Repair of a Chronic Degenerative Sagittal Band Rupture of the Right Ring Finger
Transcription
CHAPTER 1
Sagittal band ruptures representan extensor tendon injury resultingin subluxation of the extensor tendonover the metacarpal headwith active flexionand then active extension.Here, you can see the snapping tendonover the middle metacarpal head.Here is an intraoperative exampleof the same thing.The surgery is being performedunder a local anesthesia.When the patient's fingeris extended against resistance,you can see the subluxationof the extensor tendon.Sagittal band rupturescan either be traumatic in originas in this case,or degenerative in originas in the first example.
CHAPTER 2
The video case being presented here consistsof a chronic degenerative sagittal band ruptureof the ring finger.The procedure is being performedunder just a local anesthesiain a wide awake hand surgery fashion.An initial injection of the surgical sitewith lidocaine, with epinephrine,buffered with bicarbonate was appliedin the preoperative area.The patient is now being preparedfor surgery in the operating room.
The surgical site is being marked outdirectly over the metacarpal head.The surgical site is being augmentedwith some additional local anesthetic.
CHAPTER 3
The incision is placed directlyover the MP joint, consistentwith a zone five of the extensor mechanism.
CHAPTER 4
Blunt dissection is then performed downto the extensor mechanismuntil the extensor tendonand the sagittal band is fully exposed.Once adequately exposed,active motion by the patient confirms a subluxationof the extensor tendonin the ulnar directionupon active flexion followedby active extension.The ulnar subluxation of the extensor tendon impliesthat the radial sagittal bandis incompetent as being examined here.In cases of acute ruptures,the ends of the sagittal bandare readily reapproximated and repaired.In chronic ruptures,adequate tissue may not be availablefor primary repairand may require augmentationwith either a graft or a transferfrom the bordering digit sagittal band.In this case, adequate tissue is confirmedfor primary repair along the radial side.
CHAPTER 5
Prior to proceeding with the repair,the ulnar sagittal band is also examined.In chronic sagittal band rupture cases,the competent side often becomes contractedand may require release to helpwith the centering of the extensor mechanismas shown here.The release of the contracted sideshould be performed sharplyfrom proximal to distalon a slow progressive basis until satisfiedthat adequate recentralizationof the tendon has been achieved.Note, upon release of the contracted side,that active motion of the fingerhas already restored centralizationof the extensor tendoneven before repairor imbrication of the ruptured side.
CHAPTER 6
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 2-0or 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 using3-0 Ethibond were used to repairthe sagittal band.
CHAPTER 7
Once repaired, the finger is takenthrough an active range of motion by the patientto confirm a centralized motionof the extensor tendon without subluxation.
CHAPTER 8
Once satisfied with the repair,the wound is washed and closed.
CHAPTER 9
Once closed,perhaps the most important part of the caseis the splinting postoperatively.I recommend utilizing an Orthoplast yoke splintto be worn full-timefor the next four to six weeks postoperatively.These splints are made from Orthoplastin the office by our therapist.However, exiting the operating room today,a temporary plaster yoke splintis being applied as demonstrated here.This is a hand-based splintthat will place the MP jointin extension to offload the repair.The purpose of the yokeis to keep the operative MP joint extended relativeto the other MP joints while still allowingfor tendon excursion to occur.This is being performed herein the operating room,shown here by inserting rolled up Webrilbetween the operative finger and the plaster,so that the MP joint is heldin extension relative to the other fingers.However, both the DIPand PIP joints are free.
CHAPTER 10
This splint is kept on as isuntil seen in the office.The patient is allowed to move their fingerswithin 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 splintand placed in this Orthoplast yokeor relative motion splint as shown here.These images are from handsurgeryresources.com.I recommend motion within the splintfor four to six weeks postoperatively.Thereafter, they can be weaned out of the splint.
