Extensor tendon attachment to the dorsum of the proximal phalanx may fully extend the finger metacarpal phalangeal joint (MPJ). 15 fresh-frozen cadaveric hands were axially loaded in the line of pull to the extensor digitorum comunis of the index, middle, ring and small finger at the level just proximal to the MPJ. We measured force of extension at the MP joint in 3 groups: 1) native specimen, 2) extensor tendon release at the proximal interphalangeal (PIP) joint with release of lumbricals/lateral bands, 3) extensor tendon release at the PIP joint and dorsal proximal phalanx and lumbrical/lateral band release. Degree change of extension was calculated using arctan function with height change of the distal aspect of the proximal phalanx, and the length of the proximal phalanx. We used Student T-test to determine significant decrease in the extension of the phalanges. Extension of all fingers decreased slightly when the extensor tendon were severed at the PIP joint with release of the lateral bands/lumbricals (8deg+/−2deg). After this release, the finger no longer extended. Slight loss of extension was not statistically significant (p >.05) between group 1 and group 2. Groups 1 and 2 were significantly different compared to group 3. In summary, distal extensor tendon transection and release of lateral bands/lumbricals resulted in little change in force and degree of finger extension. The distal insertion of the extensor, released when exposing the PIP joint dorsally, may not need to be repaired to the base of the middle phalanx

Aims: Replacing human cadaveric specimens with fresh frozen animal tissue in biomechanical studies has become increasingly more popular due to the scarcity of young human tissue. The aims of this study were to characterise and compare the biomechanical parameters of tailored strips of equine extensor tendon, with 4 strand young human semitendinosus and gracilis (STG) tendons as an alternative tendon model for testing anterior cruciate ligament (ACL) graft reconstruction techniques using the Soffix Polyester ACL fixation device. Method: Common digital extensor tendons were harvested from normal equine forelimbs and tailored into 5 mm wide, 2 strand equine tendon strips. The doubled equine tendons were overlapped and braided around the buttonholes of a Soffix fixation device and secured with No 2 Ethibond sutures (Johnson & Johnson Ltd). The Soffix-4-strand young human STG tendon complex was prepared in an identical manner. Mechanical testing was performed measuring ultimate tensile load (UTL) and elongation to failure (EF), structural stiffness (SS) was calculated from load extension curves. Results: The Soffix-STG and the equine tendon complexes produced a mean UTL of 1186 N +/− 113.89 and 1116 N +/− 208.5 respectively showing no statistically significant difference. Conclusions: We conclude that a tailored 5mm wide 2-strand equine extensor tendon strip provides a comparable alternative for in vitro testing of young human four strand STG tendon graft using a Soffix polyester fixation device

Extensor tondon lacerations are much more common than flexor tendon injuries. The outcome of this lesions depends on mamy factors including severity of initial trauma, coexisting lesions, of the hand, site of the laceration, experience of the surgeon, and post operative rehabilitation. The aim of this prospective study was to review our results of primary extensor tendon repair with regard to the zone of injury. During a period of 28 months, 32 patients with open extensor tendon laccerations were repaired by modified kessler technique using 4-0 nonabsorbable suture. After tendon repair, immobilization with a volar splint was applied for 4-weeks and physiotherapy was carried out. Patients were followed–up for a mean of 12 months. we used the 5 extensor tendon zones and results were assesed using Miller’s rating system. Patents with closed tendon ruptures or concomitant hand fracture were excluded from the study. Seventy two extensor tendons were repaired. The mean age of patients was 24.6 years (17–46 y). Excellent and good resalts were obtained as the follows: in zone 5(88/4%), zone 3 (84%), zone 2(55.5%), zone 4(42.7%), zone 1(40%). Results were poor in zone 4(42.8%), zone 1(40%), zone 2(22.2%), zone 3(4%), and zone 5(3.9%). No in fection was seen. We found a strong correlation between the site of the repair and outcome. More excellent and good results were obtained when the repair was performed distal to the extensor retinaculum (Zone 3), and above the wrist (Zone 5). Unsatisfactory results were seen when the tendon repair was done at or near DIP joint (zone 1), in the region of complex extensor mechanism (zone 2) or beneth the extensor retinaculum (zone 4). We cocluded the anatomic location of tendon repair has an important effect in outcome

