PREOPERATIVE DIAGNOSIS: Left ring finger proximal interphalangeal joint flexion contracture with boutonniere deformity.
POSTOPERATIVE DIAGNOSIS: Left ring finger proximal interphalangeal joint flexion contracture with boutonniere deformity.
PROCEDURES PERFORMED:
1. Left ring finger proximal interphalangeal joint volar capsulotomy with checkrein ligament release and collateral ligament release.
2. Left ring finger zone 3 extensor tendon reconstruction with advancement of central tendon and dorsal translation of the lateral bands.
3. Left ring finger extensor tendon tenolysis.
4. Left ring finger proximal interphalangeal joint insertion of K-wire stabilizing the proximal interphalangeal joint in neutral.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: Local with sedation.
IMPLANTS: Stainless steel 0.045-inch Kirschner wire.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
SPECIMENS: None.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old Hispanic female who sustained an injury to her left ring finger several months ago, which resulted in boutonniere deformity, which was rigid. Exhaustive conservative care was attempted; however, she was unable to maintain neutral position at her ring finger PIP joint. Radiographs did not reveal any significant arthrosis of the joint, and after discussion of risks and benefits, she elected to proceed with surgical intervention consisting of correction of her ring finger boutonniere deformity.
OPERATIVE FINDINGS: After adequate anesthesia had been obtained, we were unable to achieve extension beyond 40 degrees at the PIP joint; this was quite rigid. Once the checkrein ligaments had been completely released, she achieved approximately 20 degrees and the remaining was achieved after collateral ligament recession had been performed. The central slip had strong insertion; however, there was approximately 5 mm of pseudotendon, which was able to be excised. After shortening and repair of the central slip and dorsal translation of the lateral bands, we were able to achieve 70-80 degrees of PIP flexion without undue tension on the repair site, and the DIP joint was not overly tightened.
DESCRIPTION OF OPERATION: After obtaining informed consent, identifying correct patient, correct operative site, the patient was taken to the operating suite where she was placed supine on the operating table. She received light sedation by the anesthesia department. Then, digital block was administered at the MP level of the ring finger with dorsal block and dorsal sensory branch of the ulnar nerve block at the level of the wrist. This was performed with 1% lidocaine and 0.5% Marcaine in a 50:50 mixture. The left hand and upper extremity were then prepped and draped in the usual sterile fashion. With adequate anesthesia and sedation, manipulation of the joint was performed; however, the above findings were noted, and it was felt that she clearly required release of the PIP joint in order to achieve passive extension. The hand was then exsanguinated with an Esmarch bandage, a well-padded forearm tourniquet inflated to appropriate arm pressure.
A longitudinal incision was created over the PIP joint extending distally at the level of the mid P2 and proximally just distal to the MP joint. Dissection was carried down through the skin and subcutaneous tissues, and flaps were elevated off the paratenon medially and laterally taking care to obtain adequate hemostasis with a bipolar electrocautery. The extensor mechanism was identified. The transverse retinacular ligament was seen on either side of the lateral bands, and this was incised to allow for improved mobilization of the lateral bands. The extensor tenolysis was then performed with a combination of sharp dissection and a Freer elevator mobilizing it off the dorsum of P1, and distally lateral bands were freed from the dorsum of P2.
Further attempted manipulation was performed; however, we were unable to achieve greater than 40-degree extension lag. Dissection was carried down on either side of the PIP joint towards the volar plate. This was visualized, and a small window was created between A3 pulley and C1 pulley. Through this window, the lateral branches of the digital arteries were identified and controlled with bipolar electrocautery, care taken not to violate the flexor sheath anymore than required and not to damage the neurovascular bundles. The checkreins were visualized and released with a Beaver blade, thereby completely releasing the volar plate from its origin on P1. This was performed on either side of the joint. Attempted extension was then performed passively, and we were able to achieve 20 degrees short of neutral correction. The collateral ligaments were then recessed from the head of P1, and with gentle manipulation, we were further able to extend the joint to neutral.
The tourniquet was then deflated, the patient was asked to extend her finger, and she was able to do so, however, lacked approximately 25-30 degrees of extension of the PIP joint. It was felt that further shortening of the central slip was required, a stout oblique retinacular ligament was not able to be visualized, and it was felt that performing lateral band tenotomy or lengthening would put her at potential risk of developing a mallet-type deformity. The tourniquet was again inflated after exsanguination of her hand.
The lateral bands were separated from the central slip sharply on either side. The remainder of the central slip insertion was tenolysed down to bone taking care not to detach the insertion of the tendon from the base of P2. Leaving the insertion on the P2, approximately 4-5 mm of pseudotendon was excised from the central tendon. The proximal stump was further tenolysed to allow for improved mobilization, and then it was advanced and repaired to the distal stump with 4-0 Mersilene suture using a grasping suture in the tendon. This was then further augmented with a running locked suture and one additional horizontal mattress stitch. Excellent stability of the repair was achieved. The lateral bands were then mobilized dorsally and repaired to the central tendon itself with further 4-0 Mersilene sutures taking care that this would not cause excessive stiffness to the DIP joint.
The tourniquet was once again released, and the patient was asked to flex and extend the finger. She was able to achieve almost full extension at the PIP joint actively lacking perhaps 5 degrees at most. The DIP joint was not excessively stiff, and she was able to make nearly a complete composite fist. It apparently was felt to be stout enough and held up through her range of motion.
The hand was once again exsanguinated and the tourniquet inflated. Under fluoroscopic assistance, a 0.045 Kirschner wire was placed across the PIP joint by holding the joint in neutral position taking care to ensure that it was not hyperextended. A pin was placed from radial distal to proximal ulnar, the position was confirmed fluoroscopically in multiple planes. It was then bent, cut short, and capped. The bed was thoroughly irrigated with normal saline, and the remaining bleeding was controlled with bipolar electrocautery. The incision was closed with 4-0 Prolene horizontal mattress sutures. It was dressed with Xeroform and bulky lightly compressive hand dressing followed by the application of a plaster splint mobilizing her MPs in approximately 70 degrees of flexion and the PIP and DIP joints at 0 with slight extension of the wrist. The tourniquet was again deflated and excellent circulation returned to all of her digits. She was taken to the recovery room in stable condition. The patient tolerated the procedure without difficulty.
