Treatment of chronic post-traumatic hyperextension deformity of proximal interphalangeal joint using the suture anchor: a case report

Chronic post-traumatic volar plate avulsions of the finger proximal interphalangeal joint: A literature review of different surgical techniques

Avulsions of the volar plate of the finger proximal interphalangeal joint (PIPJ) following sprains are often undiagnosed in the acute setting. Therefore, the chronic outcomes of this injury are most frequently the object of study and treatment. Different techniques for volar plate chronic avulsion repair are described in the literature. The most used among these are mainly two: the direct suturing with or without the use of bone anchors and the tenodesis techniques with flexor digitalis superficialis (FDS). The aim of this systematic review is to determine outcomes and complications associated with these surgical treatments of post-traumatic volar plate avulsions without phalangeal fractures. An electronic literature research was carried out and pertinent articles were selected. Surgical techniques details, outcomes and complications for direct sutures and tenodesis technique are discussed. Outcomes (Range of motion and pain) seem to be comparable, whereas authors that use the direct suture technique describe more frequently PIPJ flexion contracture complication. From this review of the literature, authors believe that both techniques are available for the repair of chronic injuries of the volar plate of the PIPJ, although direct suturing can be considered as less reproducible.

A Flexor Digitorum Superficialis Tenodesis Technique for Surgical Treatment of Finger PIP Joint Volar Plate Chronic Avulsion

Background: Chronic, post-traumatic, avulsion of the proximal interphalangeal (PIP) joint volar plate represents a disabling lesion. The purpose of this report is to describe a flexor digitorum superficialis (FDS) tenodesis using a mini-bone anchor inserted into the proximal phalanx, and its clinical outcome. Methods: 15 patients with chronic post-traumatic hyperextension instability of the PIP joint were treated surgically. From the first post-operative day patients were invited to start an early gradual joint active motion, wearing an extension block splint. Forty days after surgery, clinical evaluations were carried out, including: joint stability, pain and range of motion (ROM). The use of a circumferential splint was recommended for two further months, avoiding strenuous manual activities. The range of motion, time lost at work and the functional results were recorded six months after surgery. Results: At last follow up, 7 of the 13 reviewed patients presented an excellent functional recovery, with complete resolution of pain and stability with attainment of ROM comparable to the contralateral finger. The others 6 patients obtained good results, with remission of the functional impairment and pain, with either residual hyperextension or flexion contracture. There was one case of recurrence consecutively to a premature traumatic work-related activity. Conclusions: The FDS tenodesis via a bone anchor, combined with early active PIP joint protected motion, was shown in this study to be effective and reliable.

Treating Proximal Interphalangeal Joint Dislocations

Proximal interphalangeal (PIP) joint dislocation a common injury. Usually, concentric stable reduction can be achieved with closed reduction. Occasionally, PIP joint dislocations are irreducible and open reduction is necessary. Complications include prolonged splinting and delay in presentation with subluxation or persistent dislocation. Surgery is often recommended for contracture or joint reduction. Surgical techniques focus on contracture release, joint reduction, and range of motion. Techniques have evolved from primary repair to tenodesis and suture anchor reconstruction. Most studies on PIP joint dislocations are retrospective case reports with good outcomes but chronic mild contracture and deformity are consistent in the literature.

Modified Sublimis Tenodesis: Surgical Technique for Treating Chronic Traumatic Proximal Interphalangeal Joint Hyperextension Instability

Many surgical techniques for treating chronic posttraumatic hyperextension instability of the proximal interphalangeal (PIP) joint involve exploration of the PIP joint, often leading to stiffness in an already traumatized joint. This article outlines the indications, contraindications, surgical technique, and postoperative management for a modified flexor digitorum sublimis tenodesis that utilizes 2 small incisions, a slip of flexor digitorum sublimis, a suture anchor, and temporary pinning of the PIP joint, while avoiding violation of the PIP capsule.

