Extensor Lags Research Articles

Scar overlapping suture for treating chronic tendinous mallet finger in children

PurposeTo evaluate the effect of scar overlapping suture for treating chronic tendinous mallet finger deformity in children.MethodsSix patients younger than 18 years were investigated retrospectively. The active extensor lags of the distal interphalangeal joint (DIPJ) were all more than 40°, and the passive ranges of DIPJ motion were normal. They were all treated surgically by scar overlapping suture technique, featuring careful overlapping suture of the extensor scar and temporary transarticular Kirschner wire fixation of the DIPJ.ResultsAverage follow-up was 3.1 years (ranging from 2 to 5 years). All patients made significant improvement in DIPJ activity. Three patients achieved full active DIPJ extension, whereas one patient had a 10° extensor lag and two patients had 5° extensor lags. All patients achieved normal active flexion ranges and full passive motion ranges of DIPJ compared with their uninjured side. There was no bone dysplasia, pain, or deformity recurrence.ConclusionsScar overlapping suture for treating chronic tendinous mallet finger in children is safe and effective. According to the Crawford criteria, all patients were graded as excellent.

Biomechanical Study of Extensor Tendon Lacerations Over the Finger Metacarpophalangeal Joints

Purpose To assess the percentages of extensor tendon lacerations over the finger metacarpophalangeal (MCP) joints that may lead to an MCP joint extensor lag. Methods We obtained 8t fresh-frozen cadaveric hand specimens. The extensor and flexor tendons were isolated for simulated active extension and passive flexion. The specimens were secured to a testing jig. Sequential full-thickness, transverse cuts were made through the extensor tendons over each MCP joint. The fingers were cycled before and after each incremental tendon cut. Extensor tendon gaps were measured and inclinometer measurements of MCP joint rotation were used to determine MCP joint extensor lags. Results Incremental cuts of the extensor tendons caused sequential increases in subjacent MCP joint extensor lags in addition to interactive effects on other finger MCP joints. Extensor lags of the index and little finger MCP joints were statistically significant; lacerations extended across 75% or more of the combined widths of the extensor tendon slips. In comparison, extensor lags of the middle and ring finger MCP joints were statistically significant; lacerations involved 90% or more of the widths of the extensor tendons. A statistically significant MCP joint extensor lag in the index and little fingers was also observed when 1 of 2 extensor tendon slips in either finger was completely transected. Conclusions In this biomechanical study of extensor tendon lacerations over the finger MCP joints, we found that MCP joint extensor lags varied by both the finger involved and the percentage of tendon width damage. Additional work is needed to determine the clinical importance of MCP joint extensor lags of differing degrees. Clinical relevance Lacerations of extensor tendons overlying the finger MCP joints in clenched-fist to mouth injuries are typically repaired in a delayed fashion. An improved understanding of the relations between extensor tendon slip lacerations and MCP joint extensor lags may provide a basis for treatment algorithms that could potentially reduce the costs of care.

Tibial Tubercle Osteotomy in Revision Knee Arthroplasty

BackgroundObtaining adequate exposure while maintaining the integrity of the extensor mechanism is crucial to the success of revision knee arthroplasty. This is particularly important in infected cases where staged procedures are necessary. While the use of a long, tibial tubercle osteotomy (TTO) is an established method to improve exposure, controversy still exists concerning complication rates and sequential use. MethodsForty-two TTOs were performed in revision knee arthroplasties between 2009 and 2015. Follow-up period ranged from 3 to 24 months. Twenty-four TTOs were performed for single-stage revisions, and 18 TTOs were performed for 2-stage infected revisions. In infected cases, the initial osteotomy was left unfixed between stages. Screws were used to fix the osteotomy flap in all cases. ResultsAll osteotomies united with no fractures, and there were no extensor lags. Minor proximal migration was noted in 1 case, and refixation was required in another. Greater range of motion (ROM) and improved Oxford Knee Scores were achieved in the single-stage revision group. In the infected 2-stage group, sequential use did not decrease union rates, and infection was eradicated in 14 of the 16 knees (88%). ConclusionWe conclude that TTO is a safe and reproducible procedure when exposure needs improving in revision knee arthroplasty. In 2-stage revisions, sequential osteotomies do not decrease union rates, and leaving the osteotomy unfixed after the first stage does not cause any adverse issues.

