Techniques in Hand & Upper Extremity Surgery

Techniques in Hand and Upper Extremity Surgery 9(3):125, 2005

Ó 2005 Lippincott Williams & Wilkins, Philadelphia

E D I T O R I A L

Life-Long Learning echniques in Hand and Upper Extremity Surgery represents but one of a multitude of resources available for continuing education in our specialty. Of note is the remarkable fact that there are almost 50 new articles per day on Medline related to Orthopedics and Traumatology and over 200 new articles per day non-Medline. Why is ‘‘life-long’’ learning so important to physicians? For one, there are increasing forces in health care pushing accountability, including evidence-based care, the information revolution, systems awareness, and increasingly sophisticated patients. In addition, we are seeing increased societal accountability and scrutiny in the form of certification, licensure, and credentialing; the Internet and its impact on information available to patients; and public reporting of healthcare outcomes and clinical performance. Problems regarding the quality of healthcare are viewed somewhat differently from the perspective of society, healthcare systems, and clinicians. From the view of society, problems include how to evaluate quality, improve it, and extend it to all who are in need and how to deal with medical error. Healthcare systems tend to focus on how to pay for it, get paid for it, deal with error, and manage services and information. Problems facing clinicians as to the quality of healthcare include how to selfevaluate for adequacy of professional performance, how to self-correct, how to deal with innovation, to evaluate new information, and how to learn it all!

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There has been a paradigm shift in attitude toward continuing medical education. The past view of CME stressed emphasis on formal classroom events as a means of learning, clinical experience being viewed as subjective and not as valuable, and teachers having the responsibility of determining the quality of the learning. Now it has become apparent that learning that is clinically based and supports modifications of practice is the highest form of CME. Clinical experience is the primary avenue to high-quality learning and subsequent change in performance. Last, it has been recognized that knowledge is organized around problems and solutions rather than around discipline hierarchies. With these latter realizations of effective methods of physician ‘‘learning,’’ we are particularly pleased that this journal’s format should achieve these objectives as it provides clinical insights from respected surgeons in addition to well-illustrated presentations of how to solve clinical problems as well as use new technology. l

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Jesse B. Jupiter Co-Editor-in-Chief Director, Orthopaedic Hand Service Massachusetts General Hospital Harvard Medical School Boston, Massachusetts [email protected]

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Techniques in Hand and Upper Extremity Surgery 9(3):126–133, 2005

Ó 2005 Lippincott Williams & Wilkins, Philadelphia

T E C H N I Q U E

Algorithm for Treatment of Apert Hand Ste´phane J. Guero, MD Consultant Surgeon, Plastic and Reconstructive Surgery Hoˆpital Necker-Enfants Malades Paris, France

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ABSTRACT

The hand in Apert syndrome is one of the most complex examples of congenital deformity of the upper limb. The management is difficult, and mny different approaches have been published. The hands demonstrate many disturbances of soft tissue and bony structures. These include a short thumb with radial clinodactyly, complex syndactyly with a bony fusion involving the index, long and ring fingers, and symphalangism and simple syndactyly of the fourth web space. The soft tissue anomalies involve the intrinsic muscles, the extrinsic tendon insertions, and the neurovascular bundles. Correction of the appearance of the operated hand is readily apparent, but the complexity of the disorders in the bones and soft tissues explains the difficulty of the surgical management. The aim of this study is to propose a better surgical management: on the basis of the experience of our multidisciplinary team (188 procedures in 53 patients) in the light of recent publications and a better comprehension of the syndrome, we attempt to reduce the number of procedures and to select the best possible procedures for each patient. When possible, we perform a 3-step procedure (the first is bilateral, the others are unilateral) between 9 months and 2 years of age. Separation of the fingers improves function even though we must expect an inevitable stiffness in extension of the interphalangeal joints. Keywords: hand, child, Apert syndrome, syndactyly, symphalangism

similar previously reported cases in the literature between 1886 and 1905. He referred to the anomalies as ‘‘hereditary acrocephalosyndactyly’’ and published 9 cases in 1906.1 In 1970, Hoover published his review of 65 publications with 200 patients along with 20 new cases.2 He reported many publications concerning the results of the separation of the fingers. He recommended the amputation of digit to simplify treatment and/or improve function. Barot and Caplan, in 1986, suggested an early surgical intervention in Apert syndactyly.3 Upton, in 1991, gave the most detailed description of the anatomy of the limbs in Apert syndrome.4 Fereshetian and Upton, also in 1991, showed an anomalous distal insertion of the APB onto the radial aspect of the distal phalanx.5 Holten et al, in 1997, extended knowledge of the pathologic anatomy of hands in Apert syndrome.6 Dao and Wood7 considered the long lever arm of the abnormal APB responsible for radial angulation of the thumb, and they treated the thumb clinodactyly without osteotomy. Many recent publications insist on the desirability of reducing the number of procedures.8,9 In 2004, we published a retrospective review of 52 children who received hand surgery at the NeckerEnfants Malades hospital.10

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HISTORICAL PERSPECTIVE

In 1896, Eugene Apert was resident in the pediatric department of the Necker-Enfants Malades Hospital in Paris. A child with severe congenital craniofacial and limb anomalies was referred to his unit. He collected Address correspondence and reprint requests to Dr. Ste´phane Guero, Institut Franc xais de Chirurgie de la Main, 5 rue du Doˆme, 75116 Paris, France. E-mail: [email protected].

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INDICATIONS/ CONTRAINDICATIONS

Knowledge of the clinical features, genetics, pathologic anatomy, and classification is indispensable for management of the surgical treatment and correction.

Classification We use the Upton classification4 based on clinical examination. It is simple, immediate, and, furthermore, correlates grossly with the type of mutation.11

Techniques in Hand and Upper Extremity Surgery

Algorithm for Treatment of Apert Hand

In type I (spade hand), the thumb is separated from the index by a shallow web space, in the ring–fifth finger web space the syndactyly is always simple, and the transverse metacarpal arch is normal (Fig. 1A). In type II (spoon hand), there is partial or complete simple syndactyly of the first web space, the simple syndactyly in the fourth interdigital space is usually complete, the border digits are in marked rotation, and the palm is concave (Fig. 1B). In type III (rosebud hand), there is complex syndactyly with distal synostosis between the thumb and the

FIGURE 1. Upton classification: A, type I; B, type II; C, type III.

index finger, and a broad, conjoined nail overlies the bony fusion among the thumb, index, long, and ring fingers. The fifth digit is usually not included in the osseous union but is joined in a complete, tight, simple syndactyly (although a complete distal bony union from the first to the fifth finger can be observed) (Fig. 1C).

Description Digits. There is a complex syndactyly with synonychia and fusion of the distal phalanges of the second, third, and fourth digits. The bases of the fourth and fifth metacarpal bones are often fused. The fusion is sometimes observed during the first year of life (see Fig. 5), but the common feature is fusion after 5 years. The fourth web shows varying degrees of simple syndactyly. Symphalangism at the proximal interphalangeal (PIP) joints of the digits and at the interphalangeal (IP) joint of the thumb is constant, leading to a progressive loss of flexion between infancy and childhood. All joints are stiff except the PIP of the small finger and the metacarpophalangeal (MCP) joints of the thumb and fingers. In border digits (the index and sometimes the fifth), partial closure of the epiphyseal plate of the proximal phalanx is responsible for later lateral deviation after digit separation. Thumb. The thumb is frequently involved in syndactyly and always displays severe radial clinodactyly at the MCP joint. Fereshetian and Upton5 have shown an anomalous distal insertion of the APB onto the radial aspect of the distal phalanx. Dao and Wood7 considered the long lever arm of the abnormal APB to be responsible for radial angulation of the thumb. We totally accept this theory because, in reviewing our patients, we have never observed a true longitudinal bracketed epiphysis. Even if the proximal phalanx may resemble a delta, it is not a true delta phalanx. This point is important to help decide between primary osteotomy of the thumb and early release of the APB. In older children, the 2 phalanges of the thumb are in symphalangism despite their apparent segmentation in radiographs at birth. This explains the absence of motion at the IP level. One should not question the wisdom of performing hand surgery in children with Apert syndrome. Advances in craniofacial surgery have changed the prognosis of mental retardation. Despite poor joint motion, the overall functional improvement in the hand is remarkable. We can expect improvement of function and cosmetic appearance, but we can never expect a normal hand. Without hand surgery, function is often very restricted and, in type III, is limited to bimanual prehension. The most important procedure consists of opening the first and the fourth web spaces. Thumb motion is limited but sufficient for a useful pinch between the thumb and the index

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finger. The small finger is the most mobile finger, and separation of the syndactyly of the fourth web space provides a good grasp for voluminous objects. This leads to tripod prehension, and most of the functional gain is achieved after this procedure. The gain of function from correcting thumb clinodactyly is not so dramatic, but the cosmetic improvement is clearly desired by the parents and the older children. The same problem is encountered for the second and third web space. The function of the stiff central fingers is poor, but the cosmetic appearance is better than that of a central block of digits. It has been said that this correction of the thumb clinodactyly is not necessary and even deleterious for the opposition between the thumb and the index finger. In our experience, it does not appear that we have improved or worsened the function of the thumb, but it is very clear that the parents or the older children desire the correction for cosmetic reasons. This seems strange considering the cosmetic appearance of the face, but there was a constant demand to achieve a good realignment of the thumb.

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TECHNIQUE

Treatment of Syndactyly To separate the digits, we use an omega-shaped dorsal flap with full-thickness skin grafts to cover the defects (Fig. 2A, B). We do not recommend the use of splitthickness skin graft to avoid recurrences of syndactyly. On the dorsal aspect of the digits, we lengthen the omega flap with a zigzag incision. In case of synonychia,

we try to reconstruct the paronychium using the distal zigzag pulp flap described by Buck-Gramcko12 (Fig. 2C).

First Web Opening For the first web, we prefer the dorsal flap described by Buck-Gramcko (Fig. 3). This flap provides good coverage, usually without the necessity of an additional skin graft. In partial syndactyly we use either a 4-flap Z-plasty or a ‘‘trident flap’’ which is a modified butterfly flap.13 Surgery is performed under magnification (loupes), and the most important step is separation of the neurovascular bundles. Surgery is sometimes hazardous because the fingers can be in marked rotation. Fortunately, the blood supply is good, even after ligation of a digital artery, in case the bifurcation of the common digital artery is located very distally. After elevation of the flaps and grafts, we use absorbable sutures (Rapid VicrylÓ). The digits are separated with hydrocortisone and antibiotic gauze (CorticotulleÒ) to avoid maceration. Antibiotics are given prophylactically, but only perioperatively. The hand is enclosed in a bulky dressing extending to the elbow. If the dressing is fashioned correctly, using a strong adhesive tape, plaster immobilization is unnecessary. The first dressing is changed after 8 days and then every 2 days until complete healing is achieved. Chang et al8 left casts on for 2 weeks, and their revision rate after separation is 13%, very similar to our revision rate. We previously treated the thumb clinodactyly: we performed conventional osteotomies of the proximal phalanx, either closing-wedge osteotomy or reversed osteotomy. After the publication of Dao et al,7 we decided to stop osteotomies in very young patients and

FIGURE 2. A,B, Drawing of the incisions (omega flap) for separation of the second and third digits. In the same procedure the fourth ray has been removed. The child underwent the opening of the first and fourth webs 6 months before. C, Zigzag pulp flap for reconstruction of the paronychium.

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FIGURE 3. A, Drawing of a flap for opening of the first web in a type II. The undermining must be limited to the distal third of the flap to avoid necrosis of the extremity (underlined area). B, Result on a type III. In this second procedure, the third web was separated, and the fourth ray amputated.

instead perform a simple release of the distal insertion of the APB on the distal phalanx. The tendon is shortened and sutured onto the base of the proximal phalanx (Fig. 4). At the date of publication, our follow-up is too short to evaluate the efficiency of this procedure.

Ray Amputation If we want to achieve a 3-fingered hand, the division at the metacarpal level is driven carefully to remove the bone with the periosteum. This is technically more complex, but it prevents secondary ossification from the periosteum sheet left in place. In case of synostosis between the bases of the fourth and fifth metacarpal bones, we interpose the interosseus muscles to avoid recurrences. Dobyns14 has sometimes amputated the index ray, thereby increasing the volume capacity of the first web space. In our series this was done in 6 hands.

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FIGURE 4. Type III in a girl 9 months of age. First procedure is release of the distal insertion of the APB on the base of the distal phalanx of the thumb to prevent clinodactyly. The tendon is then reattached on the radial aspect of the proximal phalanx.

COMPLICATIONS AND LATE PROCEDURES

The surgeon should expect many secondary procedures in these complex hands. The rate of revision was 13% for Chang et al8 and 18% for Barot and Caplan.3 In our series,10 altogether, 21% of the procedures were revisions, but only 15% for contracture in the web space. The other procedures were secondary amputations for ankylosis of a finger in flexion or because of limited opening of the first web space. Dobyns14 has sometimes amputated the index ray, thereby increasing the volume capacity of the first web space. In our series, this was done in 6 hands with 2 bilateral cases.

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Guero TABLE 1. Classification of hand anomalies into 3 types according to Upton Reference No. of patients Type I Type II Type III 4 Upton (1991) 68 28 24 16 Holten et al (1997)6 45 29 10 6 Chang et al (2002)8 10 5 1 4 Present study 52 11 19 22 One patient of our series is asymmetric (one hand is type II and the other is type III) and is not included in the table.

S252W or P253R) occurring in the linking region between the second and third immunoglobulin domains of the fibroblast growth factor receptor (FGFR2) gene.16 Our Department of Genetic Research has screened 36 patients with Apert syndrome. Mutations were detected in all cases. Lajeunie et al11 concluded that P253R mutation appears to be associated with the more severe forms (type III). Furthermore, we have shown a significant correlation between the severity of syndactyly (according to the Upton classification) and the intellectual prognosis.17 In other words, the more severe the clinical aspect of syndactyly, the more limited the mental capacity.

Pathologic Anatomy FIGURE 5. Late deviation of the index finger. Note the partial closure of the epiphyseal plate of the proximal phalanx.

Maceration Hyperhidrosis is a poorly appreciated factor, but it is present in almost all Apert patients. Maceration can compromise the grafts, creating disunion of the sutures, particularly in the web space, and leading to ‘‘recurrences’’ of syndactyly. This has many implications for bandages and even for the choice of the time of year for surgery. We prefer avoiding the hot season because of excessive sweating.

Secondary Deviation As mentioned previously, the progressive deviation of the border digits is a consequence of the partial closure of the epiphyseal plate. It could be treated by osteotomy, but that is usually not necessary (Fig. 5). Stiffness is not a complication but is the natural evolution of the interphalangeal joint in Apert syndrome.

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DISCUSSION

Genetics Apert syndrome is an autosomal dominant condition. The incidence is estimated at 1 in 55,000 live births.15 The molecular basis for the syndrome appears remarkably specific: 2 adjacent amino acid substitutions (either

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Histologically, the most striking feature demonstrated by Holten et al6 is the presence of ectopic cartilage deposits in periarticular tissues and flexor tendons. They propose that the ectopic cartilage represents abnormal differentiation of the mesenchymal elements of the interzone with the formation of cartilage instead of normal periarticular tissues. This ectopic cartilage eventually calcifies and is responsible for the process of distal interphalangeal joint synostosis, ie, symphalangism.

Patient Population We have reviewed 53 children operated between 1976 and 2002. Age of presentation ranged from 1 month to 13 years. There are 21 girls and 32 boys. Eleven were type I, 19 type II, and 22 type III (Table 1). One child was asymmetric: 1 hand was a type II, and the other was a type III. A total of 189 procedures were performed on the hand. The mean number of procedures per patient is 4 with a maximum of 10 in 1 patient (operated by one of our former colleagues). Thirty-six patients were screened for the FGFR2 gene: 64% were of S252W type, and 33% of the P253R type. One patient had a double nucleotide substitution (type S252P). The most commonly associated anomalies are cleft palate (41%), limitation of the function of the shoulder (23%), and vertebral anomalies (10%). Limitation of pronosupination was mentioned in 4 cases, and radial head dislocation was found on radiographs in 2 bilateral cases.

Techniques in Hand and Upper Extremity Surgery

Algorithm for Treatment of Apert Hand

FIGURE 6. Algorithm of decision. The first procedure is bilateral; the second is unilateral, performed on one hand and, 6 months later, on the other hand.

