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Collateral Ligament Reconstruction of the Proximal Interphalangeal Joint
Abstract
Proximal interphalangeal joint collateral ligament injuries are common; however, chronic instability of this joint is rare. In such cases, however, there is no consensus on optimal management. Various repairs and reconstructions have been devised, although the literature on outcomes remains scant. We present a method of reconstruction of the proximal interphalangeal joint collateral ligament using a distally based slip of the flexor digitorum superficialis tendon. © 2016 American Society for Surgery of the Hand. All rights reserved.
... Chronic collateral instability at the PIP joint is rare, as stiffness is usually the prime concern with these injuries. Techniques described in the literature utilize palmaris longus or distally based slips of FDS, through bone tunnels or using suture anchors [12,13,14]. ...
The PIP joint is frequently injured in combat sports and often underplayed by participants, coaches, and medical staff. Outcomes are often poor due to delayed presentation, controversies as to ideal treatment, and technical challenges of repair and reconstruction of the joint.
... Most chronic radial collateral ligament (RCL) injuries of the PIP joint are associated with collateral ligament degeneration, which makes the tissue unsuitable for repair. Therefore, tissue reconstruction by tendon grafting or transfer is a standard surgical treatment (Carlo et al., 2016). ...
We present seven cases of a relatively rare swan neck deformity resulting from chronic radial collateral ligament (RCL) injury of the proximal interphalangeal (PIP) joint in the little finger. All patients were middle-aged women (mean 51 years old, range 42-55), and the duration between the initial injury and surgery was 20 years (range 5-40). The chief complaint was painful snapping of the PIP joint. All patients had hyperextension and ulnar deviation of the PIP joint with mobile swan neck deformities that had not improved with conservative treatment. Radiographs revealed osteoarthritis and ulnar deviation of the PIP joints in all cases. We describe a method for reconstruction of both the palmar plate and the RCL of the affected PIP joint using a distally-based ulnar slip of flexor superficialis tendon. The prevention of PIP joint hyperextension was critical for successful resolution of symptoms; the aim of RCL augmentation was to prevent the recurrence of the deformity.
Level of evidence:
IV.
Resumen
Introducción La laxitud en la placa volar de la articulación interfalángica proximal puede traducirse en una inestabilidad en el plano sagital por incompetencia de esta, acompañada de una hiperextensión digital con subluxación dorsal, perdida de funcionalidad y dolor.
Objetivos Presentar una serie de casos de pacientes con inestabilidad sagital en la interfalángica proximal tratado mediante una técnica quirúrgica mínimamente invasiva y evaluando los resultados a corto y mediano plazo.
Material y Métodos Pacientes tratados con una técnica quirúrgica mínimamente invasiva que implica escarificación de la placa volar guiada por ultrasonido para el tratamiento de una deformidad en hiperextensión por incompetencia de la placa volar. Esta técnica se ha utilizado en cinco pacientes en un estudio prospectivo con un seguimiento de un año, donde a la técnica percutánea le sigue un protocolo de ferulización y rehabilitación articular.
Resultados Resultados satisfactorios que muestran una reducción del dolor y una mejor función, con una tasa de resolución de la hiperextensión y del bloqueo articular en un 100%, y una mejora en el Quick-DASH y Mayo Wrist Score.
Ligamentous injuries in the hand and wrist are often underdiagnosed and can present with significant functional limitations if there is untimely recognition of injury. Adequate repair or reconstruction is critical in restoring joint stability and mobility. The purpose of this review is to provide an overview of the metacarpophalangeal joint, scapholunate interosseous ligament (SLIL), and non-SLIL carpal ligament anatomy, diagnosis, imaging, treatment consideration and options, as well as surgical techniques encompassing repair, reconstruction, and fusion.
Silicone arthroplasty for proximal interphalangeal joint ankylosis is rarely performed, partly due to the potential for lateral joint instability. We present our experience performing proximal interphalangeal joint arthroplasty for joint ankylosis, using a novel reinforcement/reconstruction technique for the proper collateral ligament. Cases were prospectively followed-up (median 13.5 months, range 9–24) and collected data included range of motion, intraoperative collateral ligament status and postoperative clinical joint stability; a seven-item Likert scale (1–5) patient-reported outcomes questionnaire was also completed. Twenty-one ankylosed proximal interphalangeal joints were treated with silicone arthroplasty, and 42 collateral ligament reinforcements undertaken in 12 patients. There was improvement in range of motion from 0° in all joints to a mean of 73° (SD 12.3); lateral joint stability was achieved in 40 out of 42 of collateral ligaments. High median patient satisfaction scores (5/5) suggest that silicone arthroplasty with collateral ligament reinforcement/reconstruction should be considered as a treatment option in selected patients with proximal interphalangeal joint ankylosis.