Open, Combat-Related Loss, or Disruption of the Knee Extensor Mechanism

To report the outcomes of repair or reconstruction of high-energy, open knee extensor disruption or loss due to combat-related injuries. Retrospective review. Tertiary (Level/Role V) Military Treatment Facility. Fourteen consecutive patients who sustained 17 complex, open knee extensor mechanism injuries during combat operations between March 2003 and May 2012. Primary repair or staged allograft extensor reconstruction after serial debridement and closure or soft tissue coverage. Final knee range of motion, extensor lag, ambulatory ability and assist devices, and complications requiring reoperation or salvage procedure. The open knee extensor mechanism injuries required a mean of 11 procedures per injury. At a mean final follow-up of 39 months (range, 12-89 months), all patients achieved regular community ambulation, with 36% requiring assist devices due to concomitant or bilateral injuries. Average knee flexion was 92 degrees, and 35% of extremities had an extensor lag >10 degrees; however, 6 of 9 extremities with allograft reconstructions had extensor lags of <10 degrees, and 5 had no extensor lag. The presence of a major periarticular or patellar fracture was significantly associated with the knee requiring a subsequent extensor mechanism allograft reconstruction procedure. One extremity each underwent knee arthrodesis or transfemoral amputation due to severe infection. High-energy, open knee extensor mechanism injuries are severe and rarely occur in isolation, but limb salvage is generally successful after multiple procedures. Patients who required staged allograft reconstruction, despite high complication rates, generally had favorable results. Therapeutic level IV. See instructions for authors for a complete description of levels of evidence.

A prospective randomized controlled trial comparing night splinting with no splinting after treatment of mallet finger.

The effectiveness of night splinting after treatment of mallet finger is unknown. We tested the hypothesis that there is no difference in extensor lag between patients with mallet finger that wear a night splint for an additional month after 6 to 8weeks of continuous splinting and patients that do not wear a night splint. Fifty-one patients were enrolled in this randomized controlled trial. At enrollment, range of motion was measured for the injured and contralateral uninjured finger. The follow-up was conducted approximately 4weeks later in person (41 patients) or by phone (10 patients). Analysis was by intention to treat. There were no significant differences in final extensor lag between patients that did and did not receive a night splint. Among the 41 patients with a final in-person evaluation, the final average extensor lag was 14°, and 34% (14 of 41 patients) had a lag of 20° or greater. Final extensor lag correlated significantly with age, enrollment distal interphalangeal joint (DIP) flexion and extensor lag, and final DIP flexion, with the latter two accounting for 28% of the variation in final lag in the final multivariable model (p < 0.001). There were no differences in disability (p = 0.67) or treatment satisfaction (p = 0.48) between patients that did and did not use night splints. Supplemental night splinting does not improve the outcome of mallet finger in terms of extensor lag, disability, or satisfaction with treatment. Patients with worse initial extensor lags should expect worse final lags; residual lags of 20° or greater are commonplace.

Central slip tenotomy for chronic mallet finger

We performed a retrospective audit of a consecutive series of twenty-three patients to evaluate the results of central slip tenotomy performed for chronic mallet finger. The surgery was performed at a mean of 42 (range four to 480) months after surgery and the pre-operative extensor lag at the distal interphalangeal joint was a mean of 44 (range 20–80) degrees. At the time of evaluation, at a mean of 33 (range six to 95) months after surgery, the extensor lag had improved to a mean of seven (range zero to 40) degrees. Using a simple clinical grading system, there were 12 excellent, six good, three fair and two poor results. Three patients had complications; one infection requiring antibiotics, and two who had post-operative extensor lags at the proximal interphalangeal joint which responded to a period of splinting and hand therapy.

Outcomes of Digital Zone IV and V and Thumb Zone TI to TIV Extensor Tendon Repairs Using a Running Interlocking Horizontal Mattress Technique

Biomechanical evidence has demonstrated that the running interlocking horizontal mattress (RIHM) repair for extensor tendon lacerations is significantly stronger, with higher ultimate load to failure and less tendon shortening compared with other techniques. We investigated the efficacy and safety of primary extensor tendon repair using the RIHM repair technique in the fingers followed by the immediate controlled active motion protocol, and in the thumb followed by a dynamic extension protocol. We conducted a retrospective review of all patients undergoing extensor tendon repair from August 2009 to April 2012 by single surgeon in an academic hand surgery practice. The inclusion criteria were simple extensor tendon lacerations in digital zones IV and V and thumb zones TI to TIV and primary repair performed using the RIHM technique. We included 8 consecutive patients with 9 tendon lacerations (3 in the thumb). One patient underwent a concomitant dorsal hand rotation flap for soft tissue coverage. We used a 3-0 nonabsorbable braided suture to perform a running simple suture in 1 direction to obtain a tension-free tenorrhaphy, followed by an RIHM corset-type suture using the same continuous strand in the opposite direction. Average time to surgery was 10 days (range, 3-33 d). Mean follow-up was 15 weeks (range, 10-26 wk). We applied the immediate controlled active motion protocol to all injuries except those in the thumb, where we used a dynamic extension protocol instead. Using the criteria of Miller, all 9 tendon repairs achieved excellent or good results. There were no tendon ruptures or extensor lags. No patients required secondary surgery for tenolysis or joint release. No wound complications occurred. The RIHM technique for primary extensor tendon repairs in zone IV and V and T1 to TIV is safe, allows for immediate controlled active motion in the fingers and an immediate dynamic extension protocol in the thumb, and achieves good to excellent functional outcomes. These clinical outcomes support prior biomechanical data. Therapeutic IV.