In accordance with published articles, we try to perform hand surgery early, before 2 years of age. Holten et al6 emphasized the role of motion in preserving the function of these altered joints. According to Upton, studies have demonstrated that there may be delayed development and impairment of body image. For Barot, early surgery appears to minimize progressive growth deformity.3 The first and most important step must be the treatment of the craniostenosis, and we are firmly opposed to combining craniofacial and hand surgery in the same procedure. The treatment of craniostenosis is complex and involves some very young children (3 months of age). It is not reasonable to add 2–3 hours of surgery for the 2 hands. We wait for a minimum of 2 weeks between the procedures, but 6 months is more logical. Thus, at 9 months of age, the patient has already undergone the first procedure on his hands. Succeeding procedures are separated by 6 months.

To reduce the number of procedures, a bilateral approach seems preferable, but we must also consider the stress for the child and for the parents if both hands are closed in a bulky bandage for 2 to 3 weeks. We have chosen to perform bilateral procedures only in children under 12 months of age.

New Treatment Algorithm The treatment algorithm depends on anatomic considerations (Fig. 6). Each patient is different, and sometimes 1 hand is different from the other (Fig. 7A). When a child is referred for the first time in our unit, we perform a clinical and radiologic analysis of the hands. In regard to the Upton classification, we are able to decide if a 4-fingered hand or a 3-fingered hand will be achieved. In types I and II, it is usually easy to create a 4-fingered hand with a thumb. In type III, the bone disorders are severe, and function will not be improved with 3 or 4 fingers; amputation of 1 digit will reduce the number of procedures.

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We usually propose the following schedule. To limit the number of operations, we have chosen a 3-step procedure. If we want to achieve a 4-fingered hand (Fig. 8), we perform a ‘‘classical’’ management as described by Barot and Caplan3 but include the correction of the thumb as proposed by Dao and al.7 We start with a bilateral procedure if the child is under 12 months of age: opening of the first and third web space and correction of the thumb clinodactyly without osteotomy. After 6 months, we separate the second and the fourth web spaces in 1 hand and, 6 months later, in the other hand (Fig. 8B). In severe deformities in which it is predictable that an amputation will be needed (3-fingered hand), based on radiography (malalignment of the fourth or the third digit, synostosis of the bases of the fourth and fifth metacarpal bones), we modify our schedule (Fig. 9). In the first procedure, we correct the thumb clinodactyly as described above and open the fourth web space. In the second and third procedures, we separate the second web in each hand. Because of the gain in function of the fifth finger after separation of the metacarpal synostosis between the fourth and the fifth rays, we prefer removing the fourth digit, including the fourth metacarpal bone. In some rare cases, we remove the third digit instead of the fourth.10 Parents should be notified that the correction of the syndactyly of the third web will not improve the function or the cosmetic result. FIGURE 7. A, Boy, 5 years old, type III. View of both hands after separation of the digits and correction of thumb clinodactyly. The right hand is 3-fingered, but for the left hand a 4-fingered hand was achieved. B, Boy, 15 years old, type II. Four-fingered hands were achieved in both hands.

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CONCLUSION

Parents can understand this if we take enough time to talk to them and explain with the help of radiographs that only a short, stiff, and unesthetic finger would be obtained with another painful procedure.

This schedule is ideal and is proposed if the child is seen at birth. We must consider every case individually, particularly if the child is coming from a foreign country for a short stay and referred to our unit after 1 year of age. Throat and nose infections are common in Apert syndrome and breath monitoring is difficult. Each child

FIGURE 8. Chronology of procedures between birth and 2 years of age, when a 4-fingered hand is achieved.

FIGURE 9. Chronology of procedures between birth and 2 years of age when a 3-fingered hand is achieved.

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Algorithm for Treatment of Apert Hand

is unique, and we must take care of his needs after the cranial surgery or after any general anesthesia. Parents should be informed as to what further development of the hand they can expect after surgery, including stiffness of the interphalangeal joints and progressive clinodactyly of the second and fifth.

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8. Chang J, et al. Reconstruction of the hand in Apert syndrome: a simplified approach. Plast Reconstr Surg. 2002; 109:465–470 [discussion 471]. 9. Fearon JA. Treatment of the hands and feet in Apert syndrome: an evolution in management. Plast Reconstr Surg. 2003;112:1–12 [discussion 13–19].

ACKNOWLEDGMENT

The author thanks Neil Citron for his help in the preparation of this manuscript.

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7. Dao KD, et al. Thumb radial angulation correction without phalangeal osteotomy in Apert’s syndrome. J Hand Surg [Am]. 2002;27A:125–132.

REFERENCES

1. Apert E. De L’acroce´phalosyndactylie. BullMem Soc Med Paris. 1906;23:1310–1330. 2. Hoover GH, Flatt AE, Weiss MW. The hand and Apert’s syndrome. J Bone Joint Surg Am. 1970;52A:878– 895. 3. Barot LR, Caplan HS. Early surgical intervention in Apert’s syndactyly. Plast Reconstr Surg. 1986;77:282–285. 4. Upton J. Apert syndrome. Classification and pathologic anatomy of limb anomalies. Clin Plast Surg. 1991;18: 321–355.

10. Guero S, et al. Surgical management of the hand in Apert syndrome. Handchir Mikrochir Plast Chir. 2004;36:179– 185. 11. Lajeunie E, et al. Clinical variability in patients with Apert’s syndrome. J Neurosurg. 1999;90:443–447. 12. Buck-Gramcko D. Congenital Malformations. Vol 1 in Nigst H et al, eds. Hand Surgery. New York: Thieme Medical Publishers, 1988. 13. Glicenstein J, Bonnefous G. La plastie en Trident. Ann Chir Plast. 1975;20:257–260. 14. Dobyns JH. The hand and Apert’s syndrome (discussion). J Bone Joint Surg Am. 1970;52-A:894–895. 15. Renier D, et al. Management of craniosynostoses. Childs Nerv Syst. 2000;16:645–658.

5. Fereshetian S, Upton J. The anatomy and management of the thumb in Apert syndrome. Clin Plast Surg. 1991;18: 365–380.

16. Wilkie AO, et al. Apert syndrome results from localized mutations of FGFR2 and is allelic with Crouzon syndrome. Nat Genet. 1995;9:165–172.

6. Holten IW, et al. The Apert syndrome hand: pathologic anatomy and clinical manifestations. Plast Reconstr Surg. 1997;99:1681–1687.

17. Journeau P, et al. Syndactyly in Apert syndrome. Utility of a prognostic classification. Ann Chir Main Memb Super. 1999;18:13–19.

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Techniques in Hand and Upper Extremity Surgery 9(3):134–141, 2005

Ó 2005 Lippincott Williams & Wilkins, Philadelphia

T E C H N I Q U E

Anatomic Basis of Dorsal Finger Skin Cover Jefferson Braga-Silva, MD, PhD Division of Hand Surgery and Microsurgery Pontifical Catholic University of Rio Grande do Sul Porto Alegre, Brazil

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ABSTRACT

This study describes the anatomy of the dorsal cutaneous vascular system of 180 digits (36 thumbs, index, middle, ring, and little fingers) from 18 pairs of fresh human cadaver hands. The aim of this paper is to incorporate the anatomic data into the current way of designing the homodigital adipofascial turnover flap for cutaneous coverage of the dorsum of the finger. We have carried out an anatomic study in preserved cadaver hands to define the distance between the joint and the origin of the dorsal cutaneous branches of the proper palmar digital artery in the proximal and middle phalanx of the long fingers and for the thumb to metacarpal and interphalangeal joint. All branches of the proper digital artery that ran to the dorsal skin were then identified, and their diameters and the distances of their origins from the proximal interphalangeal joint were measured. We showed that 2 constant branches in the proximal and middle phalanx from each proper digital artery have consistent sites of origin at predictable distances from the proximal interphalangeal joint for the long fingers and the metacarpal and interphalangeal joint for the thumb. The flap survival was excellent, and no donor site complications were observed. We showed that these branches have consistent sites of origin at predictable distances from the proximal interphalangeal joint. The adipofascial turnover arterial flap has appeared as an excellent alternative to achieve early coverage of cutaneous wounds at the dorsal aspect of the fingers. Keywords: vascularization, dorsal finger, homodigital flaps, finger flaps

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HISTORICAL PESPECTIVE

Vascularization of dorsal skin finger adipofascial flaps constitutes an excellent option because of their thinness, good pliability, minimal donor site deformity, and the Address correspondence and reprint requests to Jefferson Braga-Silva, MD, PhD, Av Ipiranga, 6690, Centro Clı´nico PUC-RS, conj 216, Porto Alegre, RS CEP, 90.610-000 Brazil. E-mail: [email protected].

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simplicity and rapidity of the procedure. Data concerning the dorsal hand vascular system have been collected during the last decades, allowing the development of new techniques of soft tissue coverage after skin loss. Levame et al1 showed that the vascular system of the dorsal skin cover the proximal phalanx consisted of 2 constant arteries (commissural arteries), which are direct branches of the radial and ulnar proper digital arteries (PDA), whereas the vascular supply to the skin cover dorsum of the middle phalanx arises from 1 or 2 different symmetrical branches from the radial and ulnar PDA. Oberlin and Le Quang2 described 2 constant cutaneous dorsal branches at the level of the proximal phalanx that originate from the radial and ulnar PDA. Yousif et al3 described 4 constant juxtarticular cutaneous dorsal branches (2 proximal and 2 distal), which constitute the vascular system over the proximal interphalangeal joint (PIP). Strauch and Moura4 reported 2 constant cutaneous dorsal branches originating from the PDA at the level of the metaphysis and epiphysis of the proximal and middle phalanges. Valenti et al5 showed a constant cutaneous vascular system over the proximal phalanx arising from a dorsal branch of the PDA and a dorsal anastomotic net at the metacarpophalangeal (MP) joint level. Endo et al6 showed that the cutaneous dorsal vascularization at the level of the MP joint is provided by the intermetacarpal arteries and that 3 branches of the PDA constitute the vascular system of the dorsal skin cover the proximal phalanx, with the proximal branch being rare. In addition, 2 branches from the PDA supply the vascular system over the middle phalanx. Flint and Harrison7 used a local neurovascular flap to repair loss of digital pulp based on the dorsal branches of the PDA. Several studies have described the existence of dorsal branches of the PDA in the proximal phalanx, which anastomose with the vascular system of the dorsal skin. We performed the homodigital dorsal adipofascial

Techniques in Hand and Upper Extremity Surgery

Anatomic Basis of Dorsal Finger Skin Cover

the digits. We do not believe that approaching a PDA for the cutaneous coverage of the dorsal aspect of the digits is appropriate once there are other possibilities that prevent using a digital artery.14 In relation to the dorsal intermetacarpal flaps, and among those who used them for treating losses of substance in the dorsal aspects of the digits, Earley showed this flap in 11 cases of losses of substance at the level of the proximal phalanx in 1989; he emphasized that this kind of reconstruction would not be reliable for distal losses to the PIP joint15,16 (Fig. 1). On the other hand, other authors17 have reported that the dorsal metacarpal flap with extended pedicle, based on the dorsal anastomosis at the level of the proximal phalanx allows for cutaneous coverage of the tip of the long fingers. The present study corroborates the anatomic findings of this study about the existence of dorsal branches at the level of the proximal phalanx.

FIGURE 1. Schematic representation of the intermetacarpal arteries.

arterial flap elevation for finger dorsum wounds, as described by Lai et al.8 We have confirmed the existence of 2 constant dorsal branches originating from the proper PDA in the proximal and middle phalanx. More importantly, we have shown that these branches arise at predictable sites, near the PIP joint. We also showed symmetry of the dorsal branches of the ulnar and radial PDA of each finger.9 Our results strongly support the feasibility of using flaps based on the dorsal cutaneous branches, which can reliably be found at fixed distances from the PIP joint.10 We did not note any marked venous insufficiency in the flaps or in the fingers. The flap is drained by small vena concomitants that follow the arterial branches. The digit is well drained by the palmar venous system, which assures the venous return when the major dorsal system has been interrupted.11–13

Options of Skin Cover of Dorsal Finger Rose made use of a flap supplied by the PDA as donor site for the cutaneous coverage of the dorsal aspect of

FIGURE 2. Deepithelization of the flap.

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FIGURE 4. Dorsal cutaneous branch of the proper palmar digital artery (PDA) to the metacarpophalangeal joint (MP), for the thumb. DCB, dorsal cutaneous branch; ET, extensor tendon.

a ‘‘kite’’ flap for the cutaneous coverage of the thumb based on the second dorsal intermetacarpal artery, with several advantages.21 Some investigations of the anatomic variations of this arterial system were carried out.22 The aim of the present study is to demonstrate how our anatomic findings influenced our designing of the flap and to report on our experience in the use of the homodigital adipofascial turnover arterial flap.

Anatomic Data

FIGURE 3. Transposition of the flap to the neighboring finger.

In relation to the heterodigital de-epithelialised flaps, Pakian is distinguished as the first to use a dorsal deepithelialised flap (crossed-finger method)18 (Figs. 2 and 3). However, the main disadvantages of this reconstruction are that early mobilization is made impossible, and there is the need of another surgery for the separation of the digits. Atasoy19 showed the reversed cross-finger subcutaneous flap with excellent results. Foucher, Merle, and Debry, in 1982, published the experiment with the deepithelialized flap described by Pakian. They pointed out the inclusion of epidermic cysts in the donor site as a complication.20 In the present study, this kind of complication was not observed because the anterior surface of the flap went to a posterior surface, with no detection of epidermic cysts. Foucher described

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One hundred eighty digits from 18 fresh cadavers (36 hands) were dissected in the Fer-a`-Moulin Laboratoire (Paris, France) between January 1998 and March 1999. The age range of the cadavers was 47 to 76 years (mean 58 years), and 16 were male and two, female. Ten were white. No thumb, index, middle, ring, or little fingers were absent in the cadavers. The anatomic dissections were carried out by the same person who injected 35 mL of colored latex (Neoprene) into the humeral artery until

FIGURE 5. Dorsal cutaneous branch (DCB) of the proper palmar digital artery (PDA) for the long fingers. PIP, proximal interphalangeal joint.

Techniques in Hand and Upper Extremity Surgery

Anatomic Basis of Dorsal Finger Skin Cover

FIGURE 6. Dorsal cutaneous branch (DCB) of the proper palmar digital artery (PDA) to the proximal (PP) and middle phalanx (MP) for the long fingers. PIP, proximal interphalangeal joint.

FIGURE 9. Arterial flap: final aspect.

the dorsal hand was colored. The latex was then allowed to polymerize for 24 hours, and the cadavers were positioned in a dorsal decubitus position with the arms abduced to 90 degrees, the elbows extended, and the forearms and hands in pronation. A dorsal incision was made from the metacarpophalangeal joint to the base of the nail of each finger, and the dorsal skin was dissected in a palmar direction. The lengths of the radial and ulnar margins of the proximal and middle phalanges of each finger were measured. Direct visualization of the dorsal arterial branches of the PDA was then possible (Fig. 4). All branches of the PDA that ran to the dorsal skin were then identified (Figs. 5 and 6), and their diameters and the distances of their origins from the PIP joint were measured. The diameter of the ulnar and radial PDA was also measured at the point where the second dorsal branch arose, and all anatomic variations were registered. Dissections and observations were carried out with the aid of loupe magnification. Parametric statistical analysis was carried out, and 95% confidence intervals were calculated. There was no statistical difference between the positions of origin of the radial dorsal branches and their corresponding ulnar branches. Thus, the sites of origin of the second and third dorsal cutaneous branches of the proper

FIGURE 7. Arterial flap: skin deepidermization.

TABLE 1. Donor Sites and Average Size of the Flaps

Donor Site

FIGURE 8. Arterial flap: adipofascial flap transposed over the defect.

Proximal phalanx (long fingers) Middle phalanx (long fingers) Metacarpal (thumb) Proximal phalanx (thumb)

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Number of Flaps No. (%)

Length 3 Width (mm)

23

54.8

24

3

18

19 9 5

45.2 64.3 35.7

18 42 18

3 3 3

16 18 20

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Braga-Silva

FIGURE 10. Loss of dorsal skin over the distal phalanx of the index finger.

