Reconstruction of Traumatic Central Slip Injuries: Technique Using a Slip of Flexor Digitorum Superficialis

Central slip defect reconstruction utilizing partial ulnar side of flexor digitorum superficial tendon for chronic boutonniere deformity: A case report

Background

Post-traumatic central slip injuries, resulting in boutonniere deformity, are a complex issue that can significantly impact hand function and quality of life. The deformity should be easily reducible in the acute phase, but if left untreated, it shortens the oblique retinacular ligament, leading to chronic contracture. This is a challenging issue in hand surgery, as chronic central slip defects cannot be sutured like other tendon. Various methods for reconstructing central slips have been discussed, but the best method for subacute or chronic injuries remains unclear. This case presents a case of chronic traumatic boutonniere deformity with central slip defect reconstruction.

Case report

A 65-year-old male patient presented with swelling and boutonniere deformity on the digiti III of the right hand. The patient had previously fallen from a motorcycle, and the patient's right middle finger got was by a motorcycle six months ago. After the incident, the patient's right middle finger cannot be fully extended. The patient's right hand showed edema with flexion of the interphalangeal (PIP) joint and hyperextension of the distal interphalangeal (DIP) joint. The Range of Motion (ROM) of the PIP joint right middle finger was 45-110 degrees. The X-ray of the right hand AP/oblique showed no bone involvement in the deformity. The patient underwent central slip defect reconstruction utilizing the partial ulnar side of the flexor digitorum superficial tendon. A PIP joint extension splint was applied for 2 weeks. Active and passive exercise of the ROM of the PIP joint began after 2 weeks of PIP extension joint splinting. The patient's ROM of the PIP joint (0-90 degrees) significantly improved 1 month after surgery. The patient's ROM of the PIP joint returned to normal after 2 months after surgery. The function of the patient's right hand is evaluated with the DASH score, which improves significantly from 50 to 4.2.

Conclusion

Central slip defect reconstruction utilizing the partial ulnar side of the flexor digitorum superficial tendon is a reliable method for traumatic chronic boutonniere deformity and results in great functional outcomes after 2 months of follow-up. Central slip defect reconstruction utilizing the partial ulnar side of the flexor digitorum superficial tendon is a simple and cost-effective method compared to other methods.

Reconstruction of the central slip insertion of the extensor tendon with the partial slip of the flexor digitorum superficialis tendon

INTRODUCTION

To introduce the surgical approach and clinical effect of transferring the partial slips of the flexor digitorum superficialis (FDS) tendon to reconstruct the insertion of the central slip of the extensor tendon (CSET) through an established bone tunnel (BT).

MATERIALS AND METHODS

From April 2019 to March 2021, nine patients (six males and three females) with the CSET insertion rupture or defect were admitted to the institution and the CSET insertion was reconstructed with partial tendon slips on both sides of the FDS. The active range of motion of the interphalangeal joint of the affected finger was measured by a goniometer, the degree of pain was evaluated by visual analogue scale (VAS), and the grip strength of the affected limb was measured by an electronic hand dynamometer.

RESULTS

The average postoperative follow-up was 12 months. No complications occurred. At the last follow-up, six of the patients were very satisfied and three were satisfied with their recovery.

CONCLUSION

The reconstruction of the CSET insertion by transferring the partial tendon slips of the FDS seem to be safe and feasible with minimal invasion to the donor tendon.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Central Slip Reconstruction With a Distally Based Flexor Digitorum Superficialis Slip: A Biomechanical Study

PURPOSE

The ideal method of central slip reconstruction is difficult to determine due to the multitude of techniques, nonstandardized outcome reporting, and small patient series in the literature. Although most boutonniere deformities may be treated with nonsurgical measures, chronic, subacute, or open injuries may require operative intervention. To aid surgeons in the choice of the ideal central slip reconstruction method, this biomechanical study compared the 3 most common methods performed at our institution: direct repair, lateral band centralization, and distally-based flexor digitorum superficialis (FDS) slip repair.

METHODS

A boutonniere deformity was induced in 35 fresh-frozen cadaver digits. The central slip was repaired in 9 digits using a primary suture repair, in 9 digits using a lateral band centralization technique, and in 9 digits using a distally-based FDS slip reconstruction. A control group without injury was tested in 8 digits. Following repair or reconstruction, each digit was tested for load to failure, strain, and stiffness at the repair.