Use of the technique for extensor tendon acceleration with an injured soldier after a metacarpal fracture

Objective The purpose of this case report was to evaluate the effectiveness of the ‘technique for extensor tendon acceleration’ (TETA) in improving an active extensor lag at the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints after a surgically repaired, stable metacarpal fracture (MCF). The TETA was used in combination with scar mobilization, exercise and splinting with an injured soldier who sustained an MCF while on active duty. Methods This case report is about a soldier injured during the Iraq War who used the TETA, in combination with other treatments, as a means for resolving an extensor lag in a stable fourth digit MCF. The pre- and post-TETA outcome measure was range of motion (ROM). The ROM was taken before initiation of the TETA and two weeks after its initiation. Results After two weeks of performing the TETA in combination with other treatments, the soldier demonstrated a measurable improvement in the extensor lags at both the MCP and PIP joints. The soldier's fourth digit total active motion improved by 55° while the MCP joint extensor lag improved by 10° and the PIP joint extensor lag improved by 20°. Conclusion This case report demonstrated a potential benefit for using the TETA in conjunction with other treatments in overcoming an active extensor lag after a stable MCF. These results are case specific and may not be generalized to a larger population until future research studies can be conducted.

Complete Allograft Reconstruction After Extensor Mechanism Failure

Extensor mechanism failure after total knee arthroplasty is an infrequent but devastating complication. Several techniques for reconstruction have been proposed. Satisfactory results have been reported using whole extensor allograft implantation. However, this surgery can be technically demanding, may require specialized tissue, and often demands attention to critical technical parts of the procedure. Preoperative considerations should include an assessment of patient potential for rehabilitation compliance, eradication of infection, and ensuring that a sufficient soft-tissue envelope will be available for a safe and successful closure. Critical surgical techniques relate to the incision and approach, preparation of the graft, distal and proximal graft fixation, all in the context of proper prosthetic component implantation. Finally, appropriate postoperative rehabilitation protocols must be adhered to protect the graft and encourage healing, while providing optimal conditions for restoration of extensor mechanism strength and knee range of motion. A review of the reported results to date suggests that the application of the principles of whole allograft reconstruction for extensor mechanism failure after total knee arthroplasty can lead to satisfactory outcomes with improved function and mild extensor lags in most patients.

Tibial Tubercle Osteotomy in Total Knee Arthroplasty Surgery

Tibial tubercle osteotomy (TTO) is a recognized technique for improving exposure when performing total knee arthroplasty surgery. Forty-two patients were reviewed at a mean of 8 years after TTO. Preoperatively, mean extension was 8° ± 14°, mean flexion 74° ± 30°, and Knee Society score 73 ± 37. At latest follow-up, mean extension was 4° ± 15°, mean flexion 91° ± 22°, and Knee Society score 124 ± 42.6 ( P ≤ .0001). Seventy-three percent of patients had an excellent/good score at latest follow-up. Twenty-five percent of patients experienced no extensor lag, and 66% of extensor lags had resolved within 6 months. Mean time for osteotomy union was 14 weeks. In this series, TTO performed to enhance surgical exposure did not adversely affect the outcome after total knee arthroplasty but resulted in serious complications in 5% of patients.