PDA in the proximal phalanx and the first and second branches in the middle phalanx are consistent and symmetrical. The first dorsal branch was found in only 6 of the 18 cadavers, and when found in 1 finger, it was found in all the other fingers of the same cadaver. For the thumb, a dorsal branch of each PDA at the level of both the MP and interphalangeal (IP) joints was a constant finding. In all cases, these dorsal branches anastomose with each other at the level of the joint line.

Clinical Data Between March 1999 and January 2004, 56 homodigital adipofascial turnover flaps were raised in 54 patients, all of them for loss of the cutaneous coverage on the finger dorsum of the middle and distal phalanx of the long fingers and proximal and distal phalanx of the thumb. The age range was 5 to 60 years (mean 27 years). The dominant hand was affected in 44 patients. The mechanisms of injury were burning (55%), crushing (40%), and human biting (5%) for the long fingers and crushing

FIGURE 11. The adipofascial flap on the proximal phalanx.

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FIGURE 12. Adipofascial flap transposed over the defect.

(64.3%) and infection (35.7%) for the thumb. The digits most often involved were the middle and thumb (25%), followed by the ring finger (21.5%), the index, and the little finger (14.2%). Defects were located at the middle (54.8%) and distal phalanges (45.2%) for the long fingers, and for the thumb proximal (64.3%) and distal phalanges (35.7%).

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TECHNIQUE

Once the defect had been defined, the skin overlying the flap was carefully incised down to the dermal layer in an ‘‘H’’ shape and undermined without the adipose component. When planning the length of the flap, we included the size of the defect, the portion that would not be laterally incised (the pedicle of the flap), and an additional 10 mm to compensate the loss of effective length observed when the flap is turned over. Because the cutaneous dorsal branches of the PDA arise near the PIP joint, this portion must always be preserved. Care was taken to preserve the skin on the lateral border of the digits (Fig. 7). Proximal and lateral incisions in the subcutis were carried out, and the flap was raised including all tissue

FIGURE 13. Skin graft on the arterial flap.

Techniques in Hand and Upper Extremity Surgery

Anatomic Basis of Dorsal Finger Skin Cover

FIGURE 14. Result.

between the dermis and the paratendon. The flap was then turned back on its attached base to reach the opposite end of the defect (Fig. 8). After the flap had been fixed to the defect, the skin over the donor site was repositioned over the paratendon, and a split-thickness skin graft was applied to the raw surface of the turnover flap (Fig. 9). The hand was immobilized for 5 to 7 days after the operation. We had observed that all defects in the middle and distal phalanges could be covered with flaps based on the third (the last branch of proximal phalanx) or on the fourth (the first branch of the middle phalanx) cutaneous dorsal branches of the PDA. To cover extensive areas of both middle and distal phalanges, the flap length can be marked to include the subcutaneous tissue over the MP joint and, sometimes, a portion of the dorsal metacarpal surface, based on the anastomosis between the dorsal vascular system of the proximal phalanx and the dorsal metacarpal vessels. The adipofascial turnover arterial flap was able to fit wounds at the dorsal aspect of the finger in all patients. All flaps easily reached the extremity of the defects, and no signs of vascular compromise were observed in the cases that the tourniquet was intentionally released before the end of the procedure. The length of the flaps varied according to the size of the defects and the donor sites. Table 1 shows the average size of the flaps (Figs. 10–14). In the present modified technique, the use of data on the dorsal vascularization of the finger, on the predictable sites of emergence of the dorsal branches, and on their symmetrical presentation, based on our anatomic study, permitted a predictable and reliable flap design. The range of motion

FIGURE 15. Vascularization of the dorsal thumb, dorsal branches at the level of the metacarpal and interphalangeal joint.

TABLE 2. Average Joint Range of Motion (Active Flexion/Extension Deficit) (Degrees) MP PIP DIP

Thumb 80/0 80/ÿ5 —

Index 80/0 80/ÿ10 50/ÿ10

Middle 80/0 90/ÿ10 60/0

Ring 80/0 85/ÿ5 70/0

Little 80/ÿ10 80/ÿ15 50/ÿ10

FIGURE 16. Loss of dorsal skin over proximal phalanx of the thumb.

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Braga-Silva

FIGURE 17. The adipofascial flap on the first metacarpal.

of the digits measured 6 months after the injury is shown in Table 2 (Figs. 15–19).

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CONTRAINDICATIONS

In case of severe circumferential crush injuries or partial degloving injuries, the use of this flap may be questioned. The digit must be carefully evaluated. The proper management should be individualized. The zone where the dorsal branches are located has to be marked out, and the most suitable vessel included in the base of the flap chosen, preoperatively, according to the defect.

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COMPLICATIONS

As a consequence, no necrosis of the skin over the donor site was found. Neither postoperative infection in donor or recipient sites nor residual edema on the digits was perceived in this series. In one patient, a 15% loss of the grafted skin was observed. Two patients manifested dissatisfaction with the conspicuous scar on the donor site of the flap. The sensitive branches are sectioned dur-

FIGURE 19. Result.

ing the elevation of this flap. The sensibility is similar to any area that has received a partial-thickness skin graft. We did not observe any remarkable tendon adhesion in our series. Dorsal skin slough was not observed in the donor site.

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ACKNOWLEDGMENT

The authors thank Professor Elizamari M. Rodrigues for the English version of this study.

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REFERENCES

1. Levame JH, Otero C, Berdugo G. Vascularisation arte´rielle des te´guments de la face dorsale de la main et des doigts. Ann Chir Plast. 1967;12:316–324. 2. Oberlin C, Le Quang G.E´tude anatomique de la vascularisation du lambeau en drapeau. Ann Chir Main. 1985;4: 169–174. 3. Yousif NJ, Cunningham MW, Sanger JR, et al. The vascular supply to the PIP joint. J Hand Surg. 1985;10A:852–861. 4. Strauch B, Moura W. Arterial system of the fingers. J Hand Surg. 1990;15A:148–154. 5. Valenti P, Masquelet AC, Be´gue´ T. Anatomic basis of a dorso-commissural flap from the 2nd, 3rd and 4th intermetacarpal spaces. Surg Radiol Anat. 1990;12:235–239. 6. Endo T, Kojima T, Hirase Y. Vascular anatomy of the finger dorsum and a new idea for coverage of the finger pulp defect that restores sensation. J Hand Surg. 1992;17A:927–932. 7. Flint MH, Harrinson SH. A local neurovascular flap to repair loss of the digital pulp. Br J Plast Surg. 1965;18:156–163. 8. Lai CS, Lin S, Yang C, et al. The adipofascial turn-over flap for complicated dorsal skin defects of the hand and finger. Br J Plast Surg. 1991;44:165–169.

FIGURE 18. Adipofascial flap transposed over the defect.

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9. Braga-Silva J, Kuyven CR, Fallopa F, et al. An anatomical study of the dorsal cutaneous branches of the digital arteries. J Hand Surg. 2002;27B:577–579.

Techniques in Hand and Upper Extremity Surgery

Anatomic Basis of Dorsal Finger Skin Cover 10. Braga-Silva J, Kuyven CR, Albertoni W, et al. The adipofascial turn-over flap for coverage of the dorsum of the finger: a modified surgical technique. J Hand Surg. 2004;29A: 1038–1043. 11. Lucas GL. The pattern of venous drainage of the digits. J Hand Surg. 1984;9A:448–450. 12. Madelenat P, De La Caffinie`re JY. Le drainage veineux des doigts. Arch Anat Pathol. 1971;19:419–422. 13. Nystro¨m A, Drasek-Ascher G, Fride´n J, et al. The palmar digital venous anatomy. Scand J Plast Reconstr Hand Surg. 1990;24:113–119. 14. Rose EH. Local arterialized island flap coverage of difficult hand defects preserving donor digit sensibility. Plast Reconstr Surg. 1983;72:848–858. 15. Earley MJ. The arterial supply of the thumb, first web and index finger and its surgical application. J Hand Surg. 1986; 11B:163–174.

16. Earley MJ. The second dorsal metacarpal artery neurovascular island flap. J Hand Surg. 1989;14B:434–440. ¨ zcan M. A new approach to the reverse dor17. Karacalar A, O sal metacarpal artery flap. J Hand Surg. 1997;22A:307– 310. 18. Pakian AI. The reversed dermis flap. Br J Plast Surg. 1978; 31:131–135. 19. Atasoy E. Reversed cross-finger subcutaneous flap. J Hand Surg. 1982;7:481–483. 20. Foucher G, Merle M, Debry R. Le lambeau de´se´pidermise´ retourne´. Ann Chir Main. 1982;1:355–357. 21. Foucher G, Braum JB. A new island flap in surgery of the hand. Plast Reconstr Surg. 1979;63:28–31. 22. Dautel G, Merle M, Borrelly J, et al. Variations anatomiques du re´seau vasculaire de la premie`re commissure dorsale. Applications au lambeau cerfvolant. Ann Chir Main. 1989;8:53–59.

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Techniques in Hand and Upper Extremity Surgery 9(3):142–148, 2005

Ó 2005 Lippincott Williams & Wilkins, Philadelphia

T E C H N I Q U E

Fixed Angle Fixation of Distal Radius Fractures Through a Minimally Invasive Approach Jorge L. Orbay, MD, Amel Touhami, MD, and Carolina Orbay Miami Hand Center, Miami, Florida

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ABSTRACT

Treating unstable distal radius fractures in osteoporotic patients remains a challenge for the surgeon. Fixed angle plate fixation requires ample surgical dissection but has been shown to improve stability, allow early functional use of the hand and facilitate rehabilitation. We herein describe a treatment method that provides the benefits of fixed angle fixation while utilizing a minimally invasive approach. Stability is achieved by the use of a new implant that is placed through a small dorsal incision and minimizes extensor tendon disruption. This method finds application in the unstable extra-articular fracture of the high risk patient where minimal surgical morbidity is desirable and when reduction can be obtained without the need of extensive dissection. Clinical examples are fractures in the elderly patient where confusion can follow prolonged anesthesia, fractures in the patient with a bleeding disorder where a small wound volume is desirable and fractures in the polytraumatized patient where surgical time must be kept to a minimum. This technique allows anatomic reduction and stable fixation to be achieved in a short operative time and with minimal surgical insult while providing the compromised patient with a rapid recovery. Keywords: distal radius fractures, fixed angle fixation, minimal invasive approach, osteoporosis

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HISTORICAL PERSPECTIVE

As the life expectancy of the older and chronically ill patient has been extended by improvements in medical care, the incidence of their distal radius fractures has proportionally increased.1–4 A variety of methods including Address correspondence and reprint requests to Jorge L. Orbay, MD, Miami Hand Center, 8905 SW 87th Ave., Suite 100, Miami, FL 33176. E-mail: [email protected]. Dr. Jorge Orbay discloses that he has ownership interests in Hand Innovations, LLC.

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nonsurgical and operative techniques have been used on these injuries5–9; however, they have many limitations.10–12 Closed treatment with casts or splints is simple but fails to maintain reduction in unstable fractures.10,13,14 Several types of external fixation— bridging, hinged, and nonbridging—have been used with the purpose of improving anatomic results. However, problems such as chronic regional pain syndrome (CRPS), pin tract infection, and patient objections to the external device have been difficult to avoid. Percutaneous pinning and Kapandji pinning are minimally invasive methods that also have failed to provide stable fixation in osteoporotic bone.15–17 Conventional plate fixation has proven inadequate for the majority of the most common dorsal injuries.18,19 On the other hand, fixedangle internal fixation through dorsal or volar approaches has been shown to adequately stabilize distal radius fractures in the older osteoporotic patient.14,20,21 The volar approach presents the advantage of avoiding extensor tendon dysfunction.22,23 Minimally invasive fixed-angle fixation of distal radius fractures was introduced in an attempt to provide the stability of fixed-angle plating through a less invasive surgical approach. The dorsal approach was selected because it is subcutaneous and therefore more accessible. To minimize extensor tendon dysfunction, a narrow partially intramedullary implant was designed to fit on the floor of the third extensor compartment after subcutaneous mobilization of the extensor pollicis longus (EPL) tendon.

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INDICATIONS/ CONTRAINDICATIONS

The most appropriate indication for this technique involves an elderly or infirm patient who presents with an unstable extraarticular distal radius fracture (AO types A2 and A3)24 and is further compromised by concomitant osteoporosis. We define instability as loss of initial reduction or as radiographic evidence of more than

Techniques in Hand and Upper Extremity Surgery

Fixed Angle of the Distal Radius

FIGURE 1. The dorsal nail plate (DNPTM, Hand Innovations LLC, Miami, FL) belongs to a new class of implants that is both a fixed-angle plate and an intramedullary locking nail. These 2 parts are connected by a neck (*) that traverses through the fracture site.

20 degrees of angulation in any plane, displacement more than two-thirds of the width of the shaft, shortening greater than 5 mm, and associated distal ulnar fracture. It is important that fractures be relatively recent and therefore amenable to manipulative reduction. For this reason, fractures more than 3 weeks old are not good indications. Intraarticular fractures can be managed with this procedure only if the articular component is nondisplaced. Ideal indications are fractures in the elderly patient, where regional anesthesia is preferred; fractures

FIGURE 3. Insertion is through a 3- to 4-cm longitudinal incision in line with the Lister tubercle.

in the polytraumatized patient, where surgical time must be kept at a minimum; and patients on renal dialysis in need of frequent heparinization, where a small wound volume is advantageous. Contraindications to the procedure include displaced intraarticular fractures, comminution that extends into the diaphyseal portion of the radius, and nascent malunions.

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TECHNIQUE

Equipment: Implant Description The technique utilizes a fixed-angle implant (Dorsal Nail Plate DNPTM; Hand Innovations LLC, Miami, FL) that can be applied rapidly, with minimal dissection and through the dorsal aspect. This implant is best described as an intrafocal nail plate because it is inserted through the fracture site and includes a distal fixed-angle plate section and a proximal intramedullary locking nail section (Fig. 1). These 2 sections are connected by a neck

FIGURE 2. The proximal part of the implant is inserted retrogradely through the fracture, aligns itself inside the medullary canal, and is fixed by unicortical locking screws (A). The distal part supports the articular surface with fixedangle pegs and avoids tendon impingement by being placed on the dorsal surface of the distal fragment between the second and fourth extensor compartment and distal to the transposed EPL (B).

FIGURE 4. The extensor pollicis longus is released several centimeters proximal and distal to the Lister tubercle and transposed toward the lateral side.

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FIGURE 5. Deep dissection is carried proximally to expose the fracture and the ridge on the dorsum of the proximal fragment (*).

FIGURE 8. The insertion jig assembled to the nail. Note the threaded drill guide on the distalmost peg hole (1) and the drilling sleeve for the proximal locking screws (2).

that remains across the fracture site. The distal plate section lies on the surface of the distal fragment, and the proximal nail section is inside the diaphysis of the radius. The head part presents a narrow cross-section area in order not to impinge on the adjoining extensor tendons and is placed on a bone surface prepared by mobilization of the EPL tendon and flattening of the Lister tubercle. Proximal surgical dissection is minimized as a result of the intramedullary location of the proximal portion of the implant, which automatically aligns itself inside the medullary canal with the axis of the radius. This

FIGURE 6. An 18-gauge needle is used to find the joint line. The implant, placed 4–6 mm proximal to the needle, serves as a template to estimate the final location of the neck.

FIGURE 7. A notch is created with a rongeur on the proximal fragment for receiving the neck of the implant.

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FIGURE 9. The fracture is reduced, and the implant inserted. The next step is to drill the distalmost peg hole. This must be performed under fluoroscopy and visualized through an anatomic lateral view (20-degree elevation lateral). The peg must be positioned immediately below the subchondral bone. Note the 18-gauge needle locating the joint space.

Techniques in Hand and Upper Extremity Surgery

Fixed Angle of the Distal Radius

FIGURE 10. Insertion of unicortical locking screws provides proximal fixation. These holes are drilled using a sleeve placed through the jig. These screws provide great stability by engaging the implant and compressing it against the endosteal surface.

feature also places the head of the implant in its correct position in space and therefore facilitates reduction of the distal fragment (indirect reduction). Distal fixation is provided by fixed-angle elements on the head portion that fan out underneath the subchondral bone. Proximal fixation is provided by unicortical locking screws that compress the body of the implant against the endosteal surface, producing a very stable interface (Fig. 2).