Posttraumatic Boutonnière and Swan Neck Deformities

Boutonnière and swan neck deformities of the finger can be the result of trauma. The complex anatomy of the extensor mechanism of the finger makes understanding the pathomechanics of these deformities challenging. These posttraumatic deformities should not be confused with those associated with inflammatory arthritis because the treatment options are often very different. An accurate clinical assessment is essential for selecting the appropriate treatment method. Physical examination, including Elson and intrinsic-plus tests, and plain radiography are important tools for diagnosis. A variety of nonsurgical and surgical treatment modalities can be used to restore the motion of the proximal and distal interphalangeal joints and rebalance the forces across these joints. An understanding of the anatomy, clinical presentation, treatment options, and expected outcomes is crucial for optimal treatment of posttraumatic boutonnière and swan neck deformities.

Surgical Techniques for Correction of Traumatic Hyperextension Instability of the Proximal Interphalangeal Joint: A Biomechanical Study

PURPOSE

To compare the biomechanical strengths of 5 surgical techniques for treatment of traumatic hyperextension instability of the proximal interphalangeal (PIP) joint.

METHODS

Thirty-six cadaveric fingers were randomly assigned to 6 groups: normal control, volar plate repair, flexor digitorum superficialis tenodesis (FDST), single lateral band transfer (SLBT), double lateral band transfer, and dual split lateral band transfer. For each experimental specimen, the volar plate and accessory collateral ligaments were transected, the PIP joint was hyperextended to 90°, and a PIP joint stabilizing procedure was completed. The ultimate strength of each procedure was ascertained by loading to failure, and the fingers were dissected to determine the pathoanatomy of failure. Force-displacement curves were used to estimate the stiffness of each group, and multiple pairwise statistical comparisons were performed.

RESULTS

The mean PIP joint stiffness in the control group was significantly greater than the mean PIP joint stiffness in the FDST and SLBT groups, but not significantly different from the mean PIP joint stiffness in the other 3 groups. There were no significant differences in the mean PIP joint stiffness between the 5 joint stabilizing techniques. The SLBT, double lateral band transfer, and dual split lateral band transfer repairs all failed by massive disruption of the flexor tendon sheath, whereas the volar plate repairs and FDST repairs failed by either suture anchor pullout or suture breakage.

CONCLUSIONS

The stiffness of 5 surgical techniques to stabilize a traumatic hyperextensible PIP joint did not vary significantly.

CLINICAL RELEVANCE

The 5 described techniques to stabilize a posttraumatic PIP joint hyperextension deformity may provide for equal restraint to PIP joint hyperextension instability in the early postoperative period. The choice of procedure should take into consideration other factors not studied, including the potential for PIP joint flexion contracture and long-term durability.

Late volar plate repair for chronic, post-traumatic hyperextension deformity of the proximal interphalangeal joint of the little finger

A chronic traumatic hyperextension of the proximal interphalangeal (PIP) joint can result from traumatic volar plate (VP) disruption. For the treatment of this disorder, reconstruction procedures have been traditionally recommended, because the condition of the VP was not considered susceptible to repair due to retraction or attenuation. The purpose of this paper is to present the operative technique and report the clinical results of late VP repair. Late VP repair was performed for chronic, post-traumatic hyperextension deformity of the PIP joint of the little finger resulting from VP disruption in seven consecutive patients. The range of motion and the lateral stability of the PIP joint were evaluated. The radiographic images were also used to evaluate the alignment and degenerative changes of the PIP joint. Clinical results were classified according to Catalano's criteria. Intraoperative findings showed that the VP could be mobilised and repaired in all cases. The hyperextension was well corrected, and none showed recurrence of the initial deformity. Average flexion of the PIP joint was 92° (range = 75-98°), and flexion contracture was 9° (range = 0-20°). On clinical evaluation, there were two excellent, three good, and two fair results. The postoperative radiographs revealed no degenerative change in the PIP joint in six patients. Late VP repair is a successful and reliable alternative and more physiologic than other reconstruction methods. One should first consider late VP repair, despite a long interval between injury and repair.

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

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