Level of evidence: IV
Résumé
Les articulations interphalangiennes proximales des doigts sont stabilisées sur le plan anatomique par des structures ligamentaires et par la conformation des pièces articulaires, et sur le plan dynamique par les tendons fléchisseurs et extenseurs. La perturbation d’une seule articulation réduit la capacité de la main à fonctionner correctement. Les circonstances du traumatisme et, surtout, une description détaillée du mécanisme constituent des informations majeures pour le diagnostic lésionnel et pour la possibilité d’anticiper les complications. L’examen clinique comprend l’évaluation de la déformation, le gonflement, l’amplitude de la mobilité active et passive, ainsi que la recherche de douleurs provoquées, les tests de stabilité articulaire, l’état des tendons et un bilan neurovasculaire. Un bilan radiographique est nécessaire pour pratiquement toutes les entorses, notamment un cliché de profil qui est suffisant dans certains cas. L’aspect le plus important du traitement est la capacité de faire la distinction entre les entorses qui pourraient nécessiter un geste chirurgical, et celles qui justifient le port d’une orthèse ou d’une attelle.
Case:
A 33-year-old man presented with a painful instability of the distal interphalangeal (DIP) joint of the little finger after recurrent sports-related traumatic injuries. Stress testing and radiography demonstrated the instability of the ulnar collateral ligament. We performed an ulnar collateral ligament reconstruction of the DIP joint using the palmaris longus tendon. One year after surgery, the patient reported a painless and stable DIP joint with good functional outcome.
Conclusion:
This procedure could be a viable treatment option for active, high-demand patients experiencing chronic symptomatic instability of the DIP joint because of a longstanding tear of the collateral ligament.
Collateral ligament injuries of the fingers in baseball players represent a small but significant percentage of injuries to the hand and wrist. In most cases, these injuries are not serious and do not require surgery but require careful evaluation and proper treatment, nonetheless, to allow for full healing and return to play.
Biomimicry consists in imitating nature to solve complex human problems. The hand surgeon usually tries to copy and recreate the structure-to-function and function-to-control relationships of the native tissues after damage. With its exceptional structure and biomechanics, the flexor digitorum superficialis (FDS) has been an important source of inspiration for artificial hand system reconstruction. The present systematic literature review highlights the twenty-two artificial hand system reconstructions derived from the FDS, and presents biomimicry as an alternative approach in clinical research in hand surgery.
This chapter offers a comprehensive overview of the management of pediatric and adult fractures, open and closed. Potential complications and operative options are discussed, if conservative management is not an option, alongside hand therapy rehabilitation.
Injuries to the collateral ligaments of the metacarpophalangeal (MCP) and interphalangeal (IP) joints are commonly encountered in both athletes and nonathletes. They require prompt evaluation to ensure proper management and prevent loss of joint motion and permanent disability. Imaging is often required to confirm the diagnosis and assess injury severity. This review article aims to provide physicians with guidelines for sonographic assessment of the collateral ligaments of the MCP and IP and related injuries. Sonographic features of ligament injuries ranging from sprains and partial-thickness tears to full-thickness tears are described. Specific lesions of the ulnar collateral ligament of the thumb MCP joint, such as gamekeeper's thumb, skier's thumb, and Stener lesions, are also included. In conclusion, sonography is effective in evaluating the collateral ligaments of the MCP and IP joints and related injuries and represents a valuable tool for diagnosis.
To evaluate the effectiveness of suture anchors in the reconstruction of chronic collateral ligaments of fingers.
We treated 8 patients, 6 with chronic instability of the collateral ligament of the thumb and 2 with the instability of the fifth finger, using the Statak suture anchor. A stable joint was achieved in each case, with no recurrent instability or pain within a mean of 14 months of the follow up.
Postoperatively, each patient returned to his or her original job, their daily activities, and sports. There was no significant difference on manual stress testing measurements between operated and uninjured fingers. Mean pinch strength and range of motion were 90% (range, 78-104%) and 94% (range, 70-100%), respectively, compared to uninjured fingers.
Suture anchor technique can be recommended as a simple and effective method of repairing the collateral ligament of fingers.
We describe anatomical collateral ligament reconstruction using a free tendon graft and intraosseous suture anchors in the digits. Eleven patients who underwent collateral ligament reconstruction at the proximal interphalangeal or metacarpophalangeal joints were enrolled in this study. Proper and accessory collateral ligaments were reconstructed using a free tendon graft in an anatomical configuration and the grafted tendons were fixed with suture anchors. The mean time from surgery to last follow-up was 9.2 months. All anchors used for fixation of grafted tendons remained securely at their original positions at the last follow-up visits. No significant complications were associated with the use of anchors. Clinical results were excellent in 10 patients and good in one. Anatomical reconstruction of collateral ligaments using suture anchors is simpler, faster, and safer than the conventional bone tunnel technique and it does not have the risks of breakage of bone bridges, skin irritation, or graft loosening.
We present a case report describing the surgical technique for the reconstruction of the proximal interphalangeal (PIP) joint collateral ligament using autograft palmaris longus tendon graft. We accomplished this successfully in a high performance professional athlete presenting with chronic instability of the PIP joint. Our surgical reconstructive technique recreated anatomic ligament position, while correcting multidirectional instability without disruption of the other dynamic anatomic structures of the PIP joint. Our results demonstrated excellent clinical and functional results, and we offer our technique as an alternative to tenodesis procedures for individuals with professions that demand PIP motion.
