Sagittal Band Research Articles

Surgical Management of Early Metacarpophalangeal Joint Silicone Implant Fracture in Patient With Rheumatoid Arthritis

Introduction: Metacarpophalangeal (MCP) joint arthroplasty is a common treatment modality to correct ulnar drift, pain, and functional deficits in patients with rheumatoid arthritis, an autoimmune condition targeting the synovium of joints. While silicone MCP joint implants are susceptible to revision in the long term, there is a lack of literature discussing their early breakage. The present case illustrates silicone implant fracture only 10 weeks after MCP arthroplasty—the first instance in the literature to the authors’ knowledge. Materials and Methods: The patient is a 64-year-old female with stage 4 rheumatoid arthritis who underwent right index and middle finger MCP joint arthroplasties using 0-degree silicone implants, radial sagittal band imbrication on these digits, and right ring and small finger extensor tendon centralization at the MCP joint. Results: During the 10th postoperative week, the patient presented with atraumatic middle finger pain and ulnar deviation. Imaging revealed a right middle finger MCP implant fracture at the distal stem, which underwent successful revision using a 30-degree flexed implant and index and middle extensor tendon centralization. Discussion: Nineteen months after revision surgery, the patient continues to have no pain and an improved range of motion. Ultimately, we are hopeful that the flexed silicone implant will last the patient's lifetime.

Boxer's knuckle: Sonographic anatomy and assessment of sagittal band tears of the dorsal hood.

Boxer's knuckle: Sonographic anatomy and assessment of sagittal band tears of the dorsal hood.

Locking of the metacarpophalangeal joint: A comprehensive review of the literature

Locked metacarpophalangeal joint is an uncommon phenomenon with many possible etiologies. Diagnosis can be difficult because of the many more common pathologies (trigger finger, sagittal band lesion, etc.) that can lead to a clinical picture that may resemble the locked metacarpophalangeal joint. Once the differential diagnoses have been eliminated, the etiology of this blockage must be determined and the surgical procedure must be oriented. The origin of the problem is often difficult to determine, especially since standard imaging tests are often not very informative. Several clinical forms are possible, with blockages in extension or flexion, but which will have a disabling functional impact on the overall function of the hand. Currently, there is no gold standard for the management of this condition. In this study, we performed a review of the literature in order to better understand the different possible etiologies but also to analyze the different diagnostic and therapeutic management. LEVEL OF EVIDENCE: IV.

Stener-Like Lesions in the Hand: A Qualitative Review.

A Stener-like lesion is defined as the interposition of the sagittal band between the torn collateral ligament of the metacarpophalangeal (MCP) joint of a finger and its origin or insertion. Owing to the rarity of this injury, standardized protocols on the diagnosis and care of these injuries are not currently available. PubMed Central and Google Scholar were searched for published studies from 1962 to 2022. Inclusion criteria admitted any injury of the MCP joints of any nonthumb fingers involving a torn collateral ligament with sagittal band injury that trapped the collateral ligament. Eight studies were ultimately included in our analysis and contained 11 cases of Stener-like lesions. Eight of the 11 cases presented radial collateral ligament injury to the ring and little fingers. All 11 cases presented showed that detailed physical examination was a primary step in diagnosis of these lesions. Metacarpophalangeal joint laxity was present in all cases reported. Imaging-aided diagnosis was used in majority of the cases presented and included arthrography, ultrasound, or magnetic resonance imaging. All cases presented in this review were managed surgically. Following surgical repair, a majority of authors opted to use immobilization techniques immediately postoperatively. As awareness of this injury pattern increases, a standardized treatment algorithm may develop.

Repair of a Chronic Degenerative Sagittal Band Rupture of the Right Ring Finger

Repair of a Chronic Degenerative Sagittal Band Rupture of the Right Ring Finger

Utilizing Bone Anchors in Sagittal Band Reconstruction with Extensor Tendon Centralization: A Case Series and Literature Review