Surgical Technique This procedure is usually performed in the outpatient setting, utilizing fluoroscopy and under local or regional

FIGURE 11. The final step is the placement of the 2 lateral pegs; this completes stabilization of the distal fragment. The head of the implant must be fixed flush with the distal fragment to minimize its profile. After application, the EPL tendon (3) will course proximal to the head of the implant, and the tendons of the second and fourth extensor compartments (1, 2) will travel on each side of it, thereby avoiding tendon impingement.

anesthesia. The patient is placed in the supine position with the arm extended on the hand table. After an initial closed reduction is rehearsed under fluoroscopy, a 3- to 4-cm longitudinal incision overlying the Lister tubercle is used for exposure (Fig. 3). The extensor pollicis longus (EPL) tendon sheath is easily located because it is usually distended by blood and released several centimeters proximal and distal to the Lister tubercle. Branches of radial sensory nerve must be protected during the distal

FIGURE 12. Preoperative AP and lateral views of a right extraarticular distal radius fracture in a 72-year-old woman (A, B). Postoperative AP and lateral views at 16 weeks after fixation (C, D).

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FIGURE 13. Functional results at 16 weeks after minimally invasive fixed-angle fixation: Extension (A), pronation (C), and supination (D) approach preinjury levels. Wrist flexion (B) recovers more slowly, perhaps because of the presence of a dorsal scar. Grip strength is 75% of contralateral (E, F).

part of the dissection. The EPL tendon is then retracted toward the radial side (Fig. 4). Lister tubercle is then exposed subperiosteally and either flattened by downward digital pressure, because it is usually fragmented, or removed with a rongeur. These 2 steps create a flat surface for seating the head of the implant. Proximal dissection is carried out to expose the fracture site and the dorsal ridge on the proximal fragment (Fig. 5). The medullary canal is now opened with an awl. With exposure completed, the joint line is located by inserting an 18-gauge needle. The silhouette of the head of the implant is drawn with a marking pen with its distal edge resting 4–6 mm proximal to the joint line (Fig. 6). This is done to carve a notch on the distal edge of the proximal fragment in line with the third extensor compartment with the purpose of receiving the neck of the device (Fig. 7). The insertion

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jig is assembled to the implant, and the threaded drill guide is applied to the most distal peg hole (Fig. 8). The implant is then introduced in a retrograde fashion, through the fracture site, into the proximal fragment and advanced with gentle rotational motion. The head of the device is seated flush on the distal fragment, and its correct rotation is verified. Under fluoroscopic guidance, in an anatomic lateral view, and while reduction is maintained, a 2-mm bit is inserted through the threaded drill guide to create the tract for the central peg. The drill should course immediately below the subchondral bone25 (Fig. 9). After careful measurement of its length to avoid protrusion through the volar cortex, a smooth peg is applied on the central hole. This peg fixes the volar tilt. By use of the jig, the first proximal unicortical holes are drilled with a 3.3-mm drill bit, and the

Techniques in Hand and Upper Extremity Surgery

Fixed Angle of the Distal Radius

proximal locking screws, which fix the radial length, are applied (Fig. 10). After removal of the insertion jig, the 2 remaining medial and lateral smooth pegs are applied. During the drilling, the distal fragment must be pushed up against the implant to assure that the head is flush with its surface. After application, the EPL tendon will course proximal to the head of the implant, and the tendons of the second and fourth extensor compartments will travel on each side of it, thereby avoiding tendon impingement (Fig. 11). Transposing the EPL out of its sheath and into a subcutaneous position creates minimal functional disturbance. Radiographic views are obtained before the wound is closed, and a postoperative dressing that allows finger motion is finally applied.

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COMPLICATIONS

Internal fixation of wrist fractures can result in infection, malunion, nonunion, and CRPS. Infection is infrequent at the wrist and generally avoided by attention to sterility and by minimizing soft tissue dissection and bone devascularization. Deformity is prevented by careful reduction technique. Loss of reduction after fixation is unusual with fixed-angle fixation but can occur if the fixed-angle elements are placed far from the subchondral bone in osteoporotic patients or rarely if implant breakage occurs. Minor imperfections in reduction such as the absence of volar tilt and slight (1 mm) loss of radial length do not usually result in appreciable functional deficits. The healing response is maximized if blood supply is respected, dissection minimized, and bone graft used when necessary. CRPS is best prevented by postoperative care measures such as assuring a loose bandage, encouraging elevation, early finger motion, and functional use of the hand in the early postoperative period. The radial nerve should be protected at the time of exposure, and the carpal tunnel released if there is evidence of a concomitant median neuropathy. If excessive pain, swelling, and loss of finger motion are observed, the surgeon must consider early treatment with modalities such as medication, physical therapy, and pain blocks. Our experience of over 200 cases has shown that complications are relatively infrequent with this method. We also have observed a wound hematoma in a dialysis patient that required drainage, loss of fixation of an articular fracture that was poorly indicated, hypertrophic scar formation, and a patient with persistent discomfort at the implantation site that was treated by implant removal.

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REHABILITATION

The patient is instructed on elevation techniques and on finger active range-of-motion (AROM) exercises immediately after surgery. At the 1-week follow-up visit, the

operative dressing is removed, the patient is referred to therapy, and a custom-formed plastic short arm splint is provided. Functional use of the hand is encouraged, and the patient is given a 5-lb weight-lifting limit on the affected extremity. We expect the patient to achieve full finger flexion (fingertips to distal palmar crease) at this time, and forearm rotation is now commenced. At 2 weeks, the sutures are removed, and scar management is initiated. At 4 weeks, the splint is discarded, and we expect the patient to have recovered significant forearm rotation; attention is now placed on wrist flexionextension and strengthening. The functional results provided by this technique are very satisfying. Most patients are utilizing their hands to perform activities of daily living after the first or second postoperative week. At 2 months most patients do not require further therapy. At 4 months wrist extension and forearm rotation are usually at preinjury levels. Wrist flexion takes somewhat longer to return, presumably because of the dorsal location of the incision (Figs. 12 and 13).

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REFERENCES

1. US Census Bureau. Statistical Abstracts of the United States. Washington, DC: US Census Bureau; 1999. 2. Schoeni RF, Freedman VA, Wallace RB. Persistent, consistent, widespread, and robust? Another look at recent trends in old-age disability. J Gerontol B Psychol Sci Soc Sci. 2001;56:S206–S218. 3. Hesp R, Klenerman L, Page L. Decreased radial bone mass in Colles’ fracture. Acta Orthop Scand. 1984;55:573–575. 4. Flinkkila T, Nikkola-Sihto A, Raatikainen T, et al. Role of metaphyseal cancellous bone defect size in secondary displacement in Colles’ fracture. Arch Orthop Trauma Surg. 1999;119:319–323. 5. Munson GO, Gainor BJ. Percutaneous pinning of distal radius fractures. J Trauma. 1981;21:1032–1035. 6. Cohen MS, Frillman T. Distal radius fractures: a prospective randomized comparison of fibreglass tape with QuickCast. Injury. 1997;28:305–309. 7. Pritchett JW. External fixation or closed medullary pinning for unstable Colles fractures? J Bone Joint Surg Br. 1995; 77:267–269. 8. Desmanet E. Osteosynthesis of the radius by double elastic spring-pinning. Functional treatment of the distal end fractures of the radius. A study of 130 cases. Ann Chir Main. 1989;8:193–206. 9. Bennett GL, Leeson MC, Smith BS. Intramedullary fixation of unstable distal radius fractures. A method of fixation allowing early motion. Orthop Rev. 1989;18:210–216. 10. Young BT, Rayan GM. Outcome following nonoperative treatment of displaced distal radius fractures in low-demand

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Orbay et al patients older than 60 years. J Hand Surg [Am]. 2000;25: 19–28. 11. Anderson JT, Lucas GL, Buhr BR. Complications of treating distal radius fractures with external fixation: a community experience. Iowa Orthop J. 2004;24:53–59. 12. Byl NN, Kohlhase W, Engel G. Functional limitation immediately after cast immobilization and closed reduction of distal radius fractures: preliminary report. J Hand Ther. 1999;12:201–211. 13. Anzarut A, Johnson JA, Rowe BH, et al. Radiologic and patient-reported functional outcomes in an elderly cohort with conservatively treated distal radius fractures. J Hand Surg [Am]. 2004;29:1121–1127. 14. Jupiter JB, Ring D, Weitzel PP. Surgical treatment of redisplaced fractures of the distal radius in patients older than 60 years. J Hand Surg [Am]. 2002;27:714– 723.

18. Liporace FA, Gupta S, Jeong GK, et al. A biomechanical comparison of a dorsal 3.5-mm T-plate and a volar fixed-angle plate in a model of dorsally unstable distal radius fractures. J Orthop Trauma. 2005;19:187–191. 19. Walz M, Kolbow B, Auerbach F. [Do fixed-angle T-plates offer advantages for distal radius fractures in elderly patients?] Unfallchirurg. 2004;107:664–670. 20. Beharrie AW, Beredjiklian PK, Bozentka DJ. Functional outcomes after open reduction and internal fixation for treatment of displaced distal radius fractures in patients over 60 years of age. J Orthop Trauma. 2004;18:680–686. 21. Rozental TD, Beredjiklian PK, Bozentka DJ. Functional outcome and complications following two types of dorsal plating for unstable fractures of the distal part of the radius. J Bone Joint Surg Am. 2003;85-A:1956–1960. 22. Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg [Am]. 2002;27:205–215.

15. Thornton L, Warner P. The management of Colles’ fractures with the Rush medullary nail. South Med J. 1955; 48:654–656.

23. Orbay JL, Fernandez DL. Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient. J Hand Surg [Am]. 2004;29:96–102.

16. Greatting MD, Bishop AT. Intrafocal (Kapandji) pinning of unstable fractures of the distal radius. Orthop Clin North Am. 1993;24:301–307.

24. Muller MR, Nazarian S, Koch P, et al. The Comprehensive Classification of Fractures of Long Bones. Berlin: SpringerVerlag; 1990.

17. Flisch CW, la Santa DR. [Osteosynthesis of distal radius fractures by flexible intramedullary nailing (Geneva experience)]. Chir Main. 1998;17:245–254.

25. Boyer MI, Korcek KJ, Gelberman RH, et al. Anatomic tilt x-rays of the distal radius: an ex vivo analysis of surgical fixation. J Hand Surg [Am]. 2004;29:116–122.

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Techniques in Hand and Upper Extremity Surgery

Techniques in Hand and Upper Extremity Surgery 9(3):149–152, 2005

Ó 2005 Lippincott Williams & Wilkins, Philadelphia

T E C H N I Q U E

Longitudinal Incision in Surgical Release of De Quervain Disease Hakan Gundes, MD Department of Hand Surgery and Orthopedics Maltepe University Hospital Istanbul, Turkey

Bilgehan Tosun, MD Department of Orthopaedic Surgery Kocaeli University Hospital Derince-41900, Kocaeli, Turkey

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ABSTRACT

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The objective of this paper is to contrast the use of a longitudinal incision in surgical decompression of De Quervain disease with a transverse incision. The advantages are ease in recognition of compartment variations and superficial branches of radial nerve and prevention of palmar tendon subluxation by permitting a more dorsal release of the compartment sheath. Since 2002, we have used a longitudinal skin incision instead of the classic transverse incision to release the first dorsal compartment. Keywords: de Quervain disease, incision

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HISTORICAL PERSPECTIVE

Stenosing tendovaginitis of the first dorsal extensor compartment is generally referred to as de Quervain disease. The classic operative approach to release the compartment is through a transverse skin incision parallel to the wrist skin creases. Anatomic variations in this compartment are common, and this may play a major role in the disease process.1 Knowledge of this variability is important for adequate surgical decompression and prevention of postoperative complications. Muskart, in 1964, indicated that a longitudinal incision is mandatory for ease in exploration of the compartment and identification of the variations to prevent recurrence and complications.2 Bruner and Belsole have emphasized the deficiencies of the transverse wrist incision.2 The transverse skin incision parallel to the skin creases has been said to result in a less prominent scar. Address correspondence and reprint requests to Bilgehan Tosun, Yenikent mah. Batıkent sitesi M/Blok D:10, Sopalıciftligi, Kocaeli, Turkey. E-mail: [email protected].

INDICATIONS

The indication for surgery is failure to relieve the symptoms of de Quervain tenosynovitis after 2 consecutive steroid injections.

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SURGICAL TECHNIQUE

The procedure is performed under axillary block and tourniquet control to obtain a bloodless field. The surgical approach is through a longitudinal skin incision beginning 1 cm proximal to the radial styloid and extending proximally along the dorsoradial aspect of the distal forearm for 3 to 4 cm (Fig. 1). Branches of the radial sensory nerve are identified by gentle, blunt transverse dissection (Fig. 2). With this approach, we found that 1 major branch of the nerve is dorsal, and the other major branch is volar to the skin incision (Fig. 3). It is always easier to dissect and explore the nerve branches with this longitudinal incision and thus avoid damage to the nerves. After identification, the nerve branches are carefully retracted and protected (Fig. 4). A dorsoradial incision is then made in the compartment sheath

FIGURE 1. Longitudinal skin incision beginning 1 cm proximal to the radial styloid and extending proximally along the dorsoradial aspect of the distal forearm.

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FIGURE 2. Branches of the radial sensory nerve were identified by gentle, blunt transverse dissection. After the identification, the nerve branches were carefully retracted and protected.

with a scalpel (Figs. 4 and 5). The compartment is carefully explored for the tendon of the extensor pollicis brevis (EPB), and the multiple tendon slips of the abductor pollicis longus (APL). The fibroosseous canal is examined for septation and extra or aberrant tendons. After exploration and retraction of EPB, a search is made volarly for an intracompartmantal septum (Figs. 3 and 6). With atraumatic technique, tension is placed on each of the tendons to simulate their function and aid proper identification. The tendons are hooked and pulled out of their tunnel to ensure their complete decompression (Fig. 7). Our incision leaves the entire compartment sleeve to prevent volar subluxation (Fig. 8). The tourniquet is deflated, and hemostasis is obtained. We use a careful subcuticular closure with 3-0 or 4-0 Monocryl (Ethicon, NJ) as deep dermal sutures and a running 4-0 Monocryl dermal subcuticular stitch. Such a closure not only is more cosmetic but in our opinion may lessen the problem of erythema and wound irritation caused by postoperative swelling. Steri-Strips may be used but should be applied longitudinally along the axis of the incision, rather than transversely across the incision, to prevent blistering and skin irritation caused by postoperative swelling. A

FIGURE 3. After decompression, the fibroosseous canal is examined for septation between the tendons of the EPB and slips of the APL. We leave the entire compartment sleeve to prevent volar subluxation, as dorsoradial decompression aids this.

bulky compressive dressing is applied. No splint is used for immobilization, and early motion is encouraged.

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RESULTS AND COMPLICATIONS

Follow-up examinations (immediate and 1 year) revealed no complications. All of our patients experienced complete relief following surgery. Finkelstein sign was negative in all patients. Surgical incisions healed uneventfully. Some of our patients had been operated on 1 side with a transverse skin incision but had their contralateral operation through a longitudinal incision. These patients had no history of development of hypertrophic scars or the formation of keloids. In spite of having no history of keloid formation, scar massage and various oil preparations were applied to prevent keloids and minimize the occurrence of new scar formation. There was no significant difference in cosmetic appearance (Fig. 9).

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DISCUSSION

De Quervain disease is a stenosing tenosynovitis of the first dorsal compartment of the wrist.3 The inflammation

FIGURE 4. A sharp dorsoradial incision is made in the compartment sheath with a scalpel. It was always easier to dissect and explore the nerve branches without damaging them with longitudinal fashioned incision.