Traditionally open extensor tendon injuries in zones III to V (PIP to MP joints) have been treated with repair and immobilization in extension for 4 to 6 weeks. Early controlled motion protocols have been successfully used in zones VI and VII of the extensors. An early controlled mobilization protocol combined with strong repair for zones III to V extensor tendon lacerations was studied prospectively. From 1999 to 2003, 27 extensor tendon lacerations in 26 patients, mean age 34 years (range 14–70), were treated using dynamic extension splinting. Inclusion criteria were zone III to V, complete lacerations involving the extensor mechanism and possibly the dorsal capsule (without associated fractures or skin deficits) in patients without healing impairment. All injuries were treated in the emergency department with a core Kessler-Tajima suture and continuous epitendon suture. After an initial immobilization in a static splint ranging from 5 days (for zone V) to 3 weeks (for zone III), controlled mobilization was initiated with a dynamic splint that included only the injured finger. The patient was weaned off the dynamic splint 5 weeks after the initial trauma. The patients were treated in an outpatient basis and did not attend any formal physiotherapy program. The mean follow up was 16 months (range 10–24 months). No ruptures or boutoniere deformities were observed and no tenolysis was necessary. The mean TAM was 242deg for the fingers and 119deg for the thumbs. The mean grip and pinch strength averaged 85% and 88% that of the contralateral unaffected extremity. 77% of the patients achieved a good or excellent result in Miller’s classification. The mean loss of flexion was found to be greater than the mean extension deficit. The protocol described above was found to be safe, simple, functional, cost effective and reproducible for zone III to V simple extensor tendon injuries. Success is based on strong initial repair, close physician observation and a cooperative patient. The addition of physiotherapy for patients with flexion deficits in the period immediately after dynamic splinting may ameliorate results

We hypothesized that the finger extensor mechanism has attachments along the dorsal surface of the entire length of the proximal phalanx and that this anatomy has not been clearly defined. The attachment along the dorsal aspect of the proximal phalanx of the index, middle, index and small fingers was dissected in 20 fresh-frozen cadavers. The lateral bands and attachments along the lateral and medial surface were released to appreciate the attachments along the dorsal aspect. We characterized the ligament attachments as very robust, moderately robust, and minimally robust at the distal, middle, and proximal portions. Three orthopaedic surgeons quantified the attachment, finding that 93% of specimens had tendinous attachments and the most robust attachment found at the most proximal and distal aspects adjacent to the articular cartilage. 87% of the specimens had very robust attachments at the proximal portion of the proximal phalanx. The middle portion of the proximal phalanx had moderate to minimally robust attachments. Greatest variability in attachment was found along the most distal portion of proximal phalanx adjacent to the proximal interphalangeal joint (26% of specimens had moderate to minimal robust attachment; 74% had robust attachments). The attachments along the proximal phalanx were attached on the dorsal half of the proximal phalanx, with no fibrous attachments extending past the lateral bands. In summary, we found tendinous attachment along the proximal phalanx that may assist in finger extension and may extend the digit at the metacarpal phalangeal joint without central band contribution.

Purpose: Since 1966 silicone implant arthroplasty has been used to treat arthritis of the PIP joint as an alternative to fusion. The volar approach to expose this joint spares the extensor mechanism at the cost of increased risk to neurovascular structures. In the dorsal approach, the extensor mechanism must be carefully handled, reattached and then protected during rehabilitation. Several surgical techniques have been used to handle the extensor mechanism. Swanson et al. recommended midline incision of the central tendon followed by release of the lateral insertion on the middle phalanx and then reattachment to the base of the middle phalanx. Our clinical experience led us to a new surgical technique; splitting then repairing the extensor mechanism without bone reattachment as recommended by Swanson. The purpose of this study was to biomechanically compare the strength and function of this proposed technique with that of Swanson.

Method: Four pairs of fresh-frozen cadaveric hands were used. The index, long and ring finger were harvested for testing. Twelve digits (3 digits × 4 hands) were designated as control and were used to measure the fixation strength of Swanson’s procedure. The other 12 digits of the paired hands were designated as experimental and were used to measure the fixation strength of the proposed new technique.