Objective: There are multiple complex tissue reconstruction techniques described for repair of sagittal band rupture in patients with subluxation of extensor tendons over the metacarpophalangeal joint. In our surgeon group, we have been performing a technically simpler repair using bone anchors with good success for several years. Our objectives are to report these findings and review any previously reported use of the technique. Methods: We reviewed all operative reports in a group of sixteen hand surgeons coding for centralization of extensor tendon from 2011 to 2022. Within those cases we selected out each case that utilized bone anchors for sagittal band repair. We then reviewed records for evidence of recurrent symptoms, subluxation, pain, or re-operation. We also noted the duration of follow up. Results: The procedure was performed by four of the sixteen surgeons. Twelve patients were identified by searching for the centralization of extensor tendon code and reviewing operative reports. We identified two additional patients who returned to our clinic for other reasons, one performed as early as 1997. We suspect several more were missed due to not searching prior to 2011 or different coding. These fourteen patients totaled 31 fingers all together. Of those, etiologies included six cases (21 fingers) of rheumatoid arthritis or other inflammatory arthritis, eight cases (10 fingers) of trauma, spontaneous rupture, or osteoarthritis. The patients with inflammatory arthritis tended to have multiple finger involvement. Follow up ranged from 6 weeks to 25 years, an average of 30 weeks (excluding the 1997 case) or 65 weeks including it. We found one case of recurrence in the first 90 days requiring reoperation. This was thought to be due to a technical error. All patients reported postoperatively no locking or clicking, reduction in pain, and improved range of motion. We excluded three patients (10 fingers) that were repaired similarly with suture tunnels through bone rather than bone anchors. These had similar postoperative results. We were only able to identify three case reports of similar repairs using bone anchors performed in the literature. These each reported good results at 1 year. Conclusion: Repair of sagittal band rupture and extensor tendon subluxation at the metacarpophalangeal joint with suture anchors is a simple, and effective technique. Although we are not the first to publish such a technique, we did identify several cases that were performed prior to the identified publications. Our data is the largest case series reported to date, and is consistent with the previously reported excellent results. Corresponding Author: Matthew Shaheen, MD, 627 Butternut Ave., Royal Oak, MI 48073

Windblown hand

<br><b>Introduction:</b> Windblown hand or congenital ulnar drift of hand is a rare deformity which affects all the digits including the thumb and can lead to functional impairment. Associated syndromes affecting the head, face, and feet should be ruled out. Windblown hand has three main features: (1) Contracture of the fingers with flexion deformity, (2) adduction contracture of the thumb causing narrowing of the first webspace, and (3) ulnar deviation of the fingers at the metacarpophalangeal joint. Early treatment is effective. <b>Methods:</b> We performed surgical correction in three cases of bilateral windblown hands. The extensor digitorum tendons were repositioned over the metacarpophalangeal heads by longitudinal plication of radial sagittal bands. In one case, skin contracture release for the first webspace was also done. Splinting with radial deviation and extension at metacarpophalangeal joint was done for 3 weeks. The average follow-up time was 6 months. <b>Results:</b> No skin necrosis or infection was seen in postoperative period. The patient satisfaction ranged from very good to excellent. For all the patients, first, the nondominant hand was operated, then all opted for surgical correction of the opposite hand as well. <b>Conclusions:</b> Windblown hand can lead to functional impairment and needs early correction. Parents and patients should be counseled about the chances of recurrence and incomplete correction. However, surgical treatment and subsequent physiotherapy can improve the functional range and aesthetics of the hand.<br>

Carpometacarpal Arthrodesis for Traumatic Carpal Boss Among Combative Athletes.

Among professional combat athletes, excessive and repetitive trauma to the carpometacarpal (CMC) joints may cause instability, arthritis, and the development of traumatic carpal boss. If nonoperative management is unsuccessful, CMC joint arthrodesis with iliac crest bone graft and supplemental Kirschner wire fixation is a reliable surgical option that results in pain-free return to full competition. From 2002 to 2015, 15 professional athletes with 17 symptomatic carpal bosses were treated with CMC joint arthrodesis after unsuccessful nonoperative management. The operative technique included decortication of the articular surface of the CMC joints, insertion of iliac cancellous and corticocancellous slot grafts, and secure Kirschner wire fixation. Patient charts and postoperative imaging were retrospectively reviewed. Outcome measures included grip strength, pain relief, fusion rate, return to competition, and complications. Mean age at the time of surgery was 28.2 years (range, 21-39 years). The radiographic fusion rate was 100% and occurred at a mean of 7.5 weeks. Mean return to competition occurred at 6 months. Grip strength at final follow-up increased 32% from preoperative level and was 90% of the grip strength of the contralateral hand. Postoperatively, 2 patients had sagittal band ruptures, and 1 patient had a fifth metacarpal fracture. No revision procedures were performed. All patients undergoing CMC arthrodesis had successful fusion, without the need for revision surgery and with return to full competition. For professional fighters, CMC arthrodesis with iliac crest autograft is a safe and effective surgical method for treating symptomatic traumatic carpal boss. [Orthopedics. 2022;45(1):e17-e22.].