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FIGURE 5. A dorsoradial incision is made in the compartment sheath with a scalpel. With this approach, 1 major branch of the nerve is dorsal, and the other major branch is volar to skin incision.

may be caused by anything that inflames and narrows the compartment or causes swelling or thickening of the tendons.4 The process is attributed to activities requiring frequent abduction of the thumb and simultaneous ulnar deviation at the wrist. Repetitive trauma, overuse, or an inflammatory process are likely causes, but frequently, the etiology of this condition is unknown.4 The common complaint is several weeks or months of pain localized to the radial side of the wrist aggravated by movements of the thumb and wrist. Other findings in de Quervain tendinitis may include radial styloid tenderness, decreased adductor thumb motion, crepitus of the tendons moving through the sheath, thickening of tendons distal to the extensor tunnel, and visible swelling.2,5 Generalized nonarticular rheumatism, trigger digits, tennis elbow, coexistence of carpal tunnel syndrome, and shoulder capsulitis may be associated with the disease.2,5,6 Arthritis of the first carpometacarpal joint, triggering of the thumb, and intersection syndrome of the forearm should be differentiated from this condition.6,7 A combination of injection of steroid and local anesthetics with splint immobilization are an effective methods

for the treatment of de Quervain tenosynovitis.8,9 When the nonoperative treatment fails, surgical release is usually performed. The first dorsal compartment is a fibroosseous tunnel lying over the radial styloid of the wrist. The tendons of the APL and EPB pass through it, both of which are covered by the extensor retinaculum. The APL tendon is bigger and is composed of 2 or more tendinous structures that variously insert themselves on the base of the first metacarpal, the trapezium, the volar carpal ligament, the opponens pollicis, or the abductor pollicis. These 2 tendons help spread the thumb away from the rest of the hand and straighten the thumb for grasping. Anatomic variation in this compartment is the rule, not the exception, and this may play a major role in the disease process.1 Knowledge of this variability is important for adequate surgical decompression and prevention of postoperative complications. A myriad of variations have

FIGURE 6. After exploration and retraction of the EPB, a search is made volarly for an intracompartmental septum.

FIGURE 8. Our incision left a reasonable amount of compartment cuff to prevent volar subluxation.

FIGURE 7. The tendons are hooked and pulled out of the tunnel to ensure their complete decompression; tension is placed on each of the tendons to simulate their functions.

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Conversely, no benefits ensue from extending the transverse incision.

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SUMMARY

In our experience, the longitudinal incision for release of the first extensor compartment for de Quervain tenosynovitis is a safe and effective technique that provides good exposure, protects vital structures, prevents possible tendon subluxation in the postoperative period, and is cosmetically acceptable.

n FIGURE 9. Comparison of the transverse and longitudinal skin incision for de Quervain release. There was no significant difference in cosmetic appearance.

been described, including multiple slips of the APL, accessory tendons of the EPB, anomalous insertions, and separate canals within the first dorsal compartment (septum formation).10–12 Recognition of the variations is important to obtain complete release of the first dorsal compartment. Failure to appreciate the presence of a separate compartment for the EPB (septum) may lead to the false assumption that one of the multiple APL tendon slips represents the EPB. Therefore, the mere opening of the first extensor compartment and the finding of 2 tendons or more can not assure the surgeon that complete decompression has been accomplished. If injections fail, it is likely that the tendon of EPB lies in a separate compartment, which should also be decompressed.8,9 Postoperative complications are rare and include damage to the superficial branch of the radial nerve, painful neuroma with radial sensory nerve deficit, adherence of the nerve branches to the fascia, scar hypertrophy, extensor tendon adherence, incomplete release with persistent symptoms, and palmar tendon subluxation.2,10,13,14 Muskart stated that, in surgical decompression, a longitudinal incision was mandatory to avoid complications because of the ease of searching for septum and aberrant tendons.2 Although the transverse wrist incision produces an acceptable scar, the diminished visualization in exploring the tendon and compartment variations (septum between APL and EPB) and nerve branches are major drawbacks in our opinion. In our opinion, the ideal surgical approach to the first dorsal compartment should afford good exposure of the entire radial aspect of the wrist. The incision should also be easily extended should an unanticipated situation be encountered, such as anatomic variations. In our opinion, the best visualization of the structures in the operation field is obtained by longitudinal incision.

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REFERENCES

1. Minamikawa Y, Peimer CA, Cox WL, et al. De Quervain’s syndrome: surgical and anatomical studies of the fibroosseous canal. Orthopedics. 1991;14:545–549. 2. Arons MS. De Quervain’s release in working women: a report of failures, complications, and associated diagnoses. J Hand Surg [Am]. 1987;12:540–544. 3. Nagaoka M, Matsuzaki H, Suzuki T. Ultrasonographic examination of de Quervain’s disease. J Orthop Sci. 2000;5:96–99. 4. Berger RA, Weiss APC. Hand Surgery. Philadelphia: Lippincott Williams & Wilkins, 2004, pp 787–790. 5. Witczak JW, Masear VR, Meyer RD. Triggering of the thumb with de Quervain’s stenosing tendovaginitis. J Hand Surg [Am]. 1990;15:265–268. 6. McMahon MS, Posner MA. Triggering of the thumb due to stenosing tenosynovitis of the extensor pollicis longus: a case report. J Hand Surg [Am]. 1994;19:623–625. No abstract available. 7. Grundberg AB, Reagan DS. Pathologic anatomy of the forearm: intersection syndrome. J Hand Surg [Am]. 1985;10:299–302. 8. Witt J, Pess G, Gelberman RH. Treatment of de Quervain tenosynovitis. A prospective study of the results of injection of steroids and immobilization in a splint. J Bone Joint Surg Am. 1991;73:219–222. 9. Harvey FJ, Harvey PM, Horsley MW. De Quervain’s disease: surgical or nonsurgical treatment. J Hand Surg [Am]. 1990;15:83–87. 10. McMahon M, Craig SM, Posner MA. Tendon subluxation after de Quervain’s release: treatment by brachioradialis tendon flap. J Hand Surg [Am]. 1991;16:30–32. 11. Leslie BM, Ericson WB Jr, Morehead JR. Incidence of a septum within the first dorsal compartment of the wrist. J Hand Surg [Am]. 1990;15:88–91. 12. Louis DS. Incomplete release of the first dorsal compartment— a diagnostic test. J Hand Surg [Am]. 1987;12:87–88. 13. Littler JW, Freedman DM, Malerich MM. Compartment reconstruction for de Quervain’s disease. J Hand Surg [Br]. 2002;27:242–244. 14. White GM, Weiland AJ. Symptomatic palmar tendon subluxation after surgical release for de Quervain’s disease: a case report. J Hand Surg [Am]. 1984;9:704–706.

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Ó 2005 Lippincott Williams & Wilkins, Philadelphia

T E C H N I Q U E

Elbow Arthroplasty Using a Convertible Implant Gregory D. Gramstad, MD Department of Orthopaedic Surgery Washington University School of Medicine St Louis, MO

Graham J. W. King, MD, MSc, FRCSC Hand and Upper Limb Centre Division of Orthopaedic Surgery University of Western Ontario London, Ontario, Canada

Shawn W. O’Driscoll, PhD, MD Department of Orthopedic Surgery Mayo Clinic and Mayo Foundation Rochester, MN

Ken Yamaguchi, MD Shoulder and Elbow Service Department of Orthopaedic Surgery Washington University School of Medicine Saint Louis, MO

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ABSTRACT

Total elbow arthroplasty remains the most definitive functional procedure for patients with end-stage painful arthritis of the elbow. Complication rates have historically been quite high, and early revision was not uncommon. A greater understanding of elbow anatomy and kinematics has led to advances in prosthetic design and surgical technique. The success of modern elbow arthroplasty for low-demand patients with rheumatoid arthritis has approached that of hip and knee arthroplasty. Mechanical failures have been noted to increase as a complication of both longevity and the use of elbow arthroplasty in a younger, higher-demand patient population. As the indications for total elbow arthroplasty widen to include more complex situations, it becomes more important to precisely recreate the flexion–extension axis of the elbow to optimally balance muscle forces and ligaments in an effort to improve implant durability. Advances in implant modularity and instrumentation can make determination and recreation of the flexion–extension axis more reliable and reproAddress correspondence and reprint requests to Graham J. W. King, Hand and Upper Limb Centre, St Joseph’s Healthcare London, 268 Grosvenor Street, London, Ontario N6A 4L6, Canada. E-mail: gking@ uwo.ca.

ducible. An anatomic convertible implant allows the surgeon great versatility in choosing to perform hemiarthroplasty or unlinked or linked total elbow arthroplasty with assurance that later revision can be performed without the compulsory removal of well-fixed components. Conversion from an unlinked to a linked constraint, and visa versa, can be performed at any time. If late conversion is required, it can be performed in a minimally invasive fashion. Keywords: elbow, arthritis, arthroplasty, convertible, linked, unlinked

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HISTORICAL PERSPECTIVE

Advanced arthritis of the elbow was historically managed with resection or interposition arthroplasty. Early attempts at hemiprosthetic replacement were largely unsuccessful. Dee, in 1972, was the first to report the use of total elbow arthroplasty in the English literature.1 Initial designs were fully constrained. The fixed-hinge design transferred stress directly to the prosthetic interface, resulting in high rates of aseptic loosening and limited prosthetic survival. Unlinked resurfacing prostheses were subsequently designed in an attempt to address this problem of loosening. These prostheses had variable amounts of intrinsic

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constraint and relied primarily on the soft tissue envelope for stability. A significant incidence of postoperative instability was reported and felt to be secondary to surgical inexperience and deficiencies in component instrumentation and design.2–6 The study of elbow anatomy and kinematics in recent years has improved significantly the science of elbow prosthetic design. Contemporary linked prostheses have a ‘‘loose-hinge’’ mechanical linkage that more accurately replicates the semiconstrained kinematics of the native elbow. The physiologic rotational and varus/valgus forces that occur during normal flexion and extension are ideally dissipated through the soft tissues rather than through the mechanical articulation or the stem fixation. If the soft tissue envelope is balanced, and the components are properly positioned, functional laxity is less than structural laxity.7 This leads to a reduction in prosthetic end-range impingement and may reduce the incidence of polyethylene bushing wear, osteolysis, and aseptic loosening. An anterior flange has also been added to the humeral component of some linked designs in an effort to resist the posterior and rotational displacement forces thought to contribute to early loosening. Advances in unlinked prosthetic design have favored a more anatomic ulnohumeral articulation. When properly positioned and balanced, an unlinked arthroplasty can restore near-normal kinematics of the elbow.8–12 Some implants have been employed with greater articular constraint, and these, while decreasing instability, have paradoxically led to a recurrence of loosening.9,13 The

addition of a radial head prosthesis has the theoretical advantage of improving elbow stability and reducing valgus forces at the ulnohumeral articulation by balancing the load distribution across the elbow joint (Fig. 1). In fact, radial head replacement is recommended as an important factor for stability in some unlinked prostheses.8,12,14 Good results have been reported after total elbow arthroplasty for rheumatoid arthritis with both linked and unlinked designs. Patient satisfaction and long-term revision-free survival approach those of hip and knee arthroplasty in the rheumatoid population.15–17 Advances in surgical technique and prosthetic design have broadened the indications for total elbow arthroplasty for use in younger patients and other diagnoses. The higher functional demands and activity level in the younger rheumatoid patient and those with osteoarthritis have further stressed the need for a more flexible, higher-demand total elbow. The importance of restoring the anatomic axis of rotation and the soft tissue balance is paramount in recreating normal elbow kinematics, postponing mechanical failures, and possibly improving prosthetic longevity. Most recently, the concepts of prosthetic modularity and convertibility have been investigated. The Tornier Latitude and DePuy Acclaim total elbow systems currently offer these options. Alignment jigs and modular components can assist in recreating the center of rotation and soft tissue balance required for proper component tracking. The Latitude system can also accommodate the retention or replacement of the radial head. Hemiarthroplasty of the distal humerus is also possible with

FIGURE 1. Much of the force across the elbow joint is transmitted through the radiocapitellar joint. When the radial head is resected, the entire load is shifted to the ulnohumeral joint, creating increased contact stresses. In addition to its role in stabilizing some implant systems, radial head replacement is also employed to balance the load distribution across the elbow and decrease wear (MA, mechanical axis).

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modular anatomic components, which are available for the reconstruction of osteopenic, comminuted fractures of the distal humerus in elderly patients (Fig. 2). Late conversion to a total elbow arthroplasty is possible without the removal of well-fixed components. A convertible prosthesis would also allow for the minimally invasive conversion of an unlinked to a linked articulation, and vice versa, without the need for extensive implant revision.

FIGURE 2. Anatomic humeral hemiarthroplasty for distal humerus fracture. An anatomic distal humeral spool can accommodate the native olecranon and radial head. Later conversion to total elbow arthroplasty can be performed without the removal of the well-fixed humeral stem by replacing the anatomic spool with an arthroplasty spool and placement of an ulnar component.

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INDICATIONS/ CONTRAINDICATIONS

Total elbow arthroplasty, whether linked or unlinked, is the most definitive functional procedure for end-stage elbow arthritis. Painful rheumatoid arthritis remains the most common indication for total elbow arthroplasty. Patients with complex nonunion, dysfunctional instability, periarticular tumors, and both primary and posttraumatic osteoarthritis have also been successfully managed with total elbow arthroplasty. More recently, complex acute intraarticular fractures of the distal humerus in elderly patients with osteopenia and comminution have become more frequent indications for total elbow arthroplasty.18,19 End-stage arthritis with disabling pain, stiffness, or instability that continues despite conservative treatment is the primary indication for TEA. Major contraindications include active sepsis, an inadequate soft tissue envelope, and a neuropathic elbow joint. Linked prostheses are currently the ‘‘gold standard’’ in the United States. They are indicated in most primary situations as well as when significant osseous or ligamentous deficiency exists. In the ideal situation, the static constraint of intact capsule and ligaments and the dynamic constraint of the muscular envelope prohibit the prosthesis from relying solely on its mechanical linkage for stability. Varying degrees of ligamentous attenuation and destruction of the osseous architecture complicate elbows with severe rheumatoid destruction, dysfunctional instability, posttraumatic arthritis, and cases of revision arthroplasty. Stress is therefore transferred directly through the linkage to the prosthetic interface. Implant stress is further increased by a failure to reconstitute the normal flexion–extension axis of the elbow. Aseptic loosening and bearing wear are primary causes of failure, especially in the younger patient population. Linked arthroplasty should therefore be performed reluctantly in patients under 65, in those who demand continued heavy use of the limb, and in those who are unable to comply with the postoperative rehabilitation program. Unlinked arthroplasty with a semiconstrained ulnohumeral articulation has enjoyed success, primarily in Europe and Asia. The maintenance of bone stock and the potential for decreased polyethylene wear and aseptic loosening have made the unlinked design a favorable alternative for younger patients who are likely to require future revision. Patients with insufficient bone stock, advanced osseous deformity, gross instability, or capsuloligamentous insufficiency are poor candidates for unlinked arthroplasty. The decision to incorporate a radial head replacement, when available, or to keep the native radial head, when possible, should be based on the intraoperative assessment of radiocapitellar and proximal radioulnar

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alignment. Proximal radial anatomy is complex and difficult to recreate with current prostheses.20,21 A bipolar radial head is one approach that can be used to accurately maintain the radiocapitellar and lesser sigmoid notch relationships. Of course, the humeral prosthesis must provide an articulation to accommodate the radial head or its replacement. If intraoperative or late instability is recognized with unlinked arthroplasty, ligamentous reconstruction or conversion to a linked articulation is indicated. Some cases of dysfunctional instability or posttraumatic arthritis require arthroplasty and ligament reconstruction. The need for prosthetic stability during healing of the ligament reconstruction is a relative contraindication to primary unlinked arthroplasty. An undesirable degree of stiffness can accompany postoperative casting, and bracing can be unreliable. The possibility currently exists for the implantation of a linked arthroplasty, for initial stability allowing early motion, with later conversion to an unlinked articulation after ligament healing through a minimally invasive approach.

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The surgical technique for the Latitudeä (Tornier, Stafford, TX) is outlined. The patient is positioned supine with the arm across the chest. A sterile tourniquet is employed because it allows more proximal exposure as necessary. Prophylactic antibiotics should be administered before tourniquet inflation. A straight posterior incision is used and centered just medial to the tip of the olecranon. Full-thickness flaps are developed medially and laterally, as necessary, on the deep fascia to preserve the cutaneous blood supply. The ulnar nerve is identified, carefully mobilized and transposed anteriorly into a subcutaneous pouch. The medial intermuscular septum is identified and excised to relieve a potential site of nerve tethering.

