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The Flexible Swan Neck Deformity in Rheumatoid Arthritis
The Flexible Swan Neck Deformity in Rheumatoid Arthritis Geoffrey C. S. Smith, MBBS, Rouin Amirfeyz, MD THE PATIENT A 42-year-old, right hand– dominant woman with wellcontrolled rheumatoid arthritis presents with swan neck deformities (SNDs) of the index middle and ring fingers. The proximal interphalangeal (PIP) joints have full passive range of motion. There is no swelling or tenderness over the volar aspect of the fingers. The wrist and metacarpophalangeal joints are well aligned and the deformity was initially evident at the PIP joint with secondary deformity at the distal interphalangeal (DIP) joint. She has difficulty with gripping objects in her work as a chef. Nonoperative treatment in the form of figure-of-8 splinting has not helped. Radiographs show that the joint is well preserved. THE QUESTION What is the best method of surgical treatment for flexible rheumatoid SND (Nalebuff type 1)1 resulting from PIP joint disease with volar plate attenuation? CURRENT OPINION Numerous surgical options exist for early-stage SND. If the etiology of SND originates at the DIP or metacarpophalangeal joint, these joints are treated primarily. The aim of surgery at the PIP joint is to prevent a fixed-extension deformity. The described soft tissue procedures include dermodesis, flexor tendon tenodesis, spiral oblique retinacular ligament reconstruction, and lateral band tenodesis. Multiple technical modifications have been proposed, with no clear consensus on their relative merits.
THE EVIDENCE Dermodesis An ellipse of skin is excised from the volar aspect of the PIP joint.2,3 The flexor sheath is not violated. The skin is closed with the PIP joint held flexed. It is said to be suitable for mild deformities only, because it tends to stretch over time and is often advised in conjunction with DIP joint arthrodesis.2,4 Flexor tendon tenodesis The technique described by Curtis5 uses a volar approach through which 1 slip of flexor digitorum superficialis (FDS) is then detached proximal to the PIP joint. The detached limb is either then attached to the bone of the proximal phalanx or the tendon sheath or back onto itself after being passed through a loop in the fibroosseous tunnel at the A2 pulley. Brulard et al6 recently published the medium-term results of FDS tenodesis using a similar technique in which the FDS was sutured to the A2 pulley. They reported 19 of 23 good or excellent results, with a correction of hyperextension of 33° and a gain in PIP flexion of 26°. At an average of 5 years, the PIP joint range of movement was reported to be 4° to 65°. In 1 patient (4 digits), the tenodesis was not powerful enough to adequately correct the PIP hyperextension deformity, although functional improvement was achieved. In all of their patients, the DIP joint position improved to some degree (70% full correction and 30% partial). The modification of Nalebuff and Millender3 avoids an incision in the digit; the FDS tendon is divided more proximally using a distal palm incision and is then passed around the A1 pulley. Although this technique is often recommended in the recent literature,7–9 there is no evidence regarding its advantages.