Surgical treatment of sagittal band injuries and classification according to operative findings

PurposeThe indications for surgery in patients with acute closed sagittal band injuries are still undetermined. The purpose of this study was to classify the types of injuries based on intraoperative findings of patients who underwent surgery for sagittal injuries, and to present the treatment plans and surgical methods.MethodsTwenty-five patients who had undergone surgical exploration for closed sagittal band injuries between January 2011 and December 2020 were included in the study, comprising 17 patients with acute injuries (within 3 weeks), four patients with chronic injuries, and four patients who underwent surgery because symptoms did not improve in response to conservative treatment. Patients with laceration, fracture, and rheumatoid arthritis were excluded.ResultsSagittal band injuries were classified into two groups: superficial sagittal band (SSB) and proper sagittal band (PSB) injuries. SSB injuries were observed in 75.0% of spontaneous rupture cases and PSB injuries were observed in 66.7% of traumatic rupture cases. SSB injuries were observed in 83.3% of Rayan and Murray classification type II cases and PSB injuries were observed in 61.5% of type III cases (p=0.041). PSB injuries were present in all four patients who underwent surgery because conservative treatment failed.ConclusionWe successfully corrected sagittal band injuries with extensor digitorum communis tendon instability through surgical treatment. Sagittal band injuries can be classified into two types depending on the anatomical injury pattern; SSB and PSB injuries. The surgical method and treatment plan can be chosen based on this classification.

A novel technique of pulley creation for additional sagittal band reconstruction

Because surgical treatment of chronic extensor tendon dislocation with sagittal band injury is complex and often requires donor grafts, we suggest a new technique: pulley creation for additional sagittal band reconstruction. A 76-year-old man diagnosed with chronic extensor tendon dislocation with radial sagittal band injury was treated by resecting the distended portion of the radial sagittal band, followed by plication. Using the remnant tissue obtained after resection, additional sagittal band reconstruction was performed using two mini soft suture anchors in the form of a pulley surrounding the extensor tendon. Three-year outcome was satisfactory. Pulley creation for additional sagittal band reconstruction with direct repair of the radial sagittal band is a new surgical option for chronic extensor tendon dislocation. The technique is quick and easy, with good patient satisfaction and no donor site complications.

Surgical Options in Chronic Extensor Tendon Subluxation

Ulnar subluxation of the extensor tendons at the metacarpophalangeal joint level after damage to the sagittal bands is a rare problem in nonrheumatoid patients. It is aimed to discuss the treatment options for the extensor tendon subluxation and present a rare chronic case. A 25-year-old male patient presented with the complaint of stucking and snapping feeling in the middle finger when moving it after falling as a child. Type 2 sagittal band injury was detected in which the extensor tendon was subluxated to the ulnar side, and the sagittal band was strengthened with a junctura tendinum flap harvested from the adjacent finger. The patient returned to his daily life, and no recurrence was detected. Extensor tendon subluxation is the instability that occurs in the tendon as a result of damage to the sagittal bands. Many techniques have been described since the ideal technique is not available yet. Techniques that provide realignment by centralizing the extensor tendon are successful ones that can be preferred in chronic sagittal band ruptures and in professional athletes in whom primary repair is not possible.

Secondary reconstruction in zones V-VII in extensor tendon injuries

Due to various functional impairments after primary extensor tendon repair or lack of treatment, secondary tendon reconstruction is often required. Anatomical considerations, the outcome of the injury and its treatment and the patients' individual demands on the function of the hand affect the choice of the procedure. Description of techniques for secondary reconstruction after extensor tendon injury in zonesV-VII. Overview of surgical treatment concepts for secondary extensor tendon repair in zonesV-VII of the extensor tendons of the fingers and thumb. Discussion of alternative surgical techniques for secondary extensor tendon repair. While techniques for reconstruction of sagittal band injuries are predominant in zoneV, side-to-side tendon transfers, the use of tendon grafts and end-to-end tendon transfers prevail in zonesVI-VII. The reconstruction of the extensor pollicis longus tendon function using transfer of the extensor indicis proprius tendon is the standard procedure. For secondary repair of an extensor tendon function, anatomical features and functional interaction of the extrinsic and intrinsic hand musculature need to be considered depending on the zone affected.

Closed Sagittal Band Injury from a Low-Energy Impact: A Case Report.

