COMBINATION OF AN OLD INJURY TO FLEXOR TENDONS AND POSTTRAUMATIC OSTEOARTHROSIS OF THE PROXIMAL INTERPHALANGEAL JOINT OF THE SECOND FINGER 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.