The management of the triceps tendon varies. A tricepson approach will spare the insertion from the risk of rupture and postoperative weakness but sacrifices visualization when bone loss is minimal. Elevation of the triceps from medial to lateral, as in the Bryan-Morrey tricepssparing approach, or lateral to medial, as in the extended Kocher approach, should be performed with care to raise periosteal flaps and maintain continuity of the triceps with forearm fascia.22–24 The triceps splitting approach divides the muscle–tendon unit centrally to the tip of the olecranon and distally over the proximal ulna. Sharp subperiosteal dissection releases Sharpey fibers from the olecranon in full-thickness fashion to preserve the sleeve of insertion for later repair. The tendon is reflected medially and laterally, maintaining continuity with the flexor carpi ulnaris and anconeus, respectively. The medial and lateral collateral ligaments and their corresponding muscular sleeves are sharply released from the epicondyles. The collateral ligament origins are tagged for later repair. At this point, joint dislocation is easily achieved. Sizing of the distal humerus is done by matching the correct anatomic spool size to the patient’s anatomy. Four spool sizes are available (small, medium, large, and large-plus). The anatomic spool should also be placed into the trochlear notch of the ulna to assess fit (Fig. 3). The capitellum should align precisely with the radial head. When size falls in between sizes, the smaller spool is preferred. The reproduction of the center of the flexion–extension axis is crucial to a successful result. All subsequent steps are based on the accurate determination of this axis. The lateral point of isometry is the center of the capitellar arc, when visualized from a lateral viewpoint (Fig. 4). Medially, the anterior and inferior base of the epicondyle, at the center of the trochlea, represents the isometric point of the anterior band of the medial collateral ligament origin and the center of the flexion–extension axis.25 The axis drill guide is placed so that the axis pin will

FIGURE 3. The anatomic spool is (A) sized against the native distal humerus and then (B) placed into the trochlear notch of the olecranon to assess fit. The radial head must align precisely with the prosthetic capitellum. When the anatomy falls between sizes, the smaller spool size is preferred.

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FIGURE 4. The center of the elbow flexion axis has an average 6-mm anterior offset from the humeral diaphyseal axis. Recreation of this flexion axis is crucial to producing a balanced arthroplasty throughout a full arc of motion. Modularity allows for a more accurate recreation of the patient’s native offset. (Reproduced with permission from Tornier Inc., Stafford, TX.)

bisect the center of rotation through the lateral isometric point and the base of the medial epicondyle at its anterior and inferior junction with the trochlea (Fig. 5). The bracket on the guide is tilted 45 degrees anterior to the coronal plane when properly positioned. Care should be taken to remove medial trochlear osteophytes and soft tissue at the base of the medial epicondyle to allow the

guide to sit flush. Residual medial epicondyle osteophyte and soft tissue will deflect the axis anteriorly and distally. Although an acceptable margin for error is not exactly known, the axis pin should probably be redrilled if a second hole is required to correct the axis (2–3 mm). Distal humeral preparation can be performed before or after axis determination. One advantage to removing the central portion of the distal humerus before axis pin placement is the ability to verify that the axis pin is placed in the center of the capitellum and trochlea. The cut surfaces of the trochlea and capitellum are flat and round and may make determination of central pin placement easier. To prepare the distal humerus, the trochlea is resected to the level of the proximal olecranon fossa (Fig. 6). If a sagittal saw is used, care must be taken to not ‘‘overcut’’ the corners to reduce the likelihood of a condylar fracture. The humeral medullary canal is opened with a burr and the diaphyseal reamer. Distal humeral offset in the sagittal plane should be determined by measuring the distance between the medullary alignment rod and the axis pin. Cutting blocks are then used to make precise distal humeral cuts based on the both intramedullary and flexion–extension axes. The humeral canal is then broached to the size previously determined by the anatomic spool. The broach is 1 size larger than the implant to ensure an adequate cement mantle. If the appropriate broach cannot be safely impacted but the previous smaller size broach was placed without difficulty, the appropriate final implant size can still be safely inserted. The appropriate spool side, size, and offset are fixed to the predetermined stem side and size, and the trial is inserted to seat flush with the bone. Radioulnar preparation is facilitated with a cutting guide also based on the flexion–extension axis. The anatomic spool and the ulnar diaphyseal axis are used to align the guide. The anatomic spool is placed in the radial notch and carefully aligned with the radial head (Fig. 7). The alignment of the radiocapitellar joint ensures accurate rotation of the proximal ulnar cut. The forearm axis pin sets the varus/valgus cut of the trochlear notch and the obliquity of the radial neck cut. Attention to detail is required while securing the guide to the proximal ulna to maintain these important relationships.

FIGURE 5. A, The axis pin is drilled through the flexion axis from the center of the capitellum laterally to the anteroinferior base of the medial epicondyle. B, The axis drill guide is placed on the axis pin with a 45-degree anterior tilt in the coronal plane.

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FIGURE 6. The humeral drill guide is positioned on the distal humerus with the aid of the medullary alignment rod and the axis pin. The holes are drilled and then connected with an osteotome. If a sagittal saw is used, care should be taken to avoid overcutting the corners and weakening the remaining epicondylar bone. (Reproduced with permission from Tornier Inc., Stafford, TX.)

A triceps-on jig is available for radioulnar preparation when the triceps has not been released. The decision to keep or replace the radial head is made based on its condition and the ability to precisely align the radiocapitellar joint. If the radial head is to be replaced, a sagittal saw resects the proximal radius, and the bell saw is used to cut the ulna from lateral to medial. If the radial head is to be preserved, the ulnar cutting guide is reversed, and the ulnar cut is made from medial to lateral. The bell saw should be continuously irrigated to prevent thermal injury to the bone. The ulnar canal is then opened and broached to the desired size. The posterior flat spot on the proximal ulna is used to assist in guiding the broach to the proper amount of axial rotation. A pin placed through the hole in the ulnar broach handle should be seen to bisect the radial head when broach rotation is correct. The ulnar canal is then reamed if a standard length stem is desired. The decision to use a short or standard stem is based

on the pathoanatomy of the diseased elbow. A short stem may be desired in primary unlinked arthroplasty to preserve bone stock. A standard stem should probably be used in linking the prosthesis or in revision situations. Reaming for a standard ulnar stem should be done cautiously to avoid dorsal or lateral cortical perforation. Using flexible reamers and removing the tip of the olecranon with a rongeur can decrease this risk. The appropriate ulnar trial is then selected and seated flush with the ulnar cut. Rotational malpositioning can be caused by not respecting the radial bow of the ulna during broaching or impinging bone in the olecranon. Repeat broaching or burring of the trochlear notch cut, respectively, should allow for proper implant seating. The radius is then broached, and the appropriate size radial head trial is placed. The bipolar radial head accommodates ± 10 degrees of angular motion but will not compensate for malalignment of the radiocapitellar articulation. Trial reduction of the components and replacing the triceps in an anatomic position should allow for an assessment of elbow alignment, stability, range of motion, and component tracking. A decision to proceed with unlinked or linked insertion is made based on patient factors and the pathoanatomy and stability of the elbow. If a linkage is required or desired, the trial ulnar cap is placed, and an assessment of stability is repeated (Fig. 8). If the radial head was resected but maltracking or malalignment exists and cannot be corrected, radial head replacement should not be performed, and the implant should be linked. Preparation for final implantation requires assembly of the modular components. A cannulated screw affixes the spool to the humeral component. Cement restrictors are placed, and pulsatile irrigation is used to clear the intramedullary canals of blood and debris. Antibioticladen cement is used to precoat the component stems and then pressurized into the ulna and radius and then into the humerus either simultaneously or as a second stage. The ulna is impacted flush with the bone cut. The distal humeral trial with the anatomic spool is used to assist in the determination of insertion height of the

FIGURE 7. A, The anatomic spool is used to align the ulnar cutting jig. Precise alignment of the radiocapitellar joint ensures proper rotation of the ulnar cut. B, The jig is securely mounted to the ulnar diaphysis and guides the radial neck and ulnar cuts. If the radial head is to be preserved, the ulnar cutting guide is reversed, and the ulnar cut is made with the bell saw from medial to lateral.

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FIGURE 8. A, The unlinked ulnohumeral arthroplasty. B, A linkage can be performed at any time by introducing an ulnar cap. C and D, The linked ulnohumeral components can accommodate the native radial head or a bipolar radial head prosthesis. (Reproduced with permission from Tornier Inc., Stafford, TX.)

radial head. It is crucial that the ulnar and radial head components are seated at the same level. A wedge of autologous bone graft from the resected distal humerus is placed under the anterior humeral flange. If the prosthesis is to be unlinked, the ulnar screw is retained to prevent cement intrusion or fibrous tissue ingrowth into the threads, making later conversion to a linkage difficult (Fig. 9). When a linkage is desired, the ulnar screw is removed after cement hardening, and the ulnar cap is placed and tightened with a torque-limiting screwdriver. A locking stitch is used to repair the collateral ligaments and muscular origins. Free suture ends from the collateral ligaments can be passed through the cannulated humeral bolt for an isometric repair. The suture ends can also be passed and tied around the ulna as further protection against postoperative instability. The triceps is repaired with heavy braided suture in locking fashion to itself and through drill holes in the ulna. The tourniquet is released before closure to achieve hemostasis. Drains are placed, and a sterile dressing applied. The elbow is placed in a well-padded splint in full extension and elevated for 3 days.

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Postoperative rehabilitation should focus on early motion as the wound allows. Avoiding flexion contracture requires the patient to be committed to a program of exercises. Active extension and strengthening are delayed

until triceps healing has occurred. Immediate active extension can be performed when a triceps-on approach is used. Most exercises can be taught by a therapist during the inpatient stay and continued with the aid of a family member or friend at home. Rarely is formal therapy required. Some surgeons prefer a sling or daytime resting splint with the elbow at 90 degrees for use between periods of therapy for 6 weeks to protect the limb. Elbows are initially splinted in full extension and elevated for 3 days. If the wound appears dusky, splinting should be continued in less flexion until the wound declares itself. As the wound allows, active flexion and gravity-assisted passive extension exercises are instituted after splint removal. Active extension can be performed immediately, however, when a triceps-on approach has been used. Forearm rotation is performed with the elbow in 90 degrees of flexion for 6 weeks to protect the collateral ligament repair. An anterior night extension splint can be used immediately for 6 weeks. After 6 weeks, a patient-controlled dynamic extension splint can be used to treat residual contracture. In triceps-reflecting approaches active extension can be instituted at 6 weeks, but light strengthening should not be instituted until at least 10 weeks. Return to full activity can be recommended after 12 weeks, although permanent restrictions should be emphasized. Repetitive lifting greater than 1 kg is not recommended, and lifting anything greater than 5 kg should be strongly discouraged. It is important that the patient understand these

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FIGURE 9. A and B, AP and lateral radiographs of a left elbow with rheumatoid arthritis. Periarticular osteopenia, loss of joint space, and subchondral resorption without gross deformity can be seen. C and D, Postoperative images taken at 6 months demonstrate an unlinked total elbow arthroplasty with a bipolar radial head replacement and a short ulnar stem. Bone graft placed under the anterior flange can be seen on the lateral image. E–H, Clinical images taken 6 months after arthroplasty demonstrate nearly normal and symmetric range of motion.

long-term restrictions before the surgical intervention to avoid early implant failure.

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The success of any procedure is largely dependent on providing sustained relief of symptoms and on the

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avoidance of complications. Elbow arthroplasty has historically been plagued by a high rate of complications.17 Morrey explains that ‘‘the elbow is a complex joint that is poorly covered by soft tissue, intimately traversed by a major nerve, and the source of significant arthritis in patients at risk of developing complications.’’22 Although

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Elbow Arthroplasty Using a Convertible Implant

some complications, such as wound breakdown, deep sepsis, triceps insufficiency, and ulnar neuropathy, are inherent in any elbow arthroplasty procedure, other complications are specific to implant design. Linked arthroplasty is more frequently associated with aseptic loosening and mechanical failure, whereas unlinked resurfacing designs are more prone to instability. The more ‘‘constrained’’ unlinked designs are susceptible to the problems of both, in proportion to their level of ulnohumeral articular constraint. Complications associated with radial head replacement are inherent to designs that can accommodate the radiocapitellar articulation. Osteolysis is a complication that is usually related to polyethylene wear and the design of the articulation. It also occurred with a PMMA precoat ulnar stem of the Coonrad-Morrey prosthesis.26 Wound-healing problems can be largely avoided by meticulous surgical technique and hemostasis. Patient factors should be addressed medically before intervention, and prior surgical incisions respected when possible. Drains and postoperative splinting can minimize hematoma and tension on the wound during the critical early stages of healing. Full-thickness flaps should be elevated from the deep fascial layers. Early signs of wound necrosis should be evaluated for flap reconstruction before deep sepsis ensues. Patient-related factors and the tenuous soft tissue envelope make total elbow arthroplasty particularly susceptible to deep sepsis. Patients with rheumatoid disease are often immunocompromised by their medical treatment, and patients who have undergone previous reconstruction may present with avascular bone, scar tissue, and occult infection. In large reported series of elbow arthroplasty for rheumatoid arthritis, deep infection has been reported to occur in approximately 2% to 5% of elbows.16,17,27–29 Deep infection complicates 5% to 11% of posttraumatic elbows, most having undergone previous surgery.30–33 Prosthetic retention is possible, but multiple debridements and/or resection arthroplasty can be the unfortunate consequence of infection after TEA, especially when the infecting organism is Staphylococcus epidermidis.34 It has been suggested that the use of antibiotic-impregnated cement for fixation may reduce the incidence of this potentially devastating complication.16,32,33 Triceps insufficiency or avulsion occurs in up to 11% of patients.16,31,35 Methods of careful release and secure fixation may decrease this complication. The meticulous release of Sharpey fibers from the proximal ulna should prevent excessive buttonholing of the triceps whether the triceps is split or reflected as a sleeve. On repair, the extensor mechanism should be grasped with heavy braided suture and repaired with locking stitches through bone tunnels in the olecranon. Refraining from active extension for at least 6 weeks should allow for early tendon healing to occur. A triceps-on approach, though more

technically challenging, could decrease the rate of these complications.36,37 Ulnar neuropathies are not uncommon in patients with elbow arthritis presenting for arthroplasty.28,35,38,39 Osteophytes, pannus invasion, and scar tissue can produce varying degrees of neuropraxia. Resolution is unreliable after arthroplasty surgery, with early ulnar nerve neuropraxia reported in up to 26% of elbows and up to 10% suffering permanent dysfunction.17,27–29,31,35,40,41 Postoperative ulnar nerve dysfunction can be exacerbated by devascularization of the transposed nerve segment, persistent proximal or distal tethering, or prolonged intraoperative dislocation when the nerve is inadequately released.42 Failing to transpose and protect the ulnar nerve during prolonged and repetitive elbow dislocation can lead to ulnar dysfunction as well. Ulnar neurolysis at the cubital tunnel should be performed before elbow dislocation with care taken to preserve the blood supply when possible. Intraoperative fractures of the humeral and ulnar shafts can occur.9,31 Excessive diaphyseal bowing, osteopenic bone, and the use of longer stems are important risk factors for this complication. Periprosthetic fractures secondary to aseptic loosening need to be addressed with revision arthroplasty with or without impaction grafting or cortical struts. Unrecognized posterior cortical penetration of the humerus can lead to cement extravasation and thermal injury to the radial nerve when the nerve is not identified and protected.26 Intraoperative condylar fractures are particularly important with unlinked designs and require secure fixation. The importance of condylar integrity in linked designs has been questioned.43 However, in our opinion, loss of the condyles increases the load on the bushing, which is no longer protected by the compressive muscular forces across the elbow. When the condyles are resected or deficient, it is important to suture the common flexor and extensor muscle origins to the triceps fascia for anchorage as well as for dynamic stability and soft tissue coverage of the implant.44 Aseptic loosening is primarily a complication of activity level, implant constraint, and imbalance across the elbow. The development of a loose linkage and an anterior flange have markedly decreased the rates of aseptic humeral loosening.16,45 Ulnar component debonding and loosening can occur during hyperflexion stress with linked implants. With the resultant increase in prosthetic longevity and the use of elbow arthroplasty in younger patients, mechanical failure has increased.33,44 Implant fracture and excessive polyethylene wear are more likely with heavy use of the limb and noncompliance with postoperative restrictions. Unlinked designs have historically had problems with instability. Their design relies on the competency of the capsule, ligaments, and muscle and the support of

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the bony architecture. Capsuloligamentous insufficiency, bone loss, and component malposition can predispose the prosthesis to maltracking, subluxation, or dislocation. Balancing the soft tissues requires experience.27,28 Advances in prosthetic design have led to an ulnohumeral articulation with greater contact surface area and the addition of a radiocapitellar articulation. Balancing load distribution across both the ulna and radius should improve prosthetic survival. If the radial head is retained or replaced, precise tracking with the capitellum must be ensured, however. Maltracking of a radial head replacement can cause accelerated polyethylene wear or dislocation of a bipolar head. Finally, if precise tracking of the ulnohumeral joint cannot be achieved with an unlinked design, conversion to a linked prosthesis should be performed.