Author(s): Lin, Jonathan; Chen, Johnathan | Abstract: The sagittal band is a sheet of connective tissue that provides lateral stability to the extensor digitorum tendon at the metacarpal joint. It is one of the three components of the dorsal extensor hood. Rupture of the one of the sagittal bands can lead to contralateral subluxation or dislocation of the extensor tendon. Closed sagittal band injury is commonly termed ‘boxer knuckle’ as it has been historically described in professional boxers who have sustained trauma to their closed fists. This injury is also associated with inflammatory conditions, such as rheumatoid arthritis. In this case report, we present a 64-year-old female with no known history of rheumatoid arthritis who sustained a closed sagittal band injury from shifting position in her bed. Ultrasonography and MRI are useful in the evaluation of a sagittal band injury. Using dynamic ultrasound imaging, the extensor tendon subluxation can be visualized with metacarpophalangeal (MCP) flexion, confirming the diagnosis of sagittal band injury.

Use of relative motion splint in extensor mechanism repairs: a retrospective case series

This case series determines the clinical outcomes of relative motion extensor splints (RMES) in extensor mechanism repairs. Nine patients who underwent extensor tendon repair, juncturae tendinum or sagittal band repair were included. A forearm-based volar blocking wrist splint was applied after surgery. The RMES was configured at the initial hand therapy appointment. Total active motion (TAM) at 4 and 8 weeks after surgery and return to work were assessed. There were 7 males and 2 females with a mean age of 28 (16-53 years). The mean TAM of the uninjured digits was 270° (245°–290°). The mean TAM of the injured digits was 209° (125°–275°) at week 4 and 245° (185°–290°) at week 8. The mean return to work time was 25 days. None of the patients had tendon ruptures and required secondary procedures. In our study, active movement with RMES was allowed immediately after surgery. The RMES program supported safer and earlier recovery of motion. All patients were able to perform activities of daily living while wearing the splint.

Functional anatomy of the sagittal bands and mechanisms of extensor tendon dislocation: a cadaveric study.

We investigated the functional anatomy of the radial sagittal band and possible mechanisms involved in its spontaneous and traumatic rupture using seven cadaveric hands. First, the extensor tendon excursion and the change in angle between the sagittal bands and the tendon path were measured during metacarpophalangeal joint flexion. The radial bands were then divided in two different ways that mimicked spontaneous or traumatic rupture. We found no significant correlation between the extensor tendon excursion and the change in angle of the sagittal bands in the middle and ring fingers. Dislocation could occur when the radial sagittal band was only partially divided. This may explain why conservative treatment of tendon dislocation in the middle and ring fingers is feasible. Complete section of the sagittal bands in the little finger caused ulnar dislocation of the extensor tendon in only one out of seven hands.

Ultrasound anatomy of the fingers: flexor and extensor system with emphasis on variations and anatomical detail.

Many anatomical details and variants occur in the finger tendons and soft tissue structures. These may lead to misdiagnosis if the radiologist is not well aware of them. We discuss the midhand extensor tendons, dorsal hood, junctura tendinea, conjoint tendons, transverse retinacular ligament, triangular ligament as well as central and distal slip anatomy and ultrasound correlation. The dorsal hood is an important structure to center the tendons at the midportion of the MCP heads, and the sagittal bands are its main components. Two tendons are present at the second digit, and two or more at the fifth digit. The extensor mechanism is anatomically interrelated with the palmar lumbricals and interosseous tendons. At the palmar side, the flexor superficialis and profundus tendons show varying relationships along the finger. The flexor profundus passes through an opening in the flexor superficialis. We also discuss the chiasma crurale, ridges at the flexor superficialis insertions and bifid flexor profundus tendon. Although a typical distribution of annular pulleys can be observed, many variants may be present of which we address some. The volar plate is a midline fibro-cartilaginous meniscus attached proximally to the well-identifiable checkrein ligaments and distally to the base of the phalanges. Knowledge of these details and variations allows for better understanding of the finger and hand ultrasound.

Pin Insertion to the Interosseous Hood Minimize the Finger Motion Restriction for the Proximal Phalangeal Percutaneous Fixation: A Cadaveric Study.

Background: The purpose of this study was to identify the optimal pin insertion point to minimize finger motion restriction for proximal phalangeal fixation in cadaver models. Methods: We used 16 fingers from three fresh-frozen cadavers (age, 82-86 years). Each finger was dissected at the level of the carpometacarpal joint and fixated to a custom-built range of motion (ROM)-measuring apparatus after skin removal. The pin was inserted into the bone through four gliding soft tissues: the interosseous hood, dorsal capsule, lateral band, and sagittal band. Then, each tendon was pulled by a prescribed weight in three finger positions (flexion, extension, and intrinsic plus position). Changes in the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) angles were measured before and after pinning. We compared the differences between the insertion points using the Tukey-Kramer post hoc test. Results: Placement of pins into the sagittal band significantly restricted MCP joint flexion, while placement into the dorsal capsule and lateral band significantly restricted PIP joint flexion. Only placement into the interosseous hood showed no significant difference in joint angles between the three finger positions compared to pre-pin insertion. There were no significant effects on MCP, PIP, and DIP joint extension. Conclusions: The ROM of the MCP joint was obstructed due to pinning in most areas of insertion. However, pin insertion to the interosseous hood did not obstruct the finger flexion ROM compared to that of other gliding soft tissues; therefore, we believe that the interosseous hood may be a suitable pin insertion point for proximal phalangeal fixation.