Results: The fixation strength mean ± SD were, respectively, 4.74 ± 0.46 N/mm for the control group and 4.62 ± 0.30 for the experimental group. The results were not statistically different, p=0.45.

Conclusion: The simple repair of the central slip without the bone reattachment preserves the function of the extensor mechanism on the PIP joint. In our clinical cases we haven’t noticed any increase in the incidence of extensor lag or boutonnière deformity as a result of that. This technique can also be applied for fracture fixation in the area.

Tendon injuries after distal radius fractures Introduction: Tendon injuries after distal radius fractures are a well-documented complication that can occur in fractures managed both operatively and non-operatively. The extensor tendons, in particular the extensor pollicis longus (EPL) tendon, can be damaged and present late after initial management in a cast, or by long prominent screws that penetrate the dorsal cortex and cause attrition. Similarly, a prominent or distally placed volar plate can damage the flexor pollicis longus tendon (FPL). The aim of our study was to evaluate the incidence of tendon injuries associated with distal radius fractures. We conducted a single centre prospective observational study. Patients aged 18–99 who presented with a distal radius fracture between May 2018 to April 2020 were enrolled and followed-up for 24 months. Tendon injuries in the group were prospectively evaluated. Results: 199 patients with distal radius fractures were enrolled. 119 fractures (59.8%) had fixation and 80 (40.2%) were managed incast. In the non-operative group, 2 (2.5%) had EPL ruptures at approximately 4 weeks post injury. There were no extensor tendon ruptures in the operative group. In the operative group, there were 6 (5%) patients that required removal of metalware for FPL irritation. At the time of operation, there were no tendon ruptures noted. Within the operative group we evaluated plate prominence using a previously described classification (Soong et al.). 5 of the 6 patients (83%) with FPL irritation had Grade 3 prominence. The incidence of both flexor and extensor tendon injury in our cohort was 4%, extensor tendon rupture was 1% and flexor tendon rupture was avoided by early metalware removal. This study demonstrates tendon injuries are not uncommon after distal radius fractures, and close examination and follow-up are necessary to prevent eventual rupture. Plate prominence at the time of fixation should be minimised to reduce the risk of rupture

Intimate partner violence (IPV) causes significant morbidity and its unlikely to be reported compared to other forms of gender-based violence (GBV). For early detection, understanding Orthopaedic injuries from GBV is vital. This study assesses the pattern of musculoskeletal injuries from GBV and determines the factors associated with it. It is a retrospective observational study of patients aged ≥18 years, with GBV-related acute Orthopaedic injuries. Data was reviewed from January 2021 to December 2021, including, demographic information, soft tissue and bony injuries, relationship to assailant, substance abuse and the day and time of injury. Frequencies and percentages for categorical data were analysed. Chi-square test was used to calculate association. T-test was used to compare groups for continuous & categorical variables. Multivariate analysis was conducted to find the odds ratio and a p-value <0.05 was statistically significant. 138 patients were included, the mean age at presentation being 35.02 years (SD=11). 92.75% of GBV victims were females. Most were unemployed (66.7%). 30.43% (n-42) had a soft tissue injury; superficial laceration being the most common (23.1%), flexor tendon injury (10.87%), hand abscess (5.8%), and extensor tendon injury (5.07%). 71.02 % (n=98) sustained appendicular fractures. 51.45% (n=71) sustained upper limb fractures; distal radius fractures (10.86%) and distal 3rd ulnar fractures (9,42%). 19.57% (n=27) had lower limb fractures; 7.25% (n=10) had lateral malleolus ankle fractures. 63.7% (n=80) of cases were by an intimate partner on weekends (50.73%). 62.31% occurred between 16h00 and 0h00. 41.1% (n=65) reported alcohol abuse. 63.04% had surgery. GBV likely occurs in early middle-aged females by intimate partners influenced by alcohol over the weekends between 16h00 to 0h00. Distal radius/distal 3rd ulnar fractures are the most common bony injuries. Superficial wrist laceration is the commonest soft tissue injury. These findings may assist with early detection and intervention to prevent adverse outcomes in GBV