Several methods have been reported for reconstruction of the extensor central slip. We describe the successful use of a distally based slip of the flexor digitorum superficialis tendon for the reconstruction of an incompetent central slip of the extensor mechanism. The flexor digitorum superficialis tendon was transferred from volar to dorsal through the base of the middle phalanx and then woven through the extensor tendon over the proximal phalanx. The technique is straightforward and appears to be robust.
A technique is described for reconstructing the unstable proximal interphalangeal joint where there has been a break in continuity of both the volar plate and the collateral ligament. Both slips of the superficialis are used. They are divided proximally and tenodesed in appropriate positions on the proximal phalanx.
This study is a review of 127 hands in 100 patients in whom one or two FDS tendons were used to correct claw-hand deformity and/or loss of opposition of the thumb. In lumbrical replacement the results were graded as excellent in 16 hands (21%) and good in 43 hands (57%). For opponensplasty the results were excellent in 26 hands (32%) and good in 42 hands (51%). Possible defects that can develop in the donor finger are: swan-neck deformity, flexion posture of the DIP joint, not as part of the swan-neck deformity, check-rein deformity or flexion contracture, and insufficient finger flexion. Of the 158 fingers swan-neck deformity was seen in 15%, DIP flexion in 29%, check-rein deformity in 26% and insufficient finger flexion in 18%. The latter occurred with another defect. In 48 fingers (30%) no defects were observed.
Injuries to the collateral ligaments of the proximal interphalangeal joints of the fingers are common and vary from simple strain to complete rupture, a condition which, if overlooked, frequently results in unilateral pain, swelling, and sharply localized tenderness and, when the ligament is completely ruptured, passive instability of the joint. This instability can be confirmed by proper stress roentgenograms. Review of our experience with injuries of one of the collateral ligaments of the proximal interphalangeal joints treated by non-operative means revealed that partial ligamentous ruptures responded satisfactorily while completely ruptured collateral ligaments frequently resulted in prolonged disability. Fourteen of eighteen fingers with completely ruptured collateral ligaments of the proximal interphalangeal joints were operated on with satisfactory results. Three patients refused operation; one was unsuitable for surgery.
The results are reported of a trial on the management of collateral mechanism disruption of the proximal interphalangeal joints of fingers. The incidence of the injury in Edinburgh, over a seven month period, averaged one case per week. Most (80%) had proximal avulsion of the main ligament.
In the operated group all reached the state of painless stability at about two months. In the unoperated group none reached this stage, even at the final follow up, 64% complained of functional disability.
It is concluded that operation is the treatment of choice for this injury.
Collateral ligament injuries to the proximal interphalangeal joint are common. When the collateral ligament is completely ruptured, surgical repair may be required. The strength of the lateral collateral ligaments of the proximal interphalangeal joint was examined using axial distraction on an electrohydraulic testing apparatus. Eighty-five fresh human adult cadaver fingers were assessed; 38 intact ligaments were first examined. The strength of the native ligament was 162.5 N. Forty-seven ligament repair preparations were tested: suture repair (27.8 N), pull-out wire repair (35.9 N), and repair using a Mitek suture anchor (38.4 N). The breaking strength of the intact ligaments was significantly greater than that of any repair. All repaired ligaments failed at the site of the repair. The ligaments repaired by the pull-out wire and Mitek anchor technique were significantly stronger than those repaired with the suture technique.
Eighteen acute grade III collateral ligament injuries were treated by using the Mitek bone suture anchor. Seven were thumb metacarpophalangeal joint injuries, and eleven were finger proximal interphalangeal joint injuries. Seventeen patients were followed more than 12 months after surgery. All patients were able to use the digits in daily living activities within 5 weeks after surgery, and return to their original work or sports activities within 12 weeks. Pain was completely relieved in 15 patients. Loss of joint motion averaged 7 degrees. In all joints the postoperative lateral stress angle was within 10 degrees of that of the contralateral digit.
Ten out of 12 complete ruptures of the collateral ligament of the proximal interphalangeal joint were repaired primarily using a suture anchor. Active finger exercise was started gently by taping the injured finger to adjacent one one week postoperatively. All patients returned to their original occupation or sports activities within seven weeks of operation. No patients complained of pain on the involved finger at rest or during movement. There was no instability of the proximal interphalangeal joint on manual lateral stress test postoperatively.
To study and clarify the anatomy of the proper collateral ligaments and accessory collateral ligaments of the proximal interphalangeal joint.
The collateral ligaments of 8 proximal interphalangeal joints were dissected under an operating microscope to gain an appreciation of their fiber direction and the anatomy of their origin and insertion. Two undissected joints were studied histologically.
The proper collateral ligament was found to arise widely from dorsal and proximal to and from the fovea on the side of the head of the proximal phalanx and insert for some distance on most of the side of the base of the middle phalanx. The ligament is stout and its fibers are oriented parallel to the middle phalanx in all positions of the joint. The accessory collateral ligament was found to be a less substantial structure lying between the proper collateral ligament and the volar plate.
The anatomy shown by this study is quite different from that shown in most of the anatomic and hand surgery literature, particularly in line drawings.