Ultrasound of Normal and Injured Ligaments and Retinacula of the Hand.

Clinical diagnosis of ligament and retinacular injuries of the hand may be challenging. Ultrasound (US) enables detailed high-resolution, dynamic, and real-time evaluation of these structures. This article is a comprehensive review of the intricate anatomy, optimal imaging technique, and normal US appearances of these ligaments and retinacula. The US features, pertinent biomechanics, clinical presentation, and differential diagnosis of injuries affecting the annular pulleys, differentiating from climber's finger; extensor hood including sagittal band and central slip rupture; proximal interphalangeal and metacarpophalangeal collateral ligaments including the Stener lesion and associated volar plate injury; and the anterior oblique or beak ligament of the trapeziometacarpal joint are reviewed. Emphasis is placed on optimal transducer positioning, value of dynamic US, injury severity, surgical indications, and other US findings with important management implications. US facilitates a timely accurate diagnosis of hand ligament and retinacular injury to ensure optimal patient management and minimize the risk of functional impairment of the hand.

A Reconstructive Extensor Tendon Centralization Technique for Sagittal Band Disruption.

Sagittal band injuries may result in extensor digitorum communis (EDC) tendon instability and may require operative treatment for symptomatic loss of extension, pain, and snapping at the metacarpophalangeal joint (MCPJ). Operative methods vary according to the source of donor tissue, as well as the anchor point of attachment. We present a surgical technique that diminishes tension of the repair with MCPJ flexion. Twenty-two EDC tendon stabilization procedures were performed between 2006 and 2017 using a tendon flap method. The selection criteria for this group of patients included completely dislocating extensor tendons with persistent complaints of pain and decrease in finger extension despite at least a 6-week conservative treatment attempt. All subjects underwent surgical treatment for tendon centralization using a distally based tendinous flap from the EDC sutured to the adjacent finger volar plate. A mathematical model was developed to analyze repair tension at 30, 60, and 90 degrees of MCPJ flexion calculating the flap length difference of 2 attachment points: deep transverse metacarpal ligament versus adjacent volar plate. Centralization was maintained in all digits with no evidence of subluxation at final postoperative evaluation. Clinical symptoms of pain and weakness resolved in all patients. Mathematical modeling provided evidence that translation of the anchor point of reconstructed flap to the volar plate of the adjacent finger resulted in lower tensile forces when compared with attachment at the intermetacarpal ligament. This optimized forces on reconstructed tendon flap experienced during MCPJ flexion.Level of Evidence: Level IV-therapeutic, case series.

Zebrin Expression in the Cerebellum of Two Crocodilian Species

While in birds and mammals the cerebellum is a highly convoluted structure that consists of numerous transverse lobules, in most amphibians and reptiles it consists of only a single unfolded sheet. Orthogonal to the lobules, the cerebellum is comprised of sagittal zones that are revealed in the pattern of afferent inputs, the projection patterns of Purkinje cells, and Purkinje cell response properties, among other features. The expression of several molecular markers, such as aldolase C, is also parasagittally organized. Aldolase C, also known as zebrin II (ZII), is a glycolytic enzyme expressed in the cerebellar Purkinje cells of the vertebrate cerebellum. In birds, mammals, and some lizards (Ctenophoresspp.), ZII is expressed in a heterogenous fashion of alternating sagittal bands of high (ZII+) and low (ZII–) expression Purkinje cells. In contrast, turtles and snakes express ZII homogenously (ZII+) in their cerebella, but the pattern in crocodilians is unknown. Here, we examined the expression of ZII in two crocodilian species (Crocodylus niloticus and Alligator mississippiensis) to help determine the evolutionary origin of striped ZII expression in vertebrates. We expected crocodilians to express ZII in a striped (ZII+/ZII–) manner because of their close phylogenetic relationship to birds and their larger and more folded cerebellum compared to that of snakes and turtles. Contrary to our prediction, all Purkinje cells in the crocodilian cerebellum had a generally homogenous expression of ZII (ZII+) rather than clear ZII+/– stripes. Our results suggest that either ZII stripes were lost in three groups (snakes, turtles, and crocodilians) or ZII stripes evolved independently three times (lizards, birds, and mammals).