The Adams-Berger reconstruction is an effective technique for treating distal radioulnar joint (DRUJ) instability. Graft preparation techniques vary amongst surgeons with insufficient evidence to support one technique over another. Our study evaluated the biomechanical properties of four graft preparation techniques. Extensor tendons were harvested from fresh frozen porcine trotters obtained from a local butcher shop and prepared in one of three configurations (n=5 per group): tendon only; tendon prepared with non-locking, running suture (2-0 FiberLoop, Arthrex, Naples, FL) spaced at 6 mm intervals; and tendon prepared with suture spaced at 12 mm intervals. A fourth configuration of suture alone was also tested. Tendons were allocated in a manner to ensure comparable average diameters amongst groups. Biomechanical testing occurred using custom jigs simulating radial and ulnar tunnels attached to a Bose Electroforce 3510 mechanical testing machine (TA Instruments). After being woven through the jigs, all tendons were sutured end-to-end with 2-0 PROLENE suture (Ethicon). Tendons then underwent a staircase cyclic loading protocol (5-25 Newtons [N] at 1 hertz [Hz] for 1000 cycles, then 5-50 N at 1 Hz for 1000 cycles, then 5-75 N at 1 Hz for 1000 cycles) until graft failure; if samples did not fail during the protocol, they were then loaded to failure. Samples were visually inspected for mode of failure after the protocol. A one-way analysis of variance was used to compare average tendon diameter; post-hac Tuhey tests were used to compare elongation and elongation rate. Survival to cyclic loading was analyzed using Kaplan-Meier survival curves with log rank. Statistical significance was set at a = 0.05. The average tendon diameter of each group was not statistically different [4.17 mm (tendon only), 4.33 mm (FiberLoop spaced 6 mm), and 4.30 mm (FiberLoop spaced 12 mm)]. The average survival of tendon augmented with FiberLoop was significantly higher than tendon only, and all groups had significantly improved survival compared to suture only. There was no difference in survival between FiberLoop spaced 6 mm and 12 mm. Elongation was significantly lower with suture compared to tendon augmented with FiberLoop spaced 6 mm. Elongation rate was significantly lower with suture compared to all groups. Modes of failure included rupture of the tendon, suture, or both at the simulated bone and suture and/or tendon interface, and elongation of the entire construct without rupture. In this biomechanical study, augmentation of porcine tendons with FiberLoop suture spaced at either 6 or 12 mm for DRUJ reconstruction significantly increased survival to a staircase cyclic loading protocol, as suture material was significantly stiffer than any of the tendon graft configurations

The most common management of open injuries of the extensor tendons in Zones III to V (PIP to MP joint) is tendon suturation and digit immobilisation in extension for 4 to 6 weeks. Dynamic splinting and early mobilisation has been already successfully tested in the treatment of extensor tendons injuries in Zones VI to VII. In the current study we performed a protocol, including strong suture technique of the lacerated extensor tendon in Zone III to IV in addition with early mobilisation. From 1999 until 2002, 23 lacerated extensor tendons (Zones III – V) in 22 patients were managed at the Orthopaedic Department of the Univercity of Ioannina. The mean age of the patients was 36 years old (14 – 70 years). The principle treatment has taken place at the emergency room and included suture of the lacerated central slip, using the Kessler-Tajima technique, plus continuous suture of the epitenon. Injuries of other structures (lateral bands, sagittal band, joint captule) were also managed by suturing. After a period of 5 days (Zone V) to 3 weeks (Zone III) of immobilisation in a static splint, injured digit mobilisation started using a dynamic extensor splint until the 5th week after injury. The mean follow up was 7 months (3–24 months). There have been no ruptures of the extensor mechanism nore permanent digit deformities. Minimal (until 30o) loss of MP flexion or DIP extension has been regarded in 5 patients. The grip strength has been affected in 4 patients, and the grip strength between the 1st and 2nd digit (“the key pinch strength”) has been affected in 12 patients, compared with the contralateral hand. No further operation for tenolysis has been necessary. Satisfactory results have been obtained, by early mobilisation using dynamic splinting, in the treatment of open injuries of extensor tendons in Zones III – IV under the following conditions: using strong suture technique, a co-operative patient and weekly examination of the patient. Using a dynamic splint only for the injured digit is better accepted by the patient