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4. O’Driscoll SW, King GJ. Treatment of instability after total elbow arthroplasty. Orthop Clin North Am. 2001;32:679– 695. ix. 5. Ring D, Koris M, Jupiter JB. Instability after total elbow arthroplasty. Orthop Clin North Am. 2001;32:671–677. ix. 6. Schuind F, O’Driscoll S, Korinek S, et al. Loose-hinge total elbow arthroplasty. An experimental study of the effects of implant alignment on three-dimensional elbow kinematics. J Arthroplasty. 1995;10:670–678.

8. Ramsey M, Neale PG, Morrey BF, et al. Kinematics and functional characteristics of the Pritchard ERS unlinked total elbow arthroplasty. J Shoulder Elbow Surg. 2003; 12:385–390. 9. Schneeberger AG, King GJ, Song SW, et al. Kinematics and laxity of the Souter-Strathclyde total elbow prosthesis. J Shoulder Elbow Surg. 2000;9:127–134. 10. King GJ, Itoi E, Niebur GL, et al. Motion and laxity of the capitellocondylar total elbow prosthesis. J Bone Joint Surg Am. 1994;76:1000–1008. 11. King GJ, Itoi E, Risung F, et al. Kinematic and stability of the Norway elbow. A cadaveric study. Acta Orthop Scand. 1993;64:657–663. 12. Inagaki K, O’Driscoll SW, Neale PG, et al. Importance of a radial head component in Sorbie unlinked total elbow arthroplasty. Clin Orthop. 2002;400:123–131. 13. Trail LA, Nuttall D, Stanley JK. Comparison of survivorship between standard and long-stem Souter-Strathclyde total elbow arthroplasty. J Shoulder Elbow Surg. 2002; 11:373–376. 14. Trepman E, Vella IM, Ewald FC. Radial head replacement in capitellocondylar total elbow arthroplasty. 2- to 6-year follow-up evaluation in rheumatoid arthritis. J Arthroplasty. 1991;6:67–77. 15. Trail IA, Nuttall D, Stanley JK. Survivorship and radiological analysis of the standard Souter-Strathclyde total elbow arthroplasty. J Bone Joint Surg Br. 1999;81:80–84. 16. Gill DR, Morrey BF. The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid arthritis. A tento fifteen-year follow-up study. J Bone Joint Surg Am. 1998; 80:1327–1335.

REFERENCES

1. Dee R, Sweetnam DR. Total replacement arthroplasty of the elbow joint for rheumatoid arthritis: two cases. Proc R Soc Med. 1970;63:653–655.

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3. Kudo H, Iwano K. Total elbow arthroplasty with a nonconstrained surface-replacement prosthesis in patients who have rheumatoid arthritis. A long-term follow-up study. J Bone Joint Surg Am. 1990;72:355–362.

7. O’Driscoll SW, An KN, Korinek S, et al. Kinematics of semi-constrained total elbow arthroplasty. J Bone Joint Surg Br. 1992;74:297–299.

The primary goal of total elbow arthroplasty is to reduce pain and restore function. Prosthetic longevity has historically been the limiting factor to long-term success. Advances in surgical technique and implant design have led to substantial improvements in this regard. Achieving hemostasis, practicing meticulous wound and extensor mechanism management, performing routine ulnar neurolysis, and using modern cement technique with antibiotic-laden cement are the most reliable ways to avoid early complications. The primary goal of the implant technique should be to preserve or reestablish the flexion-extension axis. The use of modular components and cutting jigs, based on the patient’s anatomy, can assist in reproducibly and precisely recreating the length– tension relationships in the collateral ligaments and muscular envelope. An anatomic radiocapitellar articulation should result in a more balanced distribution of load across the articulation. These factors should decrease the problem of maltracking, which can lead to instability, polyethylene wear, osteolysis, and loosening. If maltracking or instability does exist, an easy conversion from an unlinked to a linked articulation can be performed with a convertible implant in a minimally invasive fashion without the need to revise well-fixed components. Careful patient selection, meticulous surgical technique, and a well-prescribed program of rehabilitation should maximize the results and longevity of convertible total elbow arthroplasty.

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2. Davis RF, Weiland AJ, Hungerford DS, et al. Nonconstrained total elbow arthroplasty. Clin Orthop. 1982;171: 156–160.

17. Gschwend N, Simmen BR, Matejovsky Z. Late complications in elbow arthroplasty. J Shoulder Elbow Surg. 1996;5: 86–96.

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Elbow Arthroplasty Using a Convertible Implant 18. Kamineni S, Morrey BF. Distal humeral fractures treated with noncustom total elbow replacement. J Bone Joint Surg Am. 2004;86-A:940–947.

32. Kraay MJ, Figgie MP, Inglis AE, et al. Primary semiconstrained total elbow arthroplasty. Survival analysis of 113 consecutive cases. J Bone Joint Surg Br. 1994;76:636–640.

19. Garcia JA, Mykula R, Stanley D. Complex fractures of the distal humerus in the elderly. The role of total elbow replacement as primary treatment. J Bone Joint Surg Br. 2002;84:812–816.

33. Schneeberger AG, Adams R, Morrey BF. Semiconstrained total elbow replacement for the treatment of post-traumatic osteoarthrosis. J Bone Joint Surg Am. 1997;79:1211–1222.

20. Beredjiklian PK, Nalbantoglu U, Potter HG, et al. Prosthetic radial head components and proximal radial morphology: a mismatch. J Shoulder Elbow Surg. 1999;8: 471–475. 21. King GJ, Zarzour ZD, Patterson SD, et al. An anthropometric study of the radial head: implications in the design of a prosthesis. J Arthroplasty. 2001;16:112–116. 22. Morrey BF, Bryan RS. Complications of total elbow arthroplasty. Clin Orthop. 1982;170:204–212. 23. Bryan RS, Morrey BF. Extensive posterior exposure of the elbow. A triceps-sparing approach. Clin Orthop. 1982;166: 188–192. 24. Weiland AJ, Weiss AP, Wills RP, et al. Capitellocondylar total elbow replacement. A long-term follow-up study. J Bone Joint Surg Am. 1989;71:217–222. 25. Duck TR, Dunning CE, King GJ, et al. Variability and repeatability of the flexion axis at the ulnohumeral joint. J Orthop Res. 2003;21:399–404. 26. King GJ, Adams RA, Morrey BF. Total elbow arthroplasty: revision with use of a non-custom semiconstrained prosthesis. J Bone Joint Surg Am. 1997;79:394–400. 27. Ikavalko M, Lehto MU, Repo A, et al. The SouterStrathclyde elbow arthroplasty. A clinical and radiological study of 525 consecutive cases. J Bone Joint Surg Br. 2002; 84:77–82. 28. Ewald FC, Simmons ED Jr, Sullivan JA, et al. Capitellocondylar total elbow replacement in rheumatoid arthritis. Long-term results. J Bone Joint Surg Am. 1993;75:498– 507.

34. Yamaguchi K, Adams RA, Morrey BF. Infection after total elbow arthroplasty. J Bone Joint Surg Am. 1998;80:481– 491. 35. Kelly EW, Coghlan J, Bell S. Five- to thirteen-year follow-up of the GSB III total elbow arthroplasty. J Shoulder Elbow Surg. 2004;13:434–440. 36. Morrey BF, Adams RA. Semiconstrained elbow replacement for distal humeral nonunion. J Bone Joint Surg Br. 1995;77:67–72. 37. Pierce TD, Herndon JH. The triceps preserving approach to total elbow arthroplasty. Clin Orthop. 1998;354:144– 152. 38. Spinner RJ, Morgenlander JC, Nunley JA. Ulnar nerve function following total elbow arthroplasty: a prospective study comparing preoperative and postoperative clinical and electrophysiologic evaluation in patients with rheumatoid arthritis. J Hand Surg [Am]. 2000;25:360–364. 39. Ikavalko M, Belt EA, Kautiainen H, et al. Souter arthroplasty for elbows with severe destruction. Clin Orthop. 2004;421:126–133. 40. Tanaka N, Kudo H, Iwano K, et al. Kudo total elbow arthroplasty in patients with rheumatoid arthritis: a long-term follow-up study. J Bone Joint Surg Am. 2001;83-A: 1506–1513. 41. Willems K, De Smet L. The Kudo total elbow arthroplasty in patients with rheumatoid arthritis. J Shoulder Elbow Surg. 2004;13:542–547. 42. Moro JK, King GJ. Total elbow arthroplasty in the treatment of posttraumatic conditions of the elbow. Clin Orthop. 2000;370:102–114.

29. van der Lugt JC, Geskus RB, Rozing PM. Primary SouterStrathclyde total elbow prosthesis in rheumatoid arthritis. J Bone Joint Surg Am. 2004;86-A:465–473.

43. McKee MD, Pugh DM, Richards RR, et al. Effect of humeral condylar resection on strength and functional outcome after semiconstrained total elbow arthroplasty. J Bone Joint Surg Am. 2003;85-A:802–807.

30. Figgie MP, Inglis AE, Mow CS, et al. Salvage of non-union of supracondylar fracture of the humerus by total elbow arthroplasty. J Bone Joint Surg Am. 1989;71:1058–1065.

44. Ramsey ML, Adams RA, Morrey BF. Instability of the elbow treated with semiconstrained total elbow arthroplasty. J Bone Joint Surg Am. 1999;81:38–47.

31. Hildebrand KA, Patterson SD, Regan WD, et al. Functional outcome of semiconstrained total elbow arthroplasty. J Bone Joint Surg Am. 2000;82-A:1379–1386.

45. Gschwend N, Scheier NH, Baehler AR. Long-term results of the GSB III elbow arthroplasty. J Bone Joint Surg Br. 1999;81:1005–1012.

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Intrafocal Pinning for Juxtaarticular Phalanx Fractures Carmen D. Crofoot, MD, Minn Saing, MD, and James Raphael, MD Department of Orthopaedic Surgery Albert Einstein Medical Center Philadelphia, PA

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ABSTRACT

Juxtaarticular phalanx fractures can present a challenge to the treating physician. Because they are not a common occurrence, we wanted to discuss our treatment protocol for this entity. Goals of treatment include anatomic realignment, fracture stability, and early range of motion. Improper treatment can lead to malunion resulting in deformity or loss of function as well as joint stiffness. Other treatment modalities can also result in unsatisfactory results including decreased range of motion. Intrafocal pinning provides a treatment alternative for the irreducible fracture normally requiring open intervention while satisfying the requirements of fracture stabilization and early range of motion. This technique has been used in 5 patients over the past 3 years without significant complications. Two patients had fractures involving their proximal phalanx, and 3 had middle phalangeal injuries. All patients healed their fractures and maintained functional range of motion (PIPJ 90 degrees, DIPJ 65 degrees). Keywords: phalanx fracture, percutaneous pinning juxtaarticular, technique

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Operative fixation for phalanx fractures was pioneered in the first decade of the 20th century by Albin Lambotte. His 1913 book Chirurgie Operatoire des Fractures details fixation of metacarpal and phalanx fractures with carpenter’s nails, wires, and screws in multiple configurations.1 Since that time, many methods for stable fixation of phalanx fractures have been developed. Although many phalanx fractures can be treated nonoperatively, irreducible or unstable fractures make operative intervention necessary. Closed reduction and pinning Address correspondence and reprint requests to Dr. Carman D. Crofoot, Department of Orthopaedic Surgery, Albert Einstein Medical Center, Philadelphia, PA 19141. E-mail: [email protected].

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using Kirschner wires was first introduced in the 1950s.2 This approach does not disrupt the fracture hematoma and can therefore have a positive effect on healing. The diameter of the wire used and the placement of the wires directly influence their stability. For transverse fractures, cross-wire fixation with 4 0.028 wires has been shown to be the most resilient in resisting distraction and torsion. Oblique fractures are best stabilized by wire placement perpendicular to the fracture site.3 Kirschner wires must be inserted carefully to avoid piercing neurovascular structures. These wires also have no compressive action, making it crucial that the fracture be reduced anatomically before their insertion.4 In cases in which appropriate reduction can not be achieved, open reduction should be used. However, when the open technique is used with any of the various implant choices, including Kirschner wires, plates, or interfragmentary screws, one must consider that the tendon must be able to glide over the implant site freely. Impingement of tendons, especially the extensor tendon, can lead to significant postoperative stiffness and pain, especially when substantial soft tissue injury has occurred whether from injury, surgical dissection, or implant.5 The implant may necessitate a second surgery for removal of hardware and tenolysis. There is minimal discussion in the literature regarding treatment options for juxtaarticular phalanx fractures because these are uncommon entities. Often, attempts at closed reduction are unsuccessful, and most surgeons would use an open reduction technique. This increases the chance of joint stiffness or decreased range of motion because of the soft tissue dissection. Intrafocal pinning offers another alternative to open management and can improve the chance for full functional range of motion.

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INDICATIONS/ CONTRAINDICATIONS

Indications include irreducible fracture normally requiring open intervention.

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Intrafocal Phalanx Pinning

FIGURE 1. Long middle phalanx juxtaarticular fracture, dorsally displaced.

Contraindications include severely contaminated wounds.

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The patient is dressed with sterile dressing, splinted, and instructed to follow up in 3 to 5 days. At the first postoperative visit, the dressings are removed. The patient is then sent to an occupational hand therapist from the office. There, the therapist constructs a protective splint that is forearm based with the wrist in 15 degrees of extension. The MCPJ is flexed to approximately 90 degrees, and the splint is continued out to the tip of the involved finger. The splint is for intermittent use to allow for the implementation of range-of-motion exercises. The patient is also started in a formal hand therapy program including instructions on range of motion at the PIPJ and DIPJ. Pin care consists of ‘‘benign neglect.’’ The patient is allowed to start showering once the postop dressings have been removed. The patient is instructed to pat the skin dry around the pin sites after showering. The patient is also instructed to avoid application of lotions, etc to the area around the pins. If the pin sites become crusty or soupy, then the use of half-strength hydrogen peroxide and water with a cotton swab is implemented. At the 4-week mark, the K wires are removed, and the patient is instructed to continue with range-of-motion exercises.

At the 8-week mark, this particular patient had a painless range of motion of 60 degrees at the DIPJ and 100 at the PIPJ with radiographic evidence of healing. Figures 1–8 depict the Intrafocal Pinning Procedure step by step.

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Potential complications include pin site infections, loss of reduction or pin fixation, and loss of motion or joint stiffness.

FIGURE 2. Closed reduction is attempted first. Traction is applied with attempted volar translation of the fragment.

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FIGURE 3. Under C-arm guidance, a 0.045 K-wire is introduced at the fracture site.

FIGURE 4. The K-wire is used as a joystick to lever the fracture fragment to its correct anatomic position.

FIGURE 5. The K-wire is used as a joystick to lever the fracture fragment to its correct anatomic position.

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FIGURE 6. With the 0.045 wire used to maintain reduction, percutaneous pinning will be performed using 0.035 K-wires. First, 1 wire is inserted just proximal to the DIPJ and directed distal to proximal and ulnar to radial.

FIGURE 7. The same process is repeated going in the radial-to-ulnar direction.

FIGURE 8. The 0.045 K-wire is removed. Anatomic reduction is confirmed, and stability is verified under fluoroscopy. All joints are unencumbered to facilitate early range of motion, which is initiated at the first postoperative visit.

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FIGURE 9. AP and Lateral views of the hand 6 weeks post-op revealing healed fracture.

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fixation for metacarpal and phalangeal fractures. J Hand Surg [Am]. 1985;10:144–150.

REHABILITATION

Supervised hand therapy includes range of motion accompanied by protective intermittent splinting. This therapy includes active and active assisted range of motion, edema control, pin care, and custom splint (forearm based, wrist in 15 degrees of extension, MCPJ flexed to approximately 90 degrees, and the splint is continued out to the tip of the involved finger.)