From the Hand Unit, Bristol Royal Infirmary, Bristol, United Kingdom. Received for publication November 14, 2012; accepted in revised form January 5, 2013. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Rouin Amirfeyz, MBBS, Hand Unit, Bristol Royal Infirmary, Marlborough Street, Bristol BS2 8HW, UK; e-mail: [email protected]. 0363-5023/13/38A07-0022$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.01.002
Retinacular ligament reconstruction The oblique retinacular ligament can be reconstructed using the ulnar conjoint lateral band or a free tendon graft.10,11 In the former technique, the conjoint lateral band is detached proximally and routed volar to the Cleland ligament so that it lies volar to the axis of PIP joint motion, and it is then attached to the flexor tendon
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Evidence-Based Medicine
EVIDENCE-BASED MEDICINE
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sheath at the A2 pulley. An alternative is to suture it to bone of the proximal phalanx. The use of a tendon graft is said to be preferable if the lateral band is of poor quality.11 Borisch and Haubmann12 reported the results of lateral band transfer on 26 joints (out of the initial series of 30). At an average of 22 months, they had no recurrence and the correction was from 21° hyperextension to 24° flexion deformity. The overall range of movement remained the same compared with the preoperative range, but it was in a more functional range. A potential concern is that in some cases Cleland’s ligament is diseased and therefore may not maintain the position of the transferred lateral band; however, insufficiency of the ligament was not noted in this series. Lateral band tenodesis/translocation Zancolli and Zancolli13 originally described lateral band tenodesis/translocation in patients with cerebral palsy. The radial lateral band is dissected and left attached proximally and distally. It is then transposed volarly and sutured into flexor sheath over the PIP joint by raising a volarly based flap of sheath, which is then placed between flexor tendon and the volar plate. This reroutes the lateral band volar to the axis of the PIP joint. This technique has been modified in a number of ways. Tonkin et al14 created a sling for the radial lateral band by suturing the palmar plate to the radial slip of the FDS. The lateral band is placed volar to the flap, which is then repaired to its original position. In rheumatoid disease, there is a concern that the lateral band may not be of sufficient quality to maintain the correction. However, in the series of Tonkin et al,14 in which 30 fingers in 12 patients with SND of mixed etiology (7 rheumatoid arthritis, 1 psoriatic arthropathy, 1 systemic lupus erythematosus, 1 cerebral palsy, 1 traumatic volar plate injury, and 1 traumatic mallet finger) with a preoperative hyperextension deformity averaging 16° were treated, all deformities were corrected with a postoperative average flexion contracture of 11° at an average of 42 weeks postoperatively. There were no recurrences. Strickland and Dellacqua15 transposed the ulnar lateral band and created a sling by raising a dorsally based flap of flexor sheath. There are no published data, but the authors stated that the results of his technique were similar to those described by Tonkin et al.14 de Bruin et al16 recently published the long-term results of the lateral band translocation technique of Tonkin et al14 in patients with cerebral palsy. In that series, the researchers noted deterioration in outcome
over time with a success rate of deformity correction of 84% at 1 year, which fell to 60% after 5 years. Sirotokova et al17 described a combination of the techniques of Littler10 and Zancolli and Zancolli13 in which the ulnar lateral band is used, detached proximally, routed through the flexor pulley, and attached to the bone of the proximal phalanx. This technique was used in 101 fingers in 43 patients. At a mean of 20 months postoperatively, a mean hyperextension deformity of 13° was converted to a flexion deformity of 13°. There were no recurrences. SHORTCOMINGS OF THE EVIDENCE The evidence consists of a few small, uncontrolled retrospective series, often by a promoter of a given operative technique. Most published clinical studies center on the stiff SND18,19 rather than the supple deformity. Whereas many review articles describe the abovementioned techniques,2,4,7,8,20,21 little evidence exists other than the original descriptions and modifications. In addition, these studies are potentially open to bias in the sense that most of them include several measurements from the same patients (inclusion of more than 1 finger per patient). This will inflate the sample size and potentially introduce type I error. Also, because most of the commonly used statistical tools assume the independence of the data, inclusion of interlinked data (2 or more fingers from the same patient) violates this assumption unless specific tests are used (such as involving generalized estimating equations).22 The number of different techniques and their modifications and also the relatively low number of patients with early-stage SND requiring operative intervention hamper the production of any good-quality clinical outcome studies. DIRECTIONS FOR FUTURE RESEARCH Use of modern suture anchors makes bone fixation techniques appealing to maintain a tenodesis in patients with rheumatoid arthritis, in whom soft tissue fixation may be unreliable. Biomechanical studies comparing the strength of these 2 modes of fixation are worth investigating. Well-designed, randomized, prospective clinical trials are required to compare the described procedures. Because of the small numbers of patients requiring surgical treatment, it is likely that these would need to be multicenter studies to demonstrate any statistically significant differences. To assess the outcome, both patient-based and physician-based tools are desirable. The former is important to ensure functional improvement from the patients’ perspective, and possibly a validated tool such as the Disabilities of the Arm,
JHS 䉬 Vol A, July
Shoulder, and Hand questionnaire will be useful. From the surgeons’ perspective, documenting the degree of deformity correction is important to see the correlation of the achieved range of movement and patient’s perceived global functional improvement. Grip strength measurement and detailed functional assessments, although interesting, are not possibly pragmatic and add little to the understanding of the underlying surgical pathology. Long-term follow-up is a further requirement in view of the late failures documented in some of the available literature. This may be related to soft tissue attenuation in the face of further flare-ups of disease. OUR CURRENT CONCEPTS FOR THIS PATIENT All of the techniques that involve a flexor tenodesis through a volar approach allow access to the tendon sheath for flexor tenosynovectomy if required. However, they do not address the associated DIP joint flexion deformity in any way. In contrast, techniques that involve the lateral band do not allow flexor tenosynovectomy, but they do allow correction of DIP joint deformity as long as the terminal extensor is intact. They also have the advantage of allowing dissection of the scarred, displaced lateral bands and PIP release in cases of PIP joint stiffness (type 3 swan neck) and therefore offer a universal technique for all grades of SND. Theoretical disadvantages of techniques that use the lateral band are that it may not be robust and dissection can be difficult. However, the modest available literature demonstrates good results using this technique and its modifications. Although the FDS tendon is more robust than the lateral band, it may also be attenuated as a result of PIP joint synovitis and therefore may not offer a stronger restraint to PIP joint hyperextension. In this patient, we favor using FDS tenodesis because there is no clinical evidence of active PIP joint disease. We would attach the FDS proximally to the metacarpal neck through a bone anchor to avoid an incision in the palm.
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REFERENCES 1. Nalebuff EA. The rheumatoid swan-neck deformity. Hand Clin. 1989;5(2):203–214. 2. Feldon P, Terrono A, Nalebuff E, Millender L. Rheumatoid arthritis and other connective tissue diseases. In: Wolfe S, Hotchkiss R, Pederson W, Kozin S, eds. Green’s Operative Hand Surgery. 6th ed. Philadelphia: Churchill Livingstone; 2011:1993. 3. Nalebuff EA, Millender LH. Surgical treatment of the swan-neck
21.
22.
1407
deformity in rheumatoid arthritis. Orthop Clin North Am. 1975;6(3):733–752. Knight SL. Assessment and management of swan neck deformity. In: Trail I, Hayton M, eds. International Congress Series 1295, FESSH Instructional Course Book, Surgery of the Rheumatoid Hand and Wrist. 1st ed. The Netherlands: Elsevier B.V.; 2006:154 –157. Curtis R. Sublimis tenodesis. In: Edmonson A, Crenshaw A, eds. Campbell’s Operative Orthopaedics. 6th ed. St Louis: CV Mosby; 1980:319. Brulard C, Sauvage A, Mares O, Wavreille G, Fontaine C. Treatment of rheumatoid swan neck deformity by tenodesis of proximal interphalangeal joint with a half flexor digitorum superficialis tendon: about 23 fingers at 61 months follow-up. Chir Main. 2012;31(3): 118 –127. Sebastin SJ, Chung KC. Reconstruction of digital deformities in rheumatoid arthritis. Hand Clin. 2011;27(1):87–104. Chung KC, Pushman AG. Current concepts in the management of the rheumatoid hand. J Hand Surg Am. 2011;36(4):736 –747; quiz 747. Horner G, Terrono AL. Soft tissue procedures for the rheumatoid swan neck finger deformity. Tech Hand Up Extrem Surg. 2000;4(1): 22–29. Littler J. Restoration of the oblique retinacular ligament for correcting hyperextension deformity of the proximal interphalangeal joint. In: Group D’Etude De La Main, eds. La main rhumatismale. 1st ed. Paris: G.E.M.; 1966:39 – 42. Thompson JS, Littler JW, Upton J. The spiral oblique retinacular ligament (SORL). J Hand Surg Am. 1978;3(5):482– 487. Borisch N, Haubmann P. Littler tenodesis for correction of swan neck deformity in rheumatoid arthritis. Oper Orthop Traumatol. 2011;23(3):232–240. Zancolli E, Zancolli E Jr. Surgical Rehabilitation of the Spastic Upper Limb in Cerebral Palsy: The Paralyzed Hand. Edinburgh: Churchill Livingstone; 1987:153–168. Tonkin MA, Hughes J, Smith KL. Lateral band translocation for swan-neck deformity. J Hand Surg Am. 1992;17(2):260 –267. Strickland J, Dellacqua D. Rheumatoid arthritis in the hand and digits. In: Berger R, Weiss A, eds. Hand Surgery. Philadelphia: Lippincott Williams & Wilkins; 2003:1179. de Bruin M, van Vliet DC, Smeulders MJ, Kreulen M. Long-term results of lateral band translocation for the correction of swan neck deformity in cerebral palsy. J Pediatr Orthop. 2010;30(1):67–70. Sirotakova M, Figus A, Jarrett P, Mishra A, Elliot D. Correction of swan neck deformity in rheumatoid arthritis using a new lateral extensor band technique. J Hand Surg Eur Vol. 2008;33(6):712–716. Kiefhaber TR, Strickland JW. Soft tissue reconstruction for rheumatoid swan-neck and boutonniere deformities: long-term results. J Hand Surg Am. 1993;18(6):984 –989. Gainor BJ, Hummel GL. Correction of rheumatoid swan-neck deformity by lateral band mobilization. J Hand Surg Am. 1985;10(3): 370 –376. Boyer MI, Gelberman RH. Operative correction of swan-neck and boutonniere deformities in the rheumatoid hand. J Am Acad Orthop Surg. 1999;7(2):92–100. Kozlow JH, Chung KC. Current concepts in the surgical management of rheumatoid and osteoarthritic hands and wrists. Hand Clin. 2011;27(1):31– 41. Sauerland S, Lefering R, Bayer-Sandow T, Brüser P, Neugebauer EA. Fingers, hands or patients? The concept of independent observations. J Hand Surg Br. 2003;28(2):102–105.
JHS 䉬 Vol A, July
Evidence-Based Medicine
FLEXIBLE SWAN NECK DEFORMITY
THE EVIDENCE Dermodesis An ellipse of skin is excised from the volar aspect of the PIP joint.2,3 The flexor sheath is not violated. The skin is closed with the PIP joint held flexed. It is said to be suitable for mild deformities only, because it tends to stretch over time and is often advised in conjunction with DIP joint arthrodesis.2,4 Flexor tendon tenodesis The technique described by Curtis5 uses a volar approach through which 1 slip of flexor digitorum superficialis (FDS) is then detached proximal to the PIP joint. The detached limb is either then attached to the bone of the proximal phalanx or the tendon sheath or back onto itself after being passed through a loop in the fibroosseous tunnel at the A2 pulley. Brulard et al6 recently published the medium-term results of FDS tenodesis using a similar technique in which the FDS was sutured to the A2 pulley. They reported 19 of 23 good or excellent results, with a correction of hyperextension of 33° and a gain in PIP flexion of 26°. At an average of 5 years, the PIP joint range of movement was reported to be 4° to 65°. In 1 patient (4 digits), the tenodesis was not powerful enough to adequately correct the PIP hyperextension deformity, although functional improvement was achieved. In all of their patients, the DIP joint position improved to some degree (70% full correction and 30% partial). The modification of Nalebuff and Millender3 avoids an incision in the digit; the FDS tendon is divided more proximally using a distal palm incision and is then passed around the A1 pulley. Although this technique is often recommended in the recent literature,7–9 there is no evidence regarding its advantages.
From the Hand Unit, Bristol Royal Infirmary, Bristol, United Kingdom. Received for publication November 14, 2012; accepted in revised form January 5, 2013. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Rouin Amirfeyz, MBBS, Hand Unit, Bristol Royal Infirmary, Marlborough Street, Bristol BS2 8HW, UK; e-mail: [email protected]. 0363-5023/13/38A07-0022$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.01.002
Retinacular ligament reconstruction The oblique retinacular ligament can be reconstructed using the ulnar conjoint lateral band or a free tendon graft.10,11 In the former technique, the conjoint lateral band is detached proximally and routed volar to the Cleland ligament so that it lies volar to the axis of PIP joint motion, and it is then attached to the flexor tendon
© ASSH 䉬 Published by Elsevier, Inc. All rights reserved. 䉬 1405
Evidence-Based Medicine
EVIDENCE-BASED MEDICINE
1406
FLEXIBLE SWAN NECK DEFORMITY
Evidence-Based Medicine
sheath at the A2 pulley. An alternative is to suture it to bone of the proximal phalanx. The use of a tendon graft is said to be preferable if the lateral band is of poor quality.11 Borisch and Haubmann12 reported the results of lateral band transfer on 26 joints (out of the initial series of 30). At an average of 22 months, they had no recurrence and the correction was from 21° hyperextension to 24° flexion deformity. The overall range of movement remained the same compared with the preoperative range, but it was in a more functional range. A potential concern is that in some cases Cleland’s ligament is diseased and therefore may not maintain the position of the transferred lateral band; however, insufficiency of the ligament was not noted in this series. Lateral band tenodesis/translocation Zancolli and Zancolli13 originally described lateral band tenodesis/translocation in patients with cerebral palsy. The radial lateral band is dissected and left attached proximally and distally. It is then transposed volarly and sutured into flexor sheath over the PIP joint by raising a volarly based flap of sheath, which is then placed between flexor tendon and the volar plate. This reroutes the lateral band volar to the axis of the PIP joint. This technique has been modified in a number of ways. Tonkin et al14 created a sling for the radial lateral band by suturing the palmar plate to the radial slip of the FDS. The lateral band is placed volar to the flap, which is then repaired to its original position. In rheumatoid disease, there is a concern that the lateral band may not be of sufficient quality to maintain the correction. However, in the series of Tonkin et al,14 in which 30 fingers in 12 patients with SND of mixed etiology (7 rheumatoid arthritis, 1 psoriatic arthropathy, 1 systemic lupus erythematosus, 1 cerebral palsy, 1 traumatic volar plate injury, and 1 traumatic mallet finger) with a preoperative hyperextension deformity averaging 16° were treated, all deformities were corrected with a postoperative average flexion contracture of 11° at an average of 42 weeks postoperatively. There were no recurrences. Strickland and Dellacqua15 transposed the ulnar lateral band and created a sling by raising a dorsally based flap of flexor sheath. There are no published data, but the authors stated that the results of his technique were similar to those described by Tonkin et al.14 de Bruin et al16 recently published the long-term results of the lateral band translocation technique of Tonkin et al14 in patients with cerebral palsy. In that series, the researchers noted deterioration in outcome
over time with a success rate of deformity correction of 84% at 1 year, which fell to 60% after 5 years. Sirotokova et al17 described a combination of the techniques of Littler10 and Zancolli and Zancolli13 in which the ulnar lateral band is used, detached proximally, routed through the flexor pulley, and attached to the bone of the proximal phalanx. This technique was used in 101 fingers in 43 patients. At a mean of 20 months postoperatively, a mean hyperextension deformity of 13° was converted to a flexion deformity of 13°. There were no recurrences. SHORTCOMINGS OF THE EVIDENCE The evidence consists of a few small, uncontrolled retrospective series, often by a promoter of a given operative technique. Most published clinical studies center on the stiff SND18,19 rather than the supple deformity. Whereas many review articles describe the abovementioned techniques,2,4,7,8,20,21 little evidence exists other than the original descriptions and modifications. In addition, these studies are potentially open to bias in the sense that most of them include several measurements from the same patients (inclusion of more than 1 finger per patient). This will inflate the sample size and potentially introduce type I error. Also, because most of the commonly used statistical tools assume the independence of the data, inclusion of interlinked data (2 or more fingers from the same patient) violates this assumption unless specific tests are used (such as involving generalized estimating equations).22 The number of different techniques and their modifications and also the relatively low number of patients with early-stage SND requiring operative intervention hamper the production of any good-quality clinical outcome studies. DIRECTIONS FOR FUTURE RESEARCH Use of modern suture anchors makes bone fixation techniques appealing to maintain a tenodesis in patients with rheumatoid arthritis, in whom soft tissue fixation may be unreliable. Biomechanical studies comparing the strength of these 2 modes of fixation are worth investigating. Well-designed, randomized, prospective clinical trials are required to compare the described procedures. Because of the small numbers of patients requiring surgical treatment, it is likely that these would need to be multicenter studies to demonstrate any statistically significant differences. To assess the outcome, both patient-based and physician-based tools are desirable. The former is important to ensure functional improvement from the patients’ perspective, and possibly a validated tool such as the Disabilities of the Arm,
JHS 䉬 Vol A, July
Shoulder, and Hand questionnaire will be useful. From the surgeons’ perspective, documenting the degree of deformity correction is important to see the correlation of the achieved range of movement and patient’s perceived global functional improvement. Grip strength measurement and detailed functional assessments, although interesting, are not possibly pragmatic and add little to the understanding of the underlying surgical pathology. Long-term follow-up is a further requirement in view of the late failures documented in some of the available literature. This may be related to soft tissue attenuation in the face of further flare-ups of disease. OUR CURRENT CONCEPTS FOR THIS PATIENT All of the techniques that involve a flexor tenodesis through a volar approach allow access to the tendon sheath for flexor tenosynovectomy if required. However, they do not address the associated DIP joint flexion deformity in any way. In contrast, techniques that involve the lateral band do not allow flexor tenosynovectomy, but they do allow correction of DIP joint deformity as long as the terminal extensor is intact. They also have the advantage of allowing dissection of the scarred, displaced lateral bands and PIP release in cases of PIP joint stiffness (type 3 swan neck) and therefore offer a universal technique for all grades of SND. Theoretical disadvantages of techniques that use the lateral band are that it may not be robust and dissection can be difficult. However, the modest available literature demonstrates good results using this technique and its modifications. Although the FDS tendon is more robust than the lateral band, it may also be attenuated as a result of PIP joint synovitis and therefore may not offer a stronger restraint to PIP joint hyperextension. In this patient, we favor using FDS tenodesis because there is no clinical evidence of active PIP joint disease. We would attach the FDS proximally to the metacarpal neck through a bone anchor to avoid an incision in the palm.
4.
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6.
7. 8.
9.
10.
11. 12.
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14. 15.
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REFERENCES 1. Nalebuff EA. The rheumatoid swan-neck deformity. Hand Clin. 1989;5(2):203–214. 2. Feldon P, Terrono A, Nalebuff E, Millender L. Rheumatoid arthritis and other connective tissue diseases. In: Wolfe S, Hotchkiss R, Pederson W, Kozin S, eds. Green’s Operative Hand Surgery. 6th ed. Philadelphia: Churchill Livingstone; 2011:1993. 3. Nalebuff EA, Millender LH. Surgical treatment of the swan-neck
21.
22.
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deformity in rheumatoid arthritis. Orthop Clin North Am. 1975;6(3):733–752. Knight SL. Assessment and management of swan neck deformity. In: Trail I, Hayton M, eds. International Congress Series 1295, FESSH Instructional Course Book, Surgery of the Rheumatoid Hand and Wrist. 1st ed. The Netherlands: Elsevier B.V.; 2006:154 –157. Curtis R. Sublimis tenodesis. In: Edmonson A, Crenshaw A, eds. Campbell’s Operative Orthopaedics. 6th ed. St Louis: CV Mosby; 1980:319. Brulard C, Sauvage A, Mares O, Wavreille G, Fontaine C. Treatment of rheumatoid swan neck deformity by tenodesis of proximal interphalangeal joint with a half flexor digitorum superficialis tendon: about 23 fingers at 61 months follow-up. Chir Main. 2012;31(3): 118 –127. Sebastin SJ, Chung KC. Reconstruction of digital deformities in rheumatoid arthritis. Hand Clin. 2011;27(1):87–104. Chung KC, Pushman AG. Current concepts in the management of the rheumatoid hand. J Hand Surg Am. 2011;36(4):736 –747; quiz 747. Horner G, Terrono AL. Soft tissue procedures for the rheumatoid swan neck finger deformity. Tech Hand Up Extrem Surg. 2000;4(1): 22–29. Littler J. Restoration of the oblique retinacular ligament for correcting hyperextension deformity of the proximal interphalangeal joint. In: Group D’Etude De La Main, eds. La main rhumatismale. 1st ed. Paris: G.E.M.; 1966:39 – 42. Thompson JS, Littler JW, Upton J. The spiral oblique retinacular ligament (SORL). J Hand Surg Am. 1978;3(5):482– 487. Borisch N, Haubmann P. Littler tenodesis for correction of swan neck deformity in rheumatoid arthritis. Oper Orthop Traumatol. 2011;23(3):232–240. Zancolli E, Zancolli E Jr. Surgical Rehabilitation of the Spastic Upper Limb in Cerebral Palsy: The Paralyzed Hand. Edinburgh: Churchill Livingstone; 1987:153–168. Tonkin MA, Hughes J, Smith KL. Lateral band translocation for swan-neck deformity. J Hand Surg Am. 1992;17(2):260 –267. Strickland J, Dellacqua D. Rheumatoid arthritis in the hand and digits. In: Berger R, Weiss A, eds. Hand Surgery. Philadelphia: Lippincott Williams & Wilkins; 2003:1179. de Bruin M, van Vliet DC, Smeulders MJ, Kreulen M. Long-term results of lateral band translocation for the correction of swan neck deformity in cerebral palsy. J Pediatr Orthop. 2010;30(1):67–70. Sirotakova M, Figus A, Jarrett P, Mishra A, Elliot D. Correction of swan neck deformity in rheumatoid arthritis using a new lateral extensor band technique. J Hand Surg Eur Vol. 2008;33(6):712–716. Kiefhaber TR, Strickland JW. Soft tissue reconstruction for rheumatoid swan-neck and boutonniere deformities: long-term results. J Hand Surg Am. 1993;18(6):984 –989. Gainor BJ, Hummel GL. Correction of rheumatoid swan-neck deformity by lateral band mobilization. J Hand Surg Am. 1985;10(3): 370 –376. Boyer MI, Gelberman RH. Operative correction of swan-neck and boutonniere deformities in the rheumatoid hand. J Am Acad Orthop Surg. 1999;7(2):92–100. Kozlow JH, Chung KC. Current concepts in the surgical management of rheumatoid and osteoarthritic hands and wrists. Hand Clin. 2011;27(1):31– 41. Sauerland S, Lefering R, Bayer-Sandow T, Brüser P, Neugebauer EA. Fingers, hands or patients? The concept of independent observations. J Hand Surg Br. 2003;28(2):102–105.
JHS 䉬 Vol A, July
Evidence-Based Medicine
FLEXIBLE SWAN NECK DEFORMITY