Introduction. Getting the distal locking screw lengths right in volar locking plate fixation of distal radius is crucial. Long screws can lead to extensor tendon ruptures whereas short screws can lead to failure of fixation, especially if there is dorsal comminution of the fracture. The aim of our study was to determine the distal radius anatomy in relation to sagittal lengths and distance between dorsal bone edge and extensor tendons based on MRI scan. Method. One hundred consecutive MRI scans of wrist were reviewed by two of the authors on two occasions. All MRI scans were performed for different wrist pathologies except distal radius fractures or tumours. An axial image, two cuts proximal to the last visible articular surface, was selected. Sagittal length at 5 different widths, maximum volar width, radial overhang over distal radio-ulnar joint and the distance between dorsal bone edge and extensor tendons were measured. Results. A total of 120 MRI scans were included of which 74 were women and 46 were men. Mean volar width was 32mm and longest sagittal length was 22 mm (at Lister's tubercle). Length radial to Lister's tubercle was the shortest (17mm) and ulnar sides were 21mm and 29mm. Male measurements were mean 3mm longer than females. Mean radial overhang over DRUJ was 4mm. Distance from bone to tendons was within 2mm of dorsal radius edge. Conclusion. The study provides a reference guide to average screw lengths at different widths of distal radius in males and females. EPL tendon is closest to bone although all the extensor tendons are within 2mm of bone edge and carry a risk of injury from drill and screw placement. DRUJ is also at risk of injury if screws are placed within 4mm of ulnar edge of distal radius

The June 2015 Wrist & Hand Roundup360 looks at: Collagenase and Dupuytren’s disease – a genuine alternative to surgery?; iPad PROMise?; Should we learn how to do endoscopic carpal tunnel release?; Two-week radiographs a relic of the past?; Bible? Aspirate or excise?; Patient expectations and trapeziometacarpal osteoarthritis; Splintage in the treatment of sagittal band incompetence and extensor tendon subluxation

The recent advance of drug therapy for RA tends to replace preventive surgery, for example synovectomy. A rupture of a dorsal extensor tendon of the hand is an absolute indication for surgery, however. Such tendon ruptures are usually treated by tendon reconstruction and synovectomy of wrist joint. At our department, reconstructive surgery was administered with synovectomy for extensor tendon ruptures of the hand in 97 hands for 86 patients until June 2005. Recently, however, we occasionally encounter ruptures of extensor tendons not associated with severe synovitis. To treat such tendon ruptures, we usually administer tendon transfers in combination with tenosynovectomy through a small skin incision. Because this surgical procedure has achieved excellent results, we report our experience. This study included 15 patients who received tenosynovectomy in combination with tendon transfers in 14 hands since February 2001. This surgical procedure is indicated for tendon ruptures associated with mild synovitis (swelling) without instability on the ulnar distal end. As a rule, a 2–3 cm transverse skin incision was made on the dorsum of the hand under maxillary nerve block. After exposure of the distal ruptured end of the tendon, tenosynovectomy was administered through the incision. Then, the distal end was transferred to the adjacent normal tendon and fixed to it with sutures. Postoperatively, the repair was immobilized with bandage. The patient was allowed actively to extend and bend the hand on the next day. As a rule, this operation is administered on an outpatient basis. The postoperative course was uneventful, without rupture of the repair. The preoperative ranges of motion of the MP and PIP joints were retained postoperatively without difficulty in ADL

Aims: To confirm that the augmented (MGH) Becker extensor tendon repair is a strong four-strand technique that allows earlier mobilisation of repaired tendons after only 3/52 of postoperative static splinting and to assess functional outcome using revised disabilities of arm, shoulder and hand (DASH) score. Methods: In this prospective study we used the augmented Becker (MGH) suturing technique with Ethilon. Postoperatively patients were immobilised 3 weeks in volar splint and then fully mobilised with physiotherapy. 3/12 postoperatively all patients had final assessment in hand clinic for: pulp to palm distance, power grip, pinch grip, pain, Dragan criteria of progress, total active motions (TAM) of the fingers and revised DASH score. Results: Eighteen patients had extensor tendon lacerations repaired with augmented Becker (MGH) technique. Results were compared with the uninjured hand and statistically evaluated. At the final assessment the average pulp to palm distance was 0cm. All patients had good pinch and power grip (> 80% of uninjured hand for dominant hand and > 60% for non-dominant hand) and were free of pain with excellent progress using Dragan criteria. Average TAM was 268° without statistically significant difference between this and the uninjured side. Average scaled DASH score was 7.6 and within normal values. We had no wound complications or ruptures of repaired tendons. Conclusion: Augmented (MGH) Becker technique is a strong four-strand extensor tendon repair technique that allows early mobilization of patients after only 3/52 of static splinting postoperatively. Injured fingers can then be safely mobilized with expected full return of movements at 3/12 postoperatively