Patellectomy after Total Knee Arthroplasty

We retrospectively reviewed nine patients who had condylar TKA and subsequently had a patellectomy between 1969 and 2003. One patient was lost to followup, but the remaining eight patients were followed up for an average of 49 months after patellectomy. All patellectomies were done after comminuted patellar fractures at an average of 21 months (range, 4-88 months) after the initial arthroplasty. Knee scores after the initial arthroplasty were 83 points (range, 69-97 points) and 49 points (range, 10-100 points) for pain and function, respectively. Knee scores after patellectomy were 81 (range, 20-97) and 28 (range, 0-80) for pain and function, respectively. The average range of motion before and after patellectomy was 0 degrees to 104 degrees and 2 degrees to 106 degrees , respectively. Four patients had mild extensor lags at final examination, but all were less than 10 degrees . Two patients were unable to use stairs. Two patients had complications consisting of quadriceps tendon rupture and secondary instability. Midterm results after patellectomy show knee scores for pain that are comparable to those after initial arthroplasties, but the function scores were not as good. Fifty percent of the patients had extensor lags but all were mild (< 10 degrees ). Patellectomy can provide pain relief after a patellar fracture after total knee arthroplasty but the functional results are frequently poor. Therapeutic study, Level IV-1 (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Extensor mechanism slide for the treatment of proximal interphalangeal joint extension lag: An anatomic study

We describe a technique for correction of proximal interphalangeal joint (PIP) extensor lag secondary to angulation and/or shortening of proximal phalanx fractures. Proximal phalanx fracture malunions with 2.5 mm of shortening, 5.0 mm of shortening, and apex volar angulation of 40 degrees were simulated in 15 cadaver fingers, creating PIP extensor lags. The metacarpophalangeal (MCP) joint was pinned in neutral. Transection of the ulnar and radial sagittal bands, the extensor digitorum communis (EDC) insertion on the MCP joint capsule, and the juncturae tendinae then was performed. The PIP extensor lag before and after each of the earlier-noted releases was recorded. The MCP joint then was freed and MCP hyperextension was recorded. With the MCP joint in neutral position the sagittal bands then were reapproximated with sutures and MCP extension was measured. The 2.5 mm of axial shortening, 5.0 mm of axial shortening, and 40 degrees of apex volar angulation fracture models produced an average extensor lag of 6.2 degrees , 25.8 degrees , and 42.5 degrees , respectively. Maximal correction of PIP extensor lag required transection of both sagittal bands, EDC insertion on the MCP capsule, and the juncturae tendinae with an average residual extensor lag of -0.8 degrees for the 2.5-mm shortening model, 0.7 degrees for the 5.0-mm shortening model, and 3.2 degrees for the 40 degrees -angulation model. The MCP joint hyperextension increased by 20 degrees to 30 degrees after the releases but decreased to only 1.8 degrees if the sagittal bands were reapproximated to the EDC tendon at their new resting position with the MCP joint in neutral position. In the cadaver model the PIP extensor lag can be improved substantially by transection of the sagittal bands, release of the EDC insertion on the MCP capsule, transection of the juncturae tendinae, and reapproximation of the sagittal bands to the EDC tendon.

Extended Medial Gastrocnemius Rotational Flap for Treatment of Chronic Knee Extensor Mechanism Deficiency in Patients with and without Total Knee Arthroplasty

Nine patients with chronic extensor mechanism disruption were treated with an extended medial gastrocnemius rotational flap reconstruction of the extensor mechanism. Seven patients previously had total knee arthroplasty and two patients had chronic infection of nonreplaced, native knees. Four patients previously had failed Achilles' tendon allograft reconstruction after total knee arthroplasty and two were complicated by infection. Infected arthroplasty patients had a staged procedure with placement of an antibiotic spacer after debridement and extended medial gastrocnemius rotational flap, followed by total knee arthroplasty replant 8 weeks later. The four infected arthroplasty patients had medical comorbidities that included a patient with HIV and hemophilia, and two with diabetes mellitus. Another patient with rheumatoid arthritis was severely malnourished as a result of dumping syndrome. Of the four patients treated by this two-stage procedure, one died in the early postoperative period from chronic medical issues after the second stage and another patient elected to have above-knee amputation after the first stage because of severe reflex sympathetic dystrophy. The final group of seven patients was studied at a mean followup of 21 months (range, 7-31 months), the average extensor lag was 13.5 degrees (range, 0-50 degrees ), and the average range of motion was 2 degrees to 93 degrees . The two patients with nonreplaced, native knees had extensor lags of 30 degrees and 10 degrees . All patients were able to regain sufficient extensor mechanism strength to return to independent ambulation, and all infections resolved after treatment. Two patients were able to ascend stairs foot over foot without support. In addition to the patient who had amputation, the other complication involved a wound breakdown that required a free flap at 13 months in a patient who had a failed Achilles' tendon allograft reconstruction after takedown of a knee fusion. Medial gastrocnemius flap reconstruction can provide successful salvage of a failed extensor mechanism allograft or an alternative to allograft reconstruction in patients with poor soft tissue coverage, previous infection, or a compromised immune system.