RESULTS

The average load to failure after central slip reconstruction was significantly greater for a distally based FDS slip method at 82.1 ± 14.6 N (95% CI, 62.2-101.9 N) than all other repair types. Although the FDS slip reconstruction was not as strong as the intact state (82.1 N vs 156.2 N, respectively), it was 2.6 times stronger than the lateral band centralization (82.1 N vs 31.6 N, respectively) and 3 times stronger than a primary repair (82.1 N vs 27.6 N, respectively).

CONCLUSIONS

Reconstruction of the central slip using a distally-based FDS slip provided the greatest biomechanical strength compared with the direct repair or lateral band centralization.

CLINICAL RELEVANCE

The use of a distally based reconstruction using FDS may allow for safer early motion.

Flexor Digitorum Superficialis tendon transfer for a long-standing boutonniere deformity finger - a retrospective study of 11 cases

INTRODUCTION

A long-standing boutonniere deformity is challenging to treat because of well-established complex pathophysiological changes in the extensor expansion mechanism. The role of ulnar slip flexor digitorum superficialis tendon transfer for central slip reconstruction in such chronic deformities is analyzed and correlated with the functional outcome.

HYPOTHESIS

Ulnar slip FDS tendon corrects the long-standing boutonniere deformity and replicates anatomical repair.

METHODS

We conducted a retrospective study between 2014 and 2016 and operated on 11 patients by FDS tendon transfer to the extensor expansion's central slip. We compared the preoperative and postoperative range of movements in the proximal interphalangeal joint, distal interphalangeal joint, Visual analogue score, and grip strength. Also, we statistically correlated various parameters and non-parameters affecting the functional outcomes.

RESULTS

The mean time interval between the injury and surgery was 39 months. The average follow-up of our study was 15.4 months. Ten of the 11 patients had good functional outcomes with statistically significant improvement in the movements and grip strength (p<0.05).

CONCLUSIONS

Ulnar slip FDS tendon transfer is effective for central slip reconstruction in a long-standing boutonniere deformity. Minimal degrees of proximal interphalangeal joint extension deficit is inevitable due to the chronicity and adaptive changes in the ligament-tendon-bone complex.

LEVEL OF EVIDENCE

IV; retrospective case study.

Y-Shaped Tendon Graft-A Technique in the Reconstruction of Posttraumatic Chronic Boutonniere Deformity

PURPOSE

Current reconstruction strategies for chronic posttraumatic boutonniere deformities have variable outcomes and are prone to complications. This study aimed to describe the clinical outcomes of a Y-shaped tendon graft technique.

METHODS

In this retrospective case study, we reviewed the files of 18 patients treated with the Y-shaped tendon graft between January 2010 and January 2017. The technique involves release of the central slip, lateral bands, and transverse retinacular ligaments at the proximal interphalangeal (PIP) joint, total excision of scar tissue in the central slip and at the insertion site, and construction of 3 1.5-mm unicortical holes at the base of the middle phalanx, through which a Y-shaped graft of the palmaris longus is inserted to reconstruct the central slip and stabilize the lateral bands in a dorsal position. Clinical evaluations included measuring the active range of motion in the PIP joint and distal interphalangeal (DIP) joint, grip strength, Souter score, and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score.

RESULTS

The mean age of patients was 36.1 years, and 12 of the 18 patients were men. The average follow-up period was 23 months (range, 13-38 months). The preoperative PIP joint extension deficit was 48.0° ± 5.0° compared with 10.9° ± 9.3° after surgery. The preoperative DIP joint active flexion was 34.4° ± 8.0° compared with 71.4° ± 8.6° after surgery The outcomes based on the Souter score were 11 excellent, 5 good, and 2 poor. The QuickDASH score was 17.7 ± 6.4 before surgery and 11.2 ± 7.2 after surgery.

CONCLUSIONS

The Y-shaped tendon graft can be a useful procedure for the correction of chronic boutonniere deformity; in our patient series, this provided good or excellent results in 16 of 18 patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Recent Developments Are Changing Extensor Tendon Management

LEARNING OBJECTIVES

After reviewing this article, the participant should be able to: Start early protected movement at 3 to 5 days after surgery with relative motion extension splinting for zone 5 extensor tendon lacerations over the hand. Allow patients to resume regular activities much sooner than the conventional 3 to 4 weeks of splinting after extensor tendon repair. Improve the rehabilitation of boutonniere deformities with relative motion splinting.

SUMMARY

This article focuses on surgery and rehabilitation of extensor tendon injuries from the proximal interphalangeal joint (boutonniere) to the wrist. Relative motion flexion and extension splinting and wide awake, local anesthesia, no tourniquet surgery have revolutionized the management of these lesions, with early protected movement, sooner return to regular activities, and improved rehabilitation. This article explains and illustrates these new advances in extensor tendon management.