Distal radius fractures are the most common fracture of the upper extremity. Malunion of the distal radius is a common clinical problem after these injuries and frequently leads to pain, stiffness loss of strength and functional impairments. Currently, there is no consensus as to whether not the mal-aligned distal radius has an effect on carpal kinematics of the wrist. The purpose of this study was to examine the effect of dorsal angulation (DA) of the distal radius on midcarpal and radiocarpal joint kinematics, and their contributions to total wrist motion. A passive wrist motion simulator was used to test six fresh-frozen cadaveric upper extremities (age: 67 ± 17yrs). The specimens were amputated at mid humerus, leaving all wrist flexor and extensor tendons and ligamentous structures intact. Tone loads were applied to the wrist flexor and extensor tendons by pneumatic actuators via stainless steel cables. A previously developed distal radius implant was used to simulate native alignment and three DA deformity scenarios (DA 10 deg, 20 deg, and 30 deg). Specimens were rigidly mounted into the simulator with the elbow at 90 degrees of flexion, and guided through a full range of flexion and extension passive motion trials (∼5deg/sec). Carpal motion was captured using optical tracking; radiolunate and capitolunate joint motion was measured and evaluated. For the normally aligned radius, radiolunate joint motion predominated in flexion, contributing on average 65.4% (±3.4). While the capitolunate joint motion predominated in extension, contributing on 63.8% (±14.0). Increasing DA resulted in significant alterations in radiolunate and capitolunate joint kinematics (p<0.001). There was a reduction of contribution from the capitolunate joint to total wrist motion throughout flexion-extension, significant from 5 degrees of wrist extension to full extension (p = 0.024). Conversely, the radiolunate joint increased its contribution to motion with increasing DA; significant from 5 degrees of wrist extension to full extension as the radiolunate and capitolunate joint kinematics mirrored each other. A DA of 30 degrees resulted in an average radiolunate contribution of 72.6% ± 7.7, across the range of motion of 40 degrees of flexion to 25 degrees of extension. The results of our study for the radius in a normal anatomic alignment are consistent with prior investigators, showing the radiocarpal joint dominated flexion, and the midcarpal joint dominated extension; with an average 60/40 division in contributions for the radiocarpal in flexion and the midcarpal in extension, respectfully. As DA increased, the radiocarpal joint provided a larger contribution of motion throughout flexion and extension. This alteration in carpal kinematics with increased distal radius dorsal angulation may increase localised stresses and perhaps lead to accelerated joint wear and wrist pain in patients with malunited distal radial fractures

Extensor tendon ruptures have been reported in up to 8.8% of patients after volar plating and long screws have been implicated. The dihedral dorsal surface of the distal radius hinders accurate screw length determination using standard radiographic views (lateral; pronation and supination). A ‘dorsal tangential’ view has recently been described, but has not been validated. To validate this view, we mounted a plate-instrumented sawbone onto a jig. Radiographs at different angles were reviewed independently by 11 individuals. Skyline views clearly demonstrated all screw tips, whereas only 69% of screw tips were identifiable on standard views. With screws 2mm proud of the dorsal surface, skyline views detected 67% of long screws (sensitivity). The best of the standard views achieved only 11% sensitivity. At 4mm long, skyline sensitivity was 85%, compared with 25% for standard views. At 6mm long, 100% of long screws were detected on skylines, but only 50% of 8mm long screws were detected by standard views. Inter and intra-observer variability was 0.97 (p=0.005). For dorsal screw length determination of the distal radius, the skyline view is superior to standard views. It is simple to perform and its introduction should reduce the incidence of volar plate-related extensor tendon rupture

