N Borisch1, P Haubmann. 1. Abteilung für Handchirurgie, Plastische und Wiederherstellungschirurgie, DRK-Klinik Baden-Baden, Lilienmattstr. 5, 76530, Baden-Baden, Deutschland. nicola.borisch@drk-klinikbb.de
Abstract
OBJECTIVE: Correction of swan neck deformity at the PIP and DIP joint by reconstruction of the oblique retinacular ligament through palmar transposition of one distally pedicled lateral band (oblique retinacular ligament reconstruction (ORL) = Littler II). INDICATIONS: Rheumatoid swan neck deformity Nalebuff stages I-III (dynamic, partially contracted, contracted). The swan neck deformity should be of articular origin. CONTRAINDICATIONS: Advanced radiologic changes of the PIP joint (Larsen 3-4) [12]. Extrinsic and intrinsic causes of swan neck deformity. Flexor tendon synovitis. SURGICAL TECHNIQUE: Dorsal approach to the PIP joint. One lateral band is sectioned proximally at the level of the musculotendinous junction. It is then isolated from the extensor apparatus and left pedicled distal at the insertion. The isolated lateral band is then passed underneath the Cleland ligament from distal to proximal and is sutured to the distal edge of the A2 pulley. The correct tension of the tenodesis achieves flexion at the PIP joint and extension at the DIP joint. In contracted and partially contracted joints, the PIP joint is temporarily transfixed. Depending on the clinical findings, a synovectomy or dorsal arthrolysis of the PIP joint must be performed. POSTOPERATIVE MANAGEMENT: Immediate postoperative mobilization of the PIP joint for flexion. A figure-of-eight finger splint has to be worn for 12 weeks. The splint must allow full PIP flexion and limit extension over 20-30° of flexion. In case of temporary transfixation of the PIP joint, wire removal after 4-6 weeks and start of mobilization. Passive extension over 20-30° of flexion only after 12 weeks. RESULTS: From 2004-2007, 30 PIP joints in 20 rheumatoid patients were treated for swan neck deformity. In all cases, the original method as described by Littler was used. A change of the procedure due to insufficiency of the Cleland ligament or the A2 pulley was not necessary in any of the cases. After a mean of 22 months, 26 PIP joints in 17 patients could be followed up. In 12 PIP joints, the deformity was partially contracted, in two joints contracted. In 10 joints, a dorsal arthrolysis had to be performed, while a lengthening of the medial band was performed in 1 patient. The swan neck deformity could be compensated in all cases. Preoperative hyperextension of a mean 21° could be reduced to a mean 24° of flexion postoperatively. The ROM did not change much but was shifted from the extension sector to the flexion sector of the PIP joint. In no case were complications or recurrence of the deformity noted. Pain could be reduced in all patients except one. The radiologic joint situation was Larsen stage 2.2 preoperatively and 2.3 postoperatively.
OBJECTIVE: Correction of swan neck deformity at the PIP and DIP joint by reconstruction of the oblique retinacular ligament through palmar transposition of one distally pedicled lateral band (oblique retinacular ligament reconstruction (ORL) = Littler II). INDICATIONS: Rheumatoid swan neck deformity Nalebuff stages I-III (dynamic, partially contracted, contracted). The swan neck deformity should be of articular origin. CONTRAINDICATIONS: Advanced radiologic changes of the PIP joint (Larsen 3-4) [12]. Extrinsic and intrinsic causes of swan neck deformity. Flexor tendon synovitis. SURGICAL TECHNIQUE: Dorsal approach to the PIP joint. One lateral band is sectioned proximally at the level of the musculotendinous junction. It is then isolated from the extensor apparatus and left pedicled distal at the insertion. The isolated lateral band is then passed underneath the Cleland ligament from distal to proximal and is sutured to the distal edge of the A2 pulley. The correct tension of the tenodesis achieves flexion at the PIP joint and extension at the DIP joint. In contracted and partially contracted joints, the PIP joint is temporarily transfixed. Depending on the clinical findings, a synovectomy or dorsal arthrolysis of the PIP joint must be performed. POSTOPERATIVE MANAGEMENT: Immediate postoperative mobilization of the PIP joint for flexion. A figure-of-eight finger splint has to be worn for 12 weeks. The splint must allow full PIP flexion and limit extension over 20-30° of flexion. In case of temporary transfixation of the PIP joint, wire removal after 4-6 weeks and start of mobilization. Passive extension over 20-30° of flexion only after 12 weeks. RESULTS: From 2004-2007, 30 PIP joints in 20 rheumatoidpatients were treated for swan neck deformity. In all cases, the original method as described by Littler was used. A change of the procedure due to insufficiency of the Cleland ligament or the A2 pulley was not necessary in any of the cases. After a mean of 22 months, 26 PIP joints in 17 patients could be followed up. In 12 PIP joints, the deformity was partially contracted, in two joints contracted. In 10 joints, a dorsal arthrolysis had to be performed, while a lengthening of the medial band was performed in 1 patient. The swan neck deformity could be compensated in all cases. Preoperative hyperextension of a mean 21° could be reduced to a mean 24° of flexion postoperatively. The ROM did not change much but was shifted from the extension sector to the flexion sector of the PIP joint. In no case were complications or recurrence of the deformity noted. Pain could be reduced in all patients except one. The radiologic joint situation was Larsen stage 2.2 preoperatively and 2.3 postoperatively.