Central slip tenotomy for the treatment of chronic mallet finger: an anatomic study

Purpose Tenotomy of the central slip, described by Fowler, can clinically improve chronic distal interphalangeal joint (DIP) extensor lag secondary to mallet finger (terminal tendon disruption). The goal of this study is to evaluate the potential of central slip tenotomy to restore DIP joint extension. Methods A mallet deformity was reproduced in 15 fresh-frozen cadaver fingers after the extensor tendon insertion was sectioned over the DIP joint. A suture anchor inserted at the terminal insertion was then secured to the extensor tendon over the middle phalanx to reconstruct the extensor mechanism. A 500-g weight attached to the proximal extensor tendon applied extensor tension. Central slip tenotomy was then performed. DIP extensor lags before and after tenotomy were recorded. Results After sectioning of the terminal tendon over the DIP joint the average amount of extensor tendon lag produced was 45°. After central slip tenotomy was performed the average amount of extensor lag correction was 36° (range, 30°–46°). Conclusions Several clinical studies have shown that central slip tenotomy is an effective treatment for chronic mallet finger but may not fully restore DIP joint extension. Our data suggest that patients with a pre-existing extensor lag of greater than 36° may not achieve full extension from central slip tenotomy, although extensor lags of up to 46° may be corrected.

TENDON GRAFTING FOR MULTIPLE EXTENSOR TENDON RUPTURES OF FINGERS IN RHEUMATOID HANDS

We assessed the outcome of tendon grafting of multiple finger extensor tendon ruptures in 14 patients with rheumatoid arthritis. Extensor lags improved from a preoperative mean of 33° (range, 20°–65°) to a postoperative mean of 18° (range, 0–60°). However, loss of finger flexion was observed, with a mean postoperative fingertip to palm distance of 1.6 (range: 0–7.5) cm. Patient satisfaction correlated with the fingertip to palm distance, though not with the postoperative extensor lag. Because of the loss of finger flexion which was probably due to muscle contracture, we conclude that the results of tendon grafts in this situation are unsatisfactory.

Reconstruction of Patellar Tendon Rupture After Total Knee Arthroplasty With an Extensor Mechanism Allograft

Although patellar tendon rupture after total knee arthroplasty (TKA) is a rare complication, the consistently poor outcome of conventional tendon repair has convinced some to abandon such reconstruction in favor of a prospective protocol using an allograft distal extensor mechanism. The graft consists of a quadriceps tendon, a patella with a cemented prosthesis, a patellar tendon, and a tibial tubercle. Since December 1985, 13 knees in 12 patients were reconstructed using this method. Ten knees were followed for six to 51 months; five of these knees were followed for more than 24 months. Knee extension power and improved function were ultimately attained in all cases, although minimal extensor lags were present in three cases. Preoperative motion returned in all but one knee. Healing of the allograft to the host tissue was attained primarily at all of the tibial junctions. Two graft complications occurred, both in the first three months after surgery: one quadriceps junction treated by resuture failed at the one-month mark, and the other graft had to be revised for extensor weakness from rupture of the graft at the patella-patellar tendon junction, which was attributed to surgical damage to the tendon. After completion of healing to the host and rehabilitation of the knee joint, no grafts in the series failed during the course of normal daily activities. One patient fractured the allograft patella in a severe fall. The long-term durability of this construct needs to be studied further.

Salvage of Infected Total Knee Arthroplasty

Between 1981 and 1986, 25 patients with 26 infected total knee arthroplasties (TKAs) were treated with complete debridement of the knee, prosthetic removal, and six weeks of intravenous antibiotics, followed by insertion of a new prosthesis. The patients were followed for 12-57 months (average, 29 months). There was no evidence of residual infection at follow-up examination in any case. Applying the Hospital for Special Surgery knee rating system, 12 patients (50%) were rated excellent, six patients (25%) good, two patients (9%) fair, and four patients (6%) poor. Of the six patients with fair and poor results, five had reduced scores due to joint problems unrelated to the infected TKA. Fourteen patients had no pain at follow-up examination, and four had only slight pain. Nine patients had no limp, ten had a slight limp, one had a moderate limp, and the remainder either had a severe limp or were bedridden due to other joint problems. Eight patients could walk an unlimited distance and four could walk at least one-half mile. Twenty-one knees had a range of flexion greater than 90 degrees. Three patients had extensor lags of 20 degrees or greater. Only one patient required bracing for ambulation.