1. Introduction

a. Mark Incision

b. Injection of Local Anesthesia

2. Patient Preparation

3. Incision

4. Exposure of Sagittal Band and Extensor Tendon

5. Release of Contracted Sagittal Band

6. Repair of Sagittal Band

7. Confirmation of Loss of Subluxation

8. Closure

9. Placement of Plaster Yoke Splint

10. Post-op Remarks

Sagittal band rupture is an injury that causes rupture of the sagittal band, leading to subluxation of the extensor digitorum communis (EDC) tendon at the metacarpophalangeal (MCP) joint. The sagittal band encircles the EDC tendon at the MCP joint and functions as an important part of the extensor mechanism to stabilize the extensor tendon. It is a relatively uncommon injury, typically involving the long finger, that may occur with direct trauma in athletes or atraumatically in inflammatory or spontaneous cases; the mechanism may be acute or chronic. The common presentation involves pain and swelling at the MCP joint, visualization of extensor tendon subluxation during flexion, and inability to actively extend the MCP joint from a flexed position. The treatment for chronic rupture, as in this case, involves surgical repair followed by six weeks in a relative motion splint, in which the injured MCP joint is placed in greater extension relative to adjacent joints. The video here demonstrates direct repair of a chronic degenerative sagittal band rupture of the right ring finger.


<h4>CHAPTER 1</h4>

<p>Sagittal band ruptures represent
an extensor tendon injury resulting
in subluxation of the extensor tendon
over the metacarpal head
with active flexion
and then active extension.
Here, you can see the snapping tendon
over the middle metacarpal head.
Here is an intraoperative example
of the same thing.
The surgery is being performed
under a local anesthesia.
When the patient's finger
is extended against resistance,
you can see the subluxation
of the extensor tendon.
Sagittal band ruptures
can either be traumatic in origin
as in this case,
or degenerative in origin
as in the first example.</p>

<h4>CHAPTER 2</h4>

<p>The video case being presented here consists
of a chronic degenerative sagittal band rupture
of the ring finger.
The procedure is being performed
under just a local anesthesia
in a wide awake hand surgery fashion.
An initial injection of the surgical site
with lidocaine, with epinephrine,
buffered with bicarbonate was applied
in the preoperative area.
The patient is now being prepared
for surgery in the operating room.</p>

<p>The surgical site is being marked out
directly over the metacarpal head.
The surgical site is being augmented
with some additional local anesthetic.</p>

<h4>CHAPTER 3</h4>

<p>The incision is placed directly
over the MP joint, consistent
with a zone five of the extensor mechanism.</p>

<h4>CHAPTER 4</h4>

<p>Blunt dissection is then performed down
to the extensor mechanism
until the extensor tendon
and the sagittal band is fully exposed.
Once adequately exposed,
active motion by the patient confirms a subluxation
of the extensor tendon
in the ulnar direction
upon active flexion followed
by active extension.
The ulnar subluxation of the extensor tendon implies
that the radial sagittal band
is incompetent as being examined here.
In cases of acute ruptures,
the ends of the sagittal band
are readily reapproximated and repaired.
In chronic ruptures,
adequate tissue may not be available
for primary repair
and may require augmentation
with either a graft or a transfer
from the bordering digit sagittal band.
In this case, adequate tissue is confirmed
for primary repair along the radial side.</p>

<h4>CHAPTER 5</h4>

<p>Prior to proceeding with the repair,
the ulnar sagittal band is also examined.
In chronic sagittal band rupture cases,
the competent side often becomes contracted
and may require release to help
with the centering of the extensor mechanism
as shown here.
The release of the contracted side
should be performed sharply
from proximal to distal
on a slow progressive basis until satisfied
that adequate recentralization
of the tendon has been achieved.
Note, upon release of the contracted side,
that active motion of the finger
has already restored centralization
of the extensor tendon
even before repair
or imbrication of the ruptured side.</p>

<h4>CHAPTER 6</h4>

<p>Next, repair of the injured side is performed.
Again, in the case of acute ruptures,
a direct repair is possible.
In the case of chronic ruptures,
an imbrication of the extensor mechanism,
as in this case, is required.
A non-absorbable 2-0
or 3-0 suture is being used,
in a figure-of-eight fashion.
Two to three sutures typically will be adequate.
In this case, two figure-of-eights using
3-0 Ethibond were used to repair
the sagittal band.</p>

<h4>CHAPTER 7</h4>

<p>Once repaired, the finger is taken
through an active range of motion by the patient
to confirm a centralized motion
of the extensor tendon without subluxation.</p>

<h4>CHAPTER 8</h4>

<p>Once satisfied with the repair,
the wound is washed and closed.</p>

<h4>CHAPTER 9</h4>

<p>Once closed,
perhaps the most important part of the case
is the splinting postoperatively.
I recommend utilizing an Orthoplast yoke splint
to be worn full-time
for the next four to six weeks postoperatively.
These splints are made from Orthoplast
in the office by our therapist.
However, exiting the operating room today,
a temporary plaster yoke splint
is being applied as demonstrated here.
This is a hand-based splint
that will place the MP joint
in extension to offload the repair.
The purpose of the yoke
is to keep the operative MP joint extended relative
to the other MP joints while still allowing
for tendon excursion to occur.
This is being performed here
in the operating room,
shown here by inserting rolled up Webril
between the operative finger and the plaster,
so that the MP joint is held
in extension relative to the other fingers.
However, both the DIP
and PIP joints are free.</p>

<h4>CHAPTER 10</h4>

<p>This splint is kept on as is
until seen in the office.
The patient is allowed to move their fingers
within the splint as shown here.
Once in the office,
they are converted to a yoke splint.
Once seen in the office,
they are removed from their postoperative splint
and placed in this Orthoplast yoke
or relative motion splint as shown here.
These images are from handsurgeryresources.com.
I recommend motion within the splint
for four to six weeks postoperatively.
Thereafter, they can be weaned out of the splint.</p>


Watch this video of Dr. Asif Ilyas at the Rothman Institute performing and narrating the repair of a chronic degenerative saggital band rupture of the right ring finger.

Rothman Institute