The MP joint is the key joint for function of the fingers. Rheumatoid arthritis involvement of this joint is frequent (1/3 of patients), and results in severe painful deformity and functional loss. The factors leading to the classic ulnar drift and volar luxation are multiple but the permanent pathophysiological element is synovitis of the joint. No deformation will occur in the MP joint without synovitis. Etiopathogenesis: The causes of MP joint deformity in Rheumatoid arthritis are anatomical, pathological and indirect. The asymmetry of the metacarpal heads with a slight ulnar tilt induce the deformation in this direction. The weakness and the length of the radial collateral ligaments compared to the ulnar collateral ligament makes the laxity to occur on the radial side of the joint. The obliquity of the extensor tendons pull the fingers ulnarly with a tendency of dislocation over the MP joints. Synovitis is at the origin of elongation, rupture or destruction of the ligaments, attrition of the cartilage and bone resorption. The distention of the extensor hood predominate radially and accentuate the extensor tendon obliquity. The destruction of the A1 pulley of the flexor tendon participate to the volar luxation of the joints. The ulnar sliding and radial tilt of the carpus, the tension of Abductor Digiti Minimi and the contracture of the intrinsic muscle participate indirectly or aggravate the deformation. The thumb force in pinch grip and the ulnar deviation of the finger in heavy prehension participate also to the deformation. Classification: Without prognostic factor the following classification gives information on the stage of the deformation and the treatment that can be proposed. synovitis without deformation, normal radiographs. synovitis with ulnar deviation, normal radiographs. synovitis with ulnar deviation and volar subluxation, volar luxation on radiographs with almost normal cartilage. ulnar deviation and volar luxation with or without active synovitis, destroyed cartilage and more or less bone erosion on radiographs. Synovectomi with stabilization and realignment procedures can only be used in stage 1 and 2. In stage 3 and 4 arthroplasty is more appropriate. Treatment: Indication are pain, loss of function and cosmesis. Synovectomy. The prophylactic effect of synovectomy is still subject to debate. The almost impossible total synovectomy, the difficulties to control the effect of the procedure and the different stage in disease of each patient make the synovectomy unpredictable as a real prophylactic procedure. Stabilization and realignment procedures has always to be part of a synovectomy. If the destruction of the cartilage and the bone erosion are irreversible process, the elongation of the ligaments or the destruction of their bony insertions can always be reconstructed. For this purpose different techniques can be used. Suture of the extensor hood on the radial side enables reorientation of the extensor tendons. The radial collateral ligaments can be strengthened or their attachments reinserted, the Abductor Digiti Minimi or the intrinsic tendons can be divided. Some tendon transfers (intrinsic, Extensor Indicis Proprius) can also be proposed. Arthroplasty. The choice of the procedure depends most of the surgeon preferences. The silicon arthroplasties are the most often used. They associate a reduction of the ulnar and volar deformation and opened the hand with very good results on the aspect of the hand and on pain. The mobility of the MP joints is variable and depends of the mobility of the finger joints. The bone erosion and the rupture of these devices are in favor of autologous interposition arthroplasties which, on the other hand, gives lesser mobility and stability. For these reasons silicon and interposition arthroplasties are often indicated late in the MP joint destruction process. More recently, new non constrained implants have been proposed in order to offer an earlier treatment. When used with good ligament reconstruction and tendon rebalancing these devices have good results on pain, cosmesis and function. If the preliminary results are confirmed in the long term, these non constrained devices will have a good indication as early MP joint replacement in the active young rheumatoid patient. Conclusion: MP joint deformity in rheumatoid arthritis is complex. The Etiopathogenesis will guide the treatment most appropriate in each patient. However some principles has to be respected in all cases. A good stabilization and recentralization is the key stone of the surgical procedure. The ulnar deviation can be reduced and corrected by ligaments and tendon procedures. The volar subluxation/luxation indicates an advanced deformity of the MP joint that requires arthroplasty

Introduction: Various variants of the extensor indicis (EI) have be described in the literature. We wanted to detect whether there exist any variants of the EI that may cause restricted mobility of the thumb following EI transposition to the extensor pollicis longus (EPL). Patients & method: Intraoperatively the function of the extensor tendons of 168 hands (98 right / 70 left) of 159 patients (96 female / 63 male) were examined. The function of the muscles was simulated using a tendon-hook. For ethical reasons the approach was not extended for the study. Results: In 34 of 168 hands 39 accessory tendons were found: 8 were localized between EPL and EI (1 from the EPL to the index; 3 extensor pollicis et indicis; 1 from the EI-muscle to the thumb; 3 to the radial extensor hood of the index). 31 accessory tendon were found ulnar to the EI (2 to the ulnar extensor hood of the index; 25 to the middle finger; 3 to the ring finger; 1 to the little finger). The EI was missing in only one hand, were a strong extensor anularis-tendon was found, which would have been suitable for EPL-reconstruction. 8 of these variants would hinder the thumb from isolated extension following EPL-reconstruction with the EI-tendon. Conclusion: The extensor tendons should be inspected carefully through EI-transposition for reconstruction of EPL to ensure a free function of the thumb postoperatively. Small accessory tendons that may cause trouble should be cut, strong tendons should be transposed together with the EI-tendon

Correcting a malunited distal radial fracture usually requires osteosynthetic material applied on the dorsal side of the radius. However, contact of the material with the extensor tendons often produces irritation and rupture problems. The aim of this study is to evaluate the effectiveness of the specific osteosynthetic material (Trimed) in treating malunion of intra- or extra-articular fractures of the distal radius, after a corrective osteotomy. We examined 11 patients (7 females, 4 males), with average age of 42 years (ranging from 21 to 69 years old), 10 of which presented with symptomatic malunited distal radial fracture of a mean duration of 2.85 months (2–7 months). In one patient the malunited fracture was 30 years old. In 7 patients the malunited fracture was extra articular whereas in 4 patients it was intra articular. A corrective osteotomy was performed in all cases, followed by application of the special osteo-synthetic material by Trimed on the dorsal side of the radius. In seven patients iliac crest bone graft was used, whereas in four allografts were applied. Furthermore, five patients had to undergo additional surgical procedures. More specifically, shortening osteotomy of the ulna in 3 patients, radio-scapho-lunate fusion in 1 and excision of scaphoid with carpal tenodesis in 1 patient. After a mean follow-up of 15 months (6–27 months) the results were evaluated based on (Fernadez 2001), pain, range of motion, and grip strength. Excellent results (18–20 points) were observed in three patients, good results (15–17 points) in five patients and fair results (12–14 points) in two patients. We conclude that the use of this particular material provides satisfactory stability on the corrective osteotomy and because of its low profile it can be applied on the dorsal side on the radius without interfering with the extensor tendons

Introduction We report the experience of a district general hospital foot and ankle service, in performing a modified excision arthroplasty and tendon transfer to the metatarsophalangeal (MTP) joints of the lesser toes in both rheumatoid and non-rheumatoid patients. The procedure was carried out on 114 toes, in 58 feet of 55 patients over a 5-year period. Background Historically, partial proximal phalangectomy was complicated by recurrence of the extension deformity. . Stainsby (1990). described a technique of 7/8ths phalangectomy, repositioning of the plantar plate, extensor to flexor attachment and K-wire stabilisation to treat dislocated MTP joints of the lesser toes. However, it is recognised that the use of K-wires can be complicated by infection or premature removal. Angel reported the re-routing of the extensor tendon through a drill hole in the metatarsal head for MTP joint instability; this technique was attributed to Nigel Cobb. We have utilised the Stainsby technique and combined it with a Cobb tendon transfer to impart immediate stability to the toe, allowing K-wire fixation to be discarded. Technique Following a percutaneous proximal extensor tenotomy, a radical partial proximal phalangectomy (via a dorsal incision) reduces a dislocated MTP joint and the plantar plate is repositioned beneath a mobilised metatarsal head. A drill hole is then placed in the metatarsal head and the extensor tendon is re-routed from a plantar to dorsal direction. This maintains the reduction of the toe and provides interposition between the cut end of the proximal phalanx and the metatarsal head. Conclusion We believe that this modified combined technique is a reproducible alternative to the Stainsby procedure but, in addition, provides immediate stability of the MTP joint without the need for K-wire fixation