Abstract
Purpose
We investigated the outcomes of an original functional reconstruction procedure for ulnar drift (UD) