- Email: [email protected]
The superficialis finger procedure
THE SUPERFICIALIS FINGER PROCEDURE WILLIAM H. KIRKPATRICK, MD, and RAYMOND J. KOBUS, MD
Severe flexor tendon injuries and failed tendon graft procedures may require a compromise of the standard principles of restoration of a three-joint, two-tendon flexor system. The superficialis finger procedure is an option in flexor tendon surgery to restore motion to the proximal interphalangeal joint by tendon graft or recession of the profundus tendon to the middle phalanx, with arthrodesis or tenodesis of the distal interphalangeal joint. KEY WORDS: superficlalis finger, salvage, tendon grafting
Restoration of a functional finger following failed primary flexor tendon repair or flexor tendon grafting continues to be a challenge to surgeons treating hand injuries. In some cases of severe damage to the finger involving tendon, pulley, bone, nerve, and vascular injury, the goals of restoration of a three-joint, two-tendon flexor system may require a compromise for the benefit of hand function. Conversion to a superficialis finger is such a compromise in that attention is directed to restoration of proximal interphalangeal (PIP) joint motion at the sacrifice of distal interphalangeal (DIP) joint motion, establishing a two-joint, one-tendon flexor system. Indications for this "redemption operation ''1'2 include the following: (1) failure of tendon grafting as a result of an incompetent pulley system or rupture of the graft insertion in the distal phalanx; (2) flexor tendon disruption with an inadequate DIP joint caused by arthrosis or irreparable extensor tendon damage or insufficiency; (3) multiple prior failed procedures on the flexor tendon system.
the proximal one third of the middle phalanx with a drill bit or bone awl with small curettes. The w i n d o w should be of sufficient diameter to accept the distal aspect of the tendon graft. One or two Keith needles are then inserted with or without power into the palmar window and through the dorsal cortex, angulating distally to
/ / I/
t 7'
/
TECHNIQUE The principles of staged flexor tendon reconstruction have been previously discussed in this journal and must be closely followed. The distal attachment of the tendon graft is at the level of the middle phalanx or into the middle phalanx, rather than into the distal phalanx. This juncture can be made into bone or by suturing the tendon graft to a remaining 1-cm segment of the original superficialis insertion into the middle phalanx or to a portion of pulley overlying the middle phalanx. A tendon-to-bone distal juncture is more commonly used. The distal end of the tendon graft is secured with a 3-0 or 4-0 nonabsorbable pull-out suture or wire using the Bunnell suture technique. Care is taken to protect the remaining or reconstructed pulleys, in particular the A2 pulley. A unicortical window is then fashioned in From the Department of Orthopaedic Surgery, The Bryn Mawr Hospital, Bryn Mawr, PA, and Thomas Jefferson University, Philadelphia, PA; and the Department of Orthopaedic Surgery, Ohio State University Hospital, Columbus, OH. Address reprint requests to William H. Kirkpatrick, MD, Hand Surgical Associates, 830 Old Lancaster Rd, Suites 300-301, Bryn Mawr, PA 19010. Copyright 9 1993 by W. B. Saunders Company 1048-6666/93/0304-0008505.00/0
/
/J
!
l
9
/
Fig 1. A single Keith needle has been inserted through a unicortical window in the proximal third of the middle phalanx of the index finger. A nonabsorbable suture has been woven through the distal end of the tendon graft and then into the eye of the Keith needle. The DIP joint has been arthrodesed with Kirschner wire fixation.
Operative Techniques in Orthopaedics, Vol 3, No 4 (October), 1993: pp 303-305
303
avoid the insertion of the central slip. The Keith needle is left in place as the tendon sutures are looped into the eye of the needle (Fig 1). The needle is withdrawn dorsally, delivering the tendon graft into the cortical window. The suture is securely tied to a button over the middle phalanx with nonadherent gauze applied between the skin and button. If two Keith needles are used, a small incision can be made longitudinally through the extensor mechanism to tie the suture onto the dorsal periosteum and bone. Additional anchoring sutures reinforce the tendon juncture to the remaining tails of the original superficialis tendon insertion or to the periosteum (Figs 2 and 3). The resting posture of the finger should reflect adequate tension in the flexor system. With the wrist in neutral, slight increases in the degrees of flexion of the
A
, <"
!
PIP joints of the index through small digits should be observed. Improper tension could compromise the resuit. Arthrodesis of the DIP joint is performed before establishing the tendon juncture, to avoid excessive manipulation of the tendon-to-bone attachment. Various techniques 3-6 can be used with proper fixation. The cupa n d - c o n e m e t h o d or carefully p l a c e d s a w - c u t s in opposing surfaces of the middle and distal phalanges, stabilized with Kirschner wire fixation, are most commonly used, preserving 20 ~ to 30 ~ of flexion at the arthrodesis site. Tenodesis can also be performed instead of arthrodesis depending on the surgeon's preference. After surgery, a splint is applied in the operating room with the wrist in 30 ~ of flexion, the metacarpal phalangeal (MP) joints in approximately 70~ of flexion and the PIP
\ J
./
d
i
s
-- y / ~
,/ // . i
!
/
,/
J
/
#
/
/ /
/
./
/
!
/
/
/
/
/ / /
\
/
/
/
/
/
<
/
v' J '5' /
Fig 2. (A) Palmar view of completed superficialis finger procedure. The tendon graft has been drawn into the unicortical middle phalanx window and the tendon suture has been tied dorsally over a button. The retinacular pulley system has been carefully preserved (or reconstructed). (B) Lateral view of same. 304
KIRKPATRICK AND KOBUS
c o m p l i a n t w i t h the p o s t o p e r a t i v e t h e r a p y r e g i m e n o f staged flexor t e n d o n r e c o n s t r u c t i o n J 6-1s
CONCLUSION The superficialis finger p r o c e d u r e can be a useful alternative in flexor t e n d o n s u r g e r y for severe flexor t e n d o n injuries a n d failed t e n d o n graft p r o c e d u r e s . In these situations, a m o r e limited goal of a two-joint, o n e - t e n d o n flexor s y s t e m is justified to restore functional m o t i o n to the PIP joint.
Fig 3. Radiographic lateral view of completed superficlalls finger procedure, using stainless steel wire suture thru the tendon graft and button. Nonadherent gauze between the skin and button is held in place with circumferential wrapping of the wire over the gauze. joints in extension. P o s t o p e r a t i v e m a n a g e m e n t is the s a m e as u s e d w i t h a flexor t e n d o n graft a n d as p r e v i o u s l y discussed in this journal. H o w e v e r , the DIP joint m u s t be protected, p r e f e r a b l y w i t h an o r t h o p l a s t splint. T h e pull-out s u t u r e a n d b u t t o n are r e m o v e d in 4 w e e k s .
DISCUSSION Restoration of m o t i o n at the PIP joint w i t h sacrifice of m o t i o n at the DIP joint is b a s e d o n the concept that t h e PIP joint m a k e s the greatest contribution to functional r a n g e of m o t i o n in the finger. 7-9 T e n d o n graft insertion into the m i d d l e p h a l a n x e n h a n c e s PIP joint m o t i o n , requiting less m u s c l e tension for joint flexion as well as o p t i m i z i n g force t r a n s m i s s i o n s to the finger. 1~ Because f e w e r pulleys are n e e d e d for force transmission, t e n d o n drag a n d potential a d h e s i o n s are m i n i m i z e d . T h e r a p y p o s t o p e r a t i v e l y is simplified b e c a u s e of the d e c r e a s e d excursion r e q u i r e d for PIP flexion as well as the d e c r e a s e d potential for a d h e s i o n s . Little clinical i n f o r m a t i o n h a s b e e n r e p o r t e d o n this p r o c e d u r e , H b u t o u r r e v i e w of 40 patients indicates a n a v e r a g e gain of 30 ~ of active flexion at the PIP joint w i t h no significant loss of m o t i o n at the M P joint. 12 I m p r o v e d m o t i o n w a s also described b y H u n t e r et al in 15 of 16 patients. ~3 T h e y h a v e u s e d this technique for failed active t e n d o n i m p l a n t s w i t h DIP joint insufficiency, as well as s u g g e s t i n g its use in cases of multiple digit injury a n d m u l t i p l e p u l l e y injury. 14'15 S c h n e i d e r et al h a v e likewise r e c o m m e n d e d this t e c h n i q u e in the m a n a g e m e n t of s e c o n d stage t e n d o n graft r u p t u r e s a n d h a v e s u g g e s t e d its u s e in patients w h o m a y b e less t h a n fully
THE SUPERFICIALIS PROCEDURE
REFERENCES 1. Osborne G: The sublimis tendon replacement technique in tendon injuries. J Bone Joint Surg [Br] 42:647, 1960 2. Osborne G: Redemption operations for flexor tendon injuries, in Stack HG, Bolton H (eds): Proceedings of the Second Hand Club. London, England, British Society for Surgery of the H~nd, 1975, pp 248-250 3. Carroll RE, Hill NA: Small joint arthrodesis in hand reconstruction. J Bone Joint Surg [Am] 51:1219-1221, 1969 4. Engel J, Tsur H, Farin I: A comparison between K-wire and compression screw fixation after arthrodesis of the distal interphalangeal joint. Plast Reconst Surg 60:611-614, 1977 5. McGlynn JT, Smith RA, Bogumill GP: Arthrodesis of small joint of the hand: A rapid and effective technique. J Hand Surg [Am] 13: 595-599, 1988 6. Watson HK, Shaffer SR: Concave-convex arthrodesis in joints of the hand. Plast Reconst Surg 46:368-371, 1970 7. Hunter JM, Cook JF: The pulley system: Rationale for reconstruction, in Strickland JW, Steichen JB (eds): Difficult Problems in Hand Surgery. St Louis, MO, Mosby, 1982, pp 94-102 8. Littler JW: The physiology and dynamic function of the hand. Surg Clin North Am 40:259-266, 1960 9. Hume MC, Gellman H, McKellop H, et al: Functional range of motion of the joints of the hand. J Hand Surg [Am] 15:240-243, 1990 10. Brand PW: Clinical mechanics of the hand. St Louis, MO, Mosby, 1985, pp 30-60 11. Chuinard RG, Dabezies EJ, Mathews RE: Two-stage superficialis tendon reconstruction in severely damaged fingers. J Hand Surg [Am] 5:135-143, 1980 12. Kobus R, Kirkpatrick W, Hunter J: Unpublished observations, 1993 13. Hunter JM, Schneider LH, Fietti VG: Reconstruction of the sublimis finger. Orthop Trans 3:321-322, 1979 14. Hunter JM: Tendon salvage and the active tendon implant: A perspective. Hand Clin 1:181-186, 1985 15. Hunter JM, Singer DI, Mackin EJ: Staged flexor tendon reconstruction using passive and active tendon implants, In Hunter JM, Schneider LH, Mackin EJ, et al (eds): Rehabilitation of the Hand: Surgery and Therapy. St Louis, MO, Mosby, 1990, pp 446-452 16. Schneider LH, Hunter JM, Fietti VG: The flexor superficialis finger: A salvage procedure, in Hunter JM, Schneider LH, Mackin EJ (eds): Tendon Surgery in the Hand. St Louis, MO, Mosby, 1987, pp 312316 17. Schneider LH: Staged flexor tendon reconstruction using the method of Hunter. Clin Orthop Rel Res 171:164-171, 1982 18. Schneider LH: Staged tendon reconstruction. Hand Clin 1:109120,1985
305
Severe flexor tendon injuries and failed tendon graft procedures may require a compromise of the standard principles of restoration of a three-joint, two-tendon flexor system. The superficialis finger procedure is an option in flexor tendon surgery to restore motion to the proximal interphalangeal joint by tendon graft or recession of the profundus tendon to the middle phalanx, with arthrodesis or tenodesis of the distal interphalangeal joint. KEY WORDS: superficlalis finger, salvage, tendon grafting
Restoration of a functional finger following failed primary flexor tendon repair or flexor tendon grafting continues to be a challenge to surgeons treating hand injuries. In some cases of severe damage to the finger involving tendon, pulley, bone, nerve, and vascular injury, the goals of restoration of a three-joint, two-tendon flexor system may require a compromise for the benefit of hand function. Conversion to a superficialis finger is such a compromise in that attention is directed to restoration of proximal interphalangeal (PIP) joint motion at the sacrifice of distal interphalangeal (DIP) joint motion, establishing a two-joint, one-tendon flexor system. Indications for this "redemption operation ''1'2 include the following: (1) failure of tendon grafting as a result of an incompetent pulley system or rupture of the graft insertion in the distal phalanx; (2) flexor tendon disruption with an inadequate DIP joint caused by arthrosis or irreparable extensor tendon damage or insufficiency; (3) multiple prior failed procedures on the flexor tendon system.
the proximal one third of the middle phalanx with a drill bit or bone awl with small curettes. The w i n d o w should be of sufficient diameter to accept the distal aspect of the tendon graft. One or two Keith needles are then inserted with or without power into the palmar window and through the dorsal cortex, angulating distally to
/ / I/
t 7'
/
TECHNIQUE The principles of staged flexor tendon reconstruction have been previously discussed in this journal and must be closely followed. The distal attachment of the tendon graft is at the level of the middle phalanx or into the middle phalanx, rather than into the distal phalanx. This juncture can be made into bone or by suturing the tendon graft to a remaining 1-cm segment of the original superficialis insertion into the middle phalanx or to a portion of pulley overlying the middle phalanx. A tendon-to-bone distal juncture is more commonly used. The distal end of the tendon graft is secured with a 3-0 or 4-0 nonabsorbable pull-out suture or wire using the Bunnell suture technique. Care is taken to protect the remaining or reconstructed pulleys, in particular the A2 pulley. A unicortical window is then fashioned in From the Department of Orthopaedic Surgery, The Bryn Mawr Hospital, Bryn Mawr, PA, and Thomas Jefferson University, Philadelphia, PA; and the Department of Orthopaedic Surgery, Ohio State University Hospital, Columbus, OH. Address reprint requests to William H. Kirkpatrick, MD, Hand Surgical Associates, 830 Old Lancaster Rd, Suites 300-301, Bryn Mawr, PA 19010. Copyright 9 1993 by W. B. Saunders Company 1048-6666/93/0304-0008505.00/0
/
/J
!
l
9
/
Fig 1. A single Keith needle has been inserted through a unicortical window in the proximal third of the middle phalanx of the index finger. A nonabsorbable suture has been woven through the distal end of the tendon graft and then into the eye of the Keith needle. The DIP joint has been arthrodesed with Kirschner wire fixation.
Operative Techniques in Orthopaedics, Vol 3, No 4 (October), 1993: pp 303-305
303
avoid the insertion of the central slip. The Keith needle is left in place as the tendon sutures are looped into the eye of the needle (Fig 1). The needle is withdrawn dorsally, delivering the tendon graft into the cortical window. The suture is securely tied to a button over the middle phalanx with nonadherent gauze applied between the skin and button. If two Keith needles are used, a small incision can be made longitudinally through the extensor mechanism to tie the suture onto the dorsal periosteum and bone. Additional anchoring sutures reinforce the tendon juncture to the remaining tails of the original superficialis tendon insertion or to the periosteum (Figs 2 and 3). The resting posture of the finger should reflect adequate tension in the flexor system. With the wrist in neutral, slight increases in the degrees of flexion of the
A
, <"
!
PIP joints of the index through small digits should be observed. Improper tension could compromise the resuit. Arthrodesis of the DIP joint is performed before establishing the tendon juncture, to avoid excessive manipulation of the tendon-to-bone attachment. Various techniques 3-6 can be used with proper fixation. The cupa n d - c o n e m e t h o d or carefully p l a c e d s a w - c u t s in opposing surfaces of the middle and distal phalanges, stabilized with Kirschner wire fixation, are most commonly used, preserving 20 ~ to 30 ~ of flexion at the arthrodesis site. Tenodesis can also be performed instead of arthrodesis depending on the surgeon's preference. After surgery, a splint is applied in the operating room with the wrist in 30 ~ of flexion, the metacarpal phalangeal (MP) joints in approximately 70~ of flexion and the PIP
\ J
./
d
i
s
-- y / ~
,/ // . i
!
/
,/
J
/
#
/
/ /
/
./
/
!
/
/
/
/
/ / /
\
/
/
/
/
/
<
/
v' J '5' /
Fig 2. (A) Palmar view of completed superficialis finger procedure. The tendon graft has been drawn into the unicortical middle phalanx window and the tendon suture has been tied dorsally over a button. The retinacular pulley system has been carefully preserved (or reconstructed). (B) Lateral view of same. 304
KIRKPATRICK AND KOBUS
c o m p l i a n t w i t h the p o s t o p e r a t i v e t h e r a p y r e g i m e n o f staged flexor t e n d o n r e c o n s t r u c t i o n J 6-1s
CONCLUSION The superficialis finger p r o c e d u r e can be a useful alternative in flexor t e n d o n s u r g e r y for severe flexor t e n d o n injuries a n d failed t e n d o n graft p r o c e d u r e s . In these situations, a m o r e limited goal of a two-joint, o n e - t e n d o n flexor s y s t e m is justified to restore functional m o t i o n to the PIP joint.
Fig 3. Radiographic lateral view of completed superficlalls finger procedure, using stainless steel wire suture thru the tendon graft and button. Nonadherent gauze between the skin and button is held in place with circumferential wrapping of the wire over the gauze. joints in extension. P o s t o p e r a t i v e m a n a g e m e n t is the s a m e as u s e d w i t h a flexor t e n d o n graft a n d as p r e v i o u s l y discussed in this journal. H o w e v e r , the DIP joint m u s t be protected, p r e f e r a b l y w i t h an o r t h o p l a s t splint. T h e pull-out s u t u r e a n d b u t t o n are r e m o v e d in 4 w e e k s .
DISCUSSION Restoration of m o t i o n at the PIP joint w i t h sacrifice of m o t i o n at the DIP joint is b a s e d o n the concept that t h e PIP joint m a k e s the greatest contribution to functional r a n g e of m o t i o n in the finger. 7-9 T e n d o n graft insertion into the m i d d l e p h a l a n x e n h a n c e s PIP joint m o t i o n , requiting less m u s c l e tension for joint flexion as well as o p t i m i z i n g force t r a n s m i s s i o n s to the finger. 1~ Because f e w e r pulleys are n e e d e d for force transmission, t e n d o n drag a n d potential a d h e s i o n s are m i n i m i z e d . T h e r a p y p o s t o p e r a t i v e l y is simplified b e c a u s e of the d e c r e a s e d excursion r e q u i r e d for PIP flexion as well as the d e c r e a s e d potential for a d h e s i o n s . Little clinical i n f o r m a t i o n h a s b e e n r e p o r t e d o n this p r o c e d u r e , H b u t o u r r e v i e w of 40 patients indicates a n a v e r a g e gain of 30 ~ of active flexion at the PIP joint w i t h no significant loss of m o t i o n at the M P joint. 12 I m p r o v e d m o t i o n w a s also described b y H u n t e r et al in 15 of 16 patients. ~3 T h e y h a v e u s e d this technique for failed active t e n d o n i m p l a n t s w i t h DIP joint insufficiency, as well as s u g g e s t i n g its use in cases of multiple digit injury a n d m u l t i p l e p u l l e y injury. 14'15 S c h n e i d e r et al h a v e likewise r e c o m m e n d e d this t e c h n i q u e in the m a n a g e m e n t of s e c o n d stage t e n d o n graft r u p t u r e s a n d h a v e s u g g e s t e d its u s e in patients w h o m a y b e less t h a n fully
THE SUPERFICIALIS PROCEDURE
REFERENCES 1. Osborne G: The sublimis tendon replacement technique in tendon injuries. J Bone Joint Surg [Br] 42:647, 1960 2. Osborne G: Redemption operations for flexor tendon injuries, in Stack HG, Bolton H (eds): Proceedings of the Second Hand Club. London, England, British Society for Surgery of the H~nd, 1975, pp 248-250 3. Carroll RE, Hill NA: Small joint arthrodesis in hand reconstruction. J Bone Joint Surg [Am] 51:1219-1221, 1969 4. Engel J, Tsur H, Farin I: A comparison between K-wire and compression screw fixation after arthrodesis of the distal interphalangeal joint. Plast Reconst Surg 60:611-614, 1977 5. McGlynn JT, Smith RA, Bogumill GP: Arthrodesis of small joint of the hand: A rapid and effective technique. J Hand Surg [Am] 13: 595-599, 1988 6. Watson HK, Shaffer SR: Concave-convex arthrodesis in joints of the hand. Plast Reconst Surg 46:368-371, 1970 7. Hunter JM, Cook JF: The pulley system: Rationale for reconstruction, in Strickland JW, Steichen JB (eds): Difficult Problems in Hand Surgery. St Louis, MO, Mosby, 1982, pp 94-102 8. Littler JW: The physiology and dynamic function of the hand. Surg Clin North Am 40:259-266, 1960 9. Hume MC, Gellman H, McKellop H, et al: Functional range of motion of the joints of the hand. J Hand Surg [Am] 15:240-243, 1990 10. Brand PW: Clinical mechanics of the hand. St Louis, MO, Mosby, 1985, pp 30-60 11. Chuinard RG, Dabezies EJ, Mathews RE: Two-stage superficialis tendon reconstruction in severely damaged fingers. J Hand Surg [Am] 5:135-143, 1980 12. Kobus R, Kirkpatrick W, Hunter J: Unpublished observations, 1993 13. Hunter JM, Schneider LH, Fietti VG: Reconstruction of the sublimis finger. Orthop Trans 3:321-322, 1979 14. Hunter JM: Tendon salvage and the active tendon implant: A perspective. Hand Clin 1:181-186, 1985 15. Hunter JM, Singer DI, Mackin EJ: Staged flexor tendon reconstruction using passive and active tendon implants, In Hunter JM, Schneider LH, Mackin EJ, et al (eds): Rehabilitation of the Hand: Surgery and Therapy. St Louis, MO, Mosby, 1990, pp 446-452 16. Schneider LH, Hunter JM, Fietti VG: The flexor superficialis finger: A salvage procedure, in Hunter JM, Schneider LH, Mackin EJ (eds): Tendon Surgery in the Hand. St Louis, MO, Mosby, 1987, pp 312316 17. Schneider LH: Staged flexor tendon reconstruction using the method of Hunter. Clin Orthop Rel Res 171:164-171, 1982 18. Schneider LH: Staged tendon reconstruction. Hand Clin 1:109120,1985
305