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Guryanov A.M., Safronov A.A.
Orenburg State Medical University, Orenburg, Russia
COMBINATION OF AN OLD INJURY TO FLEXOR TENDONS AND POSTTRAUMATIC OSTEOARTHROSIS OF THE PROXIMAL INTERPHALANGEAL JOINT OF THE SECOND FINGER
Damage of hand tendons is the acute
problem of modern traumatology and orthopedics. Its actuality mainly relates to
a specific functional role of the hand, which performs the range of the complex
coordinated and highly accurate movements involved in the processes of
perception, communication and emotional expression. The hand’s active role in
human life determines its high susceptibility to injuries. So, from the middle
of 20th century, the number of the above-mentioned injuries increased three
times (from 7 to 20 %) and now it is more than 30 % of all locomotor injuries.
Hand tendons are injured in a half of cases. An injury to the hand structures
often results in persistent disability and work incapability [1-3].
Compact location of the anatomical
structures of the hand and variety of their injuries in different anatomic
regions determines the complexity of diagnostics and surgical reconstruction.
One of the complex clinical situations is a combination of an old damage of
flexor tendons with disorder of the function of interphalangeal joints that
complicates the recovery of lost functions [4].
The most common and efficient
reconstructive surgery for old injuries to the flexor tendons of the fingers is
the two-staged tendon plasty. One month after injury, the bone-fibrous channels
of the fingers are filled with scar tissue in the injury site, and the tendon
ends are contracted. Contractures appear in the interphalangeal joints, and the
hand function worsens significantly. The functional disorder of the first and
second fingers, which provide the great amount of different types of grip and highly-precise
movements of the hand, is the most critical [2, 3, 5].
The essence of the surgery is as
described below. The first stage supposes the dissection of tendons of the
superficial and deep flexor tendon along the bone-fibrous sheath. A silicone
implant is put onto their place. The surgery is completed with application of
skin sutures. After removing the sutures, the patient begins the development of
passive movements in the operated finger joints. A channel is formed around the
tendon during 2-3 months. This channel performs the function of destructed
synovial channel. The success of this stage is achieved with only preserved
mobility of the finger joints.
The second stage of plasty is
performed 3 months after the first one, but no sooner than recovery of full
range of passive motions in the operated finger. The tendon implant is replaced
with the autograft, which is adhered to the distal phalanx and to the proximal
parts of the replaced tendon at the level of the palm or the forearm
correspondingly. After rehabilitation period, the patient can perform the
previously lost movements.
However it is very difficult or
sometimes impossible to achieve the complete restoration of full range of
volume in the finger joints, if a combination of an old tendon injury and
posttraumatic arthrosis of the proximal interphalangeal joints of the fingers
exists. The first stage is the surgery for both removal of injured tendons and
recovery of lost mobility in the affected joint (redressement, arthrolysis,
arthroplasty). In case of intense contractures, surgeons often refuse from
attempts of restoration of motions in the joint and perform arthrodesis,
resulting in severe disorders of hand function. The recent high-quality
implants for the interphalangeal joint can significantly reduce the
possibilities of reconstructive surgery of the hand.
The endoprosthetics of the hand
joints has been implemented in the traumatology clinic of Orenburg City
Clinical Hospital No.4 in 2015. 20 procedures of endoprosthetics of the
proximal and metacarpophalangeal joints of the hand were performed with ceramic
and silicone implants (Fig. 1).
Figure 1. The
appearance of the silicone prosthesis of the proximal interphalangeal joint
Objective – to evaluate the functional outcome
of surgical treatment of a chronic injury to the flexor tendons in combination
with post-traumatic osteoarthritis of the proximal interphalangeal joint of the
second finger.
The patient gave the informed
consent for participation in the clinical study. The session of the ethical
committee confirmed the compliance with the ethical principles and the
standards (the session protocol of the local ethical committee of Orenburg
State Medical University No.138, April 1, 2016).
CLINICAL CASE
The patient G., age of 45, addressed
to the clinic. He had some complaints of disorders in the left hand,
impossibility of grip and holding the things, absence of movements in the
second finger.
The history of disease was as followed.
In March 2016, he suffered from the left hand trauma while working with the
circular saw. He received a lacerated wound of the palmar surface of the second
finger with an injury to the flexor tendons in the region 2, an opened
comminuted fracture of the middle phalanx of the second finger with a defect
around its base. The digital arteries and nerves were not injured. The
treatment was outpatient. The primary surgical preparation of the wound was
conducted during the first visit. The tendon flexors of the second fingers were
sutured.
