD, and 1 had arthrogryposis multiplex congenita. In CUD patients the middle finger had substantially greater flexion deformity of the MCP joint in comparison with other digits. Seven patients were treated surgically and 2 were treated nonsurgically. Five of the surgical patients had bilateral middle finger involvement. RESULTS: During surgery on 12 digits sagittal band hypoplasia of varying degrees was encountered in all patients and in all patients the extensor tendon of the middle finger was underdeveloped and often ulnarly displaced. Longitudinal imbrication of the remnants of the extensor tendon and centralizing the tendon if necessary by radial sagittal band reefing improved MCP joint flexion deformity. CONCLUSIONS: Congenital middle finger-in-palm deformity in our patients was caused by sagittal band and extensor tendon hypoplasia.     

Dynamic intradigital external fixation for proximal interphalangeal joint fracture dislocations

PURPOSE: Many skeletal traction devices have been described to treat fracture dislocations of the proximal interphalangeal (PIP) joint. Most of these techniques are technically challenging or involve cumbersome frames. We present a design modification that enhances the stability of a simple dynamic fixation system described previously and report our results with this technique. METHODS: A previously described simple dynamic fixator with no rubber bands was applied to 6 patients who sustained fracture dislocations of the PIP joint. The middle finger was involved in 3 patients, the ring finger in 1 patient, and the small finger in 2 patients. The average age of the patients was 27 years (range, 21-42 y). The average involvement of the base of the middle phalanx was 48% (range, 35% to 60%). The average time from the injury to the surgery was 6 days (range, 1-14 d). The average follow-up period was 24 months (range, 7-43 mo). Immediate active flexion extension was allowed and the fixator was removed after 3 to 4 weeks. RESULTS: The average range of motion of the PIP joint at the final follow-up evaluation was 5 degrees to 89 degrees (range, 0 degrees to 100 degrees ). Two patients developed pin track infection that resolved with oral antibiotics. Only one patient complained of mild pain with extreme flexion. Proper reduction and congruency of the joint was noted on final anteroposterior and lateral radiographs. CONCLUSIONS: A simple dynamic fixator for the treatment of unstable PIP joint fracture dislocations was used successfully in 6 digits to maintain reduction and restore digital range of motion. The addition of modifications to the original technique not only improves the solidity of the construct but also provides satisfactory functional results. Based on our experience we recommend this easy technique to treat fracture dislocations of the PIP joint.