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3. Viegas SF, Ferren EL, Self J, et al. Comparative mechanical properties of various Kirschner wire configurations in transverse and oblique phalangeal fractures. J Hand Surg [Am]. 1988;13:246–253. 4. Kozin SH, Thoder JJ, Lieberman G. Operative treatment of metacarpal and phalangeal shaft fractures. J Am Acad Orthop Surg. 2000;8:111–121.

REFERENCES

1. Meals RA, Mueli HC. Carpenter’s nails, phonograph needles, piano wires, and safety pins: the history of operative

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2. Stern PJ. Fractures of metacarpal and phalanges. In: Green DP, ed. Operative Hand Surgery, 3rd ed. New York: Churchill Livingstone; 1993:695–758.

5. Diao E. Metacarpal fixation. Hand Clin. 1997;13:557– 571.

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Techniques in Hand and Upper Extremity Surgery 9(3):169–171, 2005

Ó 2005 Lippincott Williams & Wilkins, Philadelphia

C O M M E N T A R Y

Postoperative Management: Hand Therapy Program Following Intrafocal Pinning for Juxtaarticular Phalanx Fractures Margaret R. Tull, PT, CHT Moss Rehabilitation Outpatient Center Philadelphia, PA

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Intrafocal pinning is a fracture management technique for reduction and stabilization of juxtaarticular phalanx fractures. This technique provides fracture stability with minimal soft tissue disruption from surgery and allows early range of motion (ROM) of the interphalangeal joints. The purpose of this article is to discuss postoperative rehabilitation specific to the management of this fracture and fixation technique that facilitates early ROM, edema control, pin care, custom splinting, and therapeutic exercise. Keywords: finger, fracture, rehabilitation

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HISTORICAL PERSPECTIVE

Unstable phalanx fractures are a challenge for the hand surgeon and therapist. The orthopedic hand surgeons at our facility presented a unique technique to manage juxtaarticular phalanx fractures in the previous article of this issue.1 Juxtaarticular phalanx fractures can be unstable fractures that often require open reduction with internal fixation (ORIF) to assure good alignment. This uncommonly occurring fracture was seen in 5 patients at our facility, primarily in the younger patient population. Four adolescents and one adult were treated operatively with intrafocal pinning and were referred to hand therapy on their first postoperative visit with the surgeon. A custom forearm-based splint was molded with the wrist positioned in 15 degrees of extension. The involved and adjacent digits were included in the splint with the metacarpophanangeal joints (MCPJ) flexed 50 to 90 degrees (degrees of flexion to tolerance) and the interphalangeal joints (IPJ) in neutral extension. A molded splint was fabricated to provide protection of the pins as needed (Fig. 1). Address correspondence and reprint requests to Margaret R. Tull, Moss Rehabilitation Outpatient Center, Einstein Center One, Suite 328, 9880 Bustleton Avenue, Philadelphia, PA 19115. E-mail: [email protected].

The patients were instructed in an active range of motion (AROM), active-assisted range of motion (A/AROM) program for the involved digit and the adjacent digits (as needed). Early protected AROM is initiated to prevent adhesions, minimize joint stiffness, and promote tendon gliding. This fixation technique appears to provide sufficient stability to permit these controlled, protected range-of-motion exercises. The therapist should communicate with the referring surgeon to determine if and when early motion can be initiated. There is support in the literature for initiation of early motion in the inflammatory phase of bone healing if there is adequate fracture stabilization.2 There is additional support in the literature to initiate differential tendon-gliding exercises for the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) tendons. ‘‘This research suggests for proximal (P1) and middle phalanx (P2) fractures, flexor tendons need to achieve maximal differential glide to prevent restrictive adhesions with loss of

FIGURE 1. Thermoplastic forearm-based splint with wrist in approximately 15 degrees of extension; MCPJ is flexed to 50 degrees. The splint includes the involved and adjacent fingers.

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FIGURE 2. Blocking exercises for the PIPJ and DIPJ. The patient is instructed to apply gentle pressure for blocking, and finger position is modified as needed.

motion.’’3 An optimal fracture repair is one that ‘‘restores anatomy with a method permitting active IPJ motion with tendon gliding during healing.’’4 Gentle blocking exercises are directed to the proximal interphalangeal joint (PIPJ) and distal interphalangeal joint (DIPJ) (Fig. 2). These exercises are repeated 3 to 4 times daily, 10 repetitions each. AROM is not limited at the PIPJ because there is no disruption of the extensor mechanism. Patients are progressed to tendon gliding throughout the movement arc as ROM improves.

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CASE REPORT

The patient whose hand is pictured in Figure 3A is a 14-year-old boy with a juxtaarticular fracture at the head of the proximal phalanx of the ring finger. Surgical correction was done 13 days following injury. Figure 3B shows a reduced, pinned fracture at the first postoperative visit. Figure 3C portrays the fracture status after removal of pins at 5 weeks. As mentioned above, this patient was seen for custom splinting and instructed in range-of-motion

FIGURE 3. A, Initial injury films of 14-year-old with juxtaarticular fracture of the head of the proximal phalanx of the ring finger. B, Reduced, pinned fracture at first postoperative visit. C, Following removal of pins at 5 weeks after surgery.

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Postoperative Therapy After Pinning for Phalanx Fracture TABLE 1. Post Operative Rehabilitation Week 1

3 4

8

Activities Custom splint—worn full time, remove for exercise, 3–4 times daily Edema management—Intermittent use of elastic wrap as needed Pin care—use of half strength hydrogen peroxide and water with cotton swab, as needed Active range of motion—blocking exercises to involved digit Continue above program, progress AROM and add tendon glides Removal of pins Discontinue splint Begin passive range of motion—composite flexion Continue to progress tendon gliding AROM & PROM exercises, tendon gliding exercise Begin strengthening

exercises, as outlined (see Figs. 1 and 2). Table 1 depicts the twice-weekly hand therapy program, which includes edema management, pin care, and the range-of-motion progression. At the time of pin removal (5 weeks), passive range of motion (PROM) was initiated, and the splint was discontinued. Supportive modalities (superficial heat and cold) were used as needed. The patient was progressed to a strengthening program at 8 weeks postop, including theraputty exercises for gripping, finger extension, and the intrinsic musculature. Figure 4 shows the patient at 9 weeks, demonstrating full PIPJ extension and excellent hook and full fisting. This patient achieved pain-free motion of 0–95 degrees at the MCPJ, 0–95 degrees at the PIPJ, and 0–95 degrees at the DIPJ. His grip strength was R/L level I, 70/41; III, 100/61; and V, 79/49. A surgical technique that provides fracture stability and allows for early ROM combined with a supervised hand therapy program based on ‘‘temporal sequencing of when and what type of stress to apply to healing bone and soft tissues’’1 helped to promote functional healing.

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REFERENCES

1. Crofoot CD, Sainy M, Raphael J. Intrafocal pinning for juxtaarticular phalanx fractures. TIHUES. 2005;9:164–168. 2. LaStayo PC, Winters KM, Hardy M. Fracture healing: bone healing, fracture management, and current concepts related to the hand. J Hand Ther. 2003;16:81–93.

FIGURE 4. Same patient at 9 weeks postop demonstrating finger extension (A), hook fist (B), and full fist (C).

3. Hardy M. Principles of metacarpal and phalangeal fracture management: a review of rehabilitation concepts. J Orthop Sports Phys Ther. 2004;34:781–799. 4. Purdy B, Wilson RL. Management of nonarticular fractures of the hand. In: Hunter J, Mackin E, Callahan A, eds. Rehabilitation of the Hand and Upper Extremity, 5th ed. Philadelphia, PA: Mosby, 2002, pp 380–395.

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Techniques in Hand and Upper Extremity Surgery 9(3):172–174, 2005

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C O M M E N T A R Y

Suture Anchor Technique for Anatomic Reconstruction in Chronic Boutonni ere Deformity Yury A. Slesarenko, MD, Lawrence C. Hurst, MD, and Kenny Mai, MD Division of Hand Surgery Department of Orthopaedic Surgery State University of New York, University Hospital Stony Brook, NY

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HISTORICAL PROSPECTIVE

In chronic boutonniere deformity, the central slip of the extensor tendon may be disrupted or attenuated. Disruption of the central slip over the proximal interphalangeal (PIP) joint is accompanied by stretching of the triangular ligament, which allows the lateral bands to subluxate volarward. Palmar subluxation of the lateral bands accentuates the flexion posture of the PIP joint and creates hyperextension at the distal interphalangeal joint. If left untreated, the lateral bands become contracted, and a fixed flexion contracture of the proximal interphalangeal joint with hyperextension of the distal interphalangeal joint occurs. Reconstruction procedures for chronic flexible boutonniere deformities can be divided into three categories: tendon relocation, tenotomy, and tendon grafting. Mobilization and relocation of the adjacent extensor tendon has been described in different forms for treatment of chronic boutonniere deformity. Littler and Eaton described the chronic boutonniere deformity and a method of repair using the lateral bands, which are detached from the oblique retinacular ligament.1 The lateral bands are incised over the proximal and middle phalanges, transposed dorsally, and sutured to the insertion of the central slip. Burton and Melchior noted that this technique is not an option when the central slip is too attenuated to hold sutures.2 Many authors have reported their experience with resection of the attenuated central slip and direct repair of the central slip and lateral bands.3–7

Address correspondence and reprints to Yury A. Slesarenko MD, Department of Orthopaedics, HSC T-18, SUNY Stony Brook, Stony Brook, NY 11794-8191. E-mail: [email protected]. No benefits or funds were received in support of this manuscript. The authors report no actual or potential conflict of interest in relation to this article.

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The technique to be described represents our experience with the Littler tendon relocation technique, modified by using an anchor suture.

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INDICATIONS/ CONTRAINDICATIONS

This technique is indicated for flexible (passively correctable) chronic boutonniere deformities. The procedure is contraindicated if the PIP joint can not be fully and easily passively extended.

FIGURE 1. The dorsum of the finger is approached using a zigzag incision centered over the PIP joint.

Techniques in Hand and Upper Extremity Surgery

Lateral Popliteal Blocks for Postoperative Anesthesia

dorsum of the finger is approached using a zigzag incision that is centered over the PIP joint (Fig. 1). Blunt dissection is performed to the subcutaneous tissue. Small veins in the subcutaneous tissue are isolated and coagulated as the dissection proceeds down to the extensor tendon. The scar overlying the dorsum of the PIP joint is

FIGURE 2. (A) The central slip is excised, and an anchor suture is inserted into the dorsal base of the middle phalanx (see arrow). (B) The lateral bands are divided longitudinally over the middle phalanx (see arrows) and then flipped over to reinforce the central extensor slip.

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TECHNIQUE

After induction of anesthesia, the upper extremity is scrubbed, prepared, and draped in the standard sterile fashion. A finger is squeezed by an assistant, and Penrose drain applied to the base of the proximal phalanx as a tourniquet. Alternatively, a commercially available rubber ring or surgical glove can be used for simultaneous exsanquination of the finger and as a tourniquet. The

FIGURE 3. Posteroanterior (A) and lateral (B) x-ray films. The PIP joint is fixed in full extension using a 0.45 Kirschner wire that is passed from distal to proximal across the joint below the elevated lateral bands.

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FIGURE 4. (A) The relocated lateral bands are sutured to each other with a nonabsorbable 4.0 running suture (see arrow) and then into the insertion of the central slip using a previously inserted anchor suture (B) (see arrows).

excised. If the distal stump of the central slip is preserved and able to hold sutures satisfactorily, the Littler procedure (described above) is a reasonable option to consider. If the central slip is avulsed from its middle phalanx insertion or too attenuated to hold sutures, we consider it insufficient for purpose of surgical reconstruction and insert an anchor suture into the dorsal base of the middle phalanx to secure the repair (Fig. 2A). We use a 1.33mm microanchor with 4.0 Ethibond suture for this purpose. The lateral bands are then incised longitudinally over the middle phalanx and transposed to reinforce the central extensor slip (Fig. 2B). The PIP joint is fixed in full extension using a 0.45 Kirschner wire that is passed from distal to proximal across the joint below the elevated lateral bands (Fig. 3). The lateral bands are sutured to each other with a nonabsorbable 4.0 running suture and then into the insertion of the central slip using a previously inserted anchor suture (Fig. 4). Postoperatively, the finger and hand are supported in a hand dressing and a splint for 3 weeks. At 3 weeks, we remove the K-wire and splint the PIP joint dorsally in full extension, with the DIP and MP joints left free. After 4 weeks, gentle active motion may be initiated with the PIP joint splinted in extension between exercises for a total of 2 to 3 months after surgery.

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CONCLUSIONS

In our opinion, the Littler lateral band relocation technique is an adequate procedure to allow reliable transfer of extensor forces to the base of the middle phalanx when the distal stump of the central slip is preserved. If there is

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insufficient distal stump of the central slip into which to sew the relocated lateral bands, the extension forces bypass the PIP joint, minimizing the effect of the reconstruction. We believe that insertion of the anchor suture near to the PIP joint axis may have an advantage on joint biomechanics. In addition, use of the anchor suture may allow for better centralization of the relocated lateral bands over the PIP joint. We believe that an anchor is an easy additional intraoperative step that may allow for more anatomic reconstruction of chronic boutonniere deformity.

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REFERENCES

1. Littler JW, Eaton RG. Redistribution of forces in correction of boutonniere deformity. J Bone Joint Surg Am. 1967;49: 1267–1274. 2. Burton RI, Melchior JA. Extensor tendons—late reconstruction. In: Green DP, ed. Operative Hand Surgery, 4th ed. New York: Churchill Livingstone, 1999:1988–2021. 3. Grundberg AB: Anatomic repair of boutonniere deformity. Clin Orthop. 1980;153:226–229. 4. Elliott RA. Injuries to the extensor mechanism of the hand. Orthop Clin North Am. 1970;1:335–354. 5. Pardini AG, Costa RD, Morais MS. Surgical repair of the boutonniere deformity of the fingers. Hand. 1979;11:87–92. 6. Schneider LH, Smith KL. Boutonniere deformity. In: Hunter JM, Schneider LH, Mackin EJ, eds. Tendon Surgery in the Hand. St. Louis: CV Mosby, 1987:349–357. 7. Souter WA. The boutonniere deformity: A review of 101 patients with division of the central slip of the extensor expansion of the fingers. J Bone Joint Surg Br. 1967;49:710–721.

Techniques in Hand and Upper Extremity Surgery

Volume 9(3)

September 2005

(C) 2005 Lippincott Williams & Wilkins, Inc.

ISSN: 1089-3393

Viewing 1-9 of 9 Results pg. 125

01 Life-Long Learning. Jupiter, Jesse B [EDITORIAL] pg. 126-133

02 Algorithm for Treatment of Apert Hand. Guero, Stephane J MD [TECHNIQUE] pg. 134-141

03 Anatomic Basis of Dorsal Finger Skin Cover. Braga-Silva, Jefferson MD, PhD [TECHNIQUE] pg. 142-148

04 Fixed Angle Fixation of Distal Radius Fractures Through a Minimally Invasive Approach. Orbay, Jorge L MD; Touhami, Amel MD; Orbay, Carolina [TECHNIQUE] pg. 149-152

05 Longitudinal Incision in Surgical Release of De Quervain Disease. Gundes, Hakan MD 1; Tosun, Bilgehan MD 2 [TECHNIQUE] pg. 153-163

06 Elbow Arthroplasty Using a Convertible Implant. Gramstad, Gregory D MD 1; King, Graham J. W MD, MSc, FRCSC 2; O'Driscoll, Shawn W PhD, MD 3; Yamaguchi, Ken MD 4 [TECHNIQUE] pg. 164-168

07 Intrafocal Pinning for Juxtaarticular Phalanx Fractures. Crofoot, Carmen D MD; Saing, Minn MD; Raphael, James MD [COMMENTARY] pg. 169-171

08 Postoperative Management: Hand Therapy Program Following Intrafocal Pinning for Juxtaarticular Phalanx Fractures. Tull, Margaret R PT, CHT [COMMENTARY]

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09 Suture Anchor Technique for Anatomic Reconstruction in Chronic Boutonniere Deformity. Slesarenko, Yury A MD; Hurst, Lawrence C MD; Mai, Kenny MD [COMMENTARY]