The patient was admitted to the
orthopedic clinic of Orenburg City Clinical Hospital No.4 one year after the
injury. During the examination, the second finger was in the position of flexion
contracture; active and passive extension was impossible. A postsurgical scar
with transition to the proximal phalanx was on the palmar surface in the plane
of the interphalangeal joint. The scar was dense, amenable and painless. There
were no signs of injuries to the digital arteries and nerves. The X-ray images
showed some defects of the articular surfaces with some signs of posttraumatic
osteoarthrosis of the proximal interphalangeal joint of the second finger (Fig.
2).
Figure2. The
hand X-ray image shows a defect in the base of the middle phalanx and the sings
of posttraumatic osteoarthrosis in the proximal interphalangeal joint
The range of active and passive
motions in the proximal interphalangeal joint of the second finger was as
described below: flexion – 0° and 7°, extension – 0° and 10° correspondingly.
Passive motions in the distal interphalangeal and metacarpophalangeal joints of
the second finger were within the full range.
The patient received the surgery.
The first stage was a zigzag surgical approach along the palmar surface from
the nail phalanx of the injured finger to its base under conduction analgesia
of the brachial plexus. The tendon suture was inconsistent. A diastasis with
scar tissue was between the ends of the suture. The tendons of the superficial
and deep flexors of the second finger and scar tissue were dissected along the
bone-fibrous channel along the hand zone 2. Only the distal end of the tendon
of the deep flexor (1.0 cm) near the place of adherence to the distal phalanx
was not dissected. The proximal ends of the tendons at the level of the distal
palmar line were sutured with use of microsurgical technique. Some defects of
the affrontee articular surfaces of the proximal and the middle phalanxes of
the second finger were identified. The endoprosthetics of the proximal
interphalangeal joint with the silicone implant was performed through this
approach (Fig. 3-5).
Figure 3. The
intrasurgical photo: the proximal interphalangeal joint was resected, and the
endoprosthesis was mounted
Figure 4. The
intrasurgical lateral X-ray image: the endoprosthesis of the proximal
interphalangeal joint
Figure
5. The
intrasurgical frontal X-ray image of the hand: the endoprosthesis of the
proximal interphalangeal joint
The next stage was placement of a
tube silicone implant onto the place of the removed tendons, which was sutured
distally to the remaining fragment of the tendon of the deep flexor, with
proximal fixation to the ends of the sutured tendons of the superficial and
deep flexors of the finger. The surgery was completed with application of skin
sutures and plaster immobilization. On the third postsurgical day, the patient
initiated the development of passive motions in the operated finger joints.
Remedial gymnastics and kinesiotherapy were initiated. The postsurgical period
was without complications.
The second stage was performed 3
months later. Under conduction anesthesia of the brachial plexus and through a
longitudinal dissection on the border of distal and middle one-third of the
palmar surface of the forearm, the tendon of the superficial flexor of the
injured finger was separated and transected 1 cm more distal than the
tendon-muscular transition. The tendon of the superficial flexor was output to
the wound and was sutured to the proximal end of the silicone implant by the
end-to-end technique. Then the distal end of the implant was separated through the
incision in the region of the palmar surface of the nail and middle phalanxes.
With implant stretching, the tendon was conducted distally into the created
channel in the finger and sutured to the stump of the deep flexor tendon. The wounds
were sutured. The immobilization with the dorsal plaster bar was performed for
3 weeks. The patient received two months of rehabilitation course. The
examination was carried out two months after the rehabilitation procedures
(Fig. 6, 7). The patient demonstrated the recovery of the full range of motions
in the second finger, and the high functional result according to DASH (Disability
of the Arm, Shoulder and Hand).
Figure 6. The
hand function 3 months after the second stage of surgery. Extension of the
fingers
Figure 7. Hand
function 3 months after the second stage of surgery. Flexion of the fingers
CONCLUSION
This clinical study shows one of the
uncommon examples of the combination of tendon injuries with posttraumatic
arthrosis of the proximal interphalangeal joint of the finger. Each condition
requires the individual surgical procedures for reconstruction of the joint and
injured tendons.
The single-moment realization of the
above-mentioned surgical interventions at the first stage of the treatment
provided the possibility for early passive movements and primary recovery of
kinematic chain “joint – tendon – muscle” that simplified the period of
preparation for the second stage of reconstruction, reduced the total period of
rehabilitation and gave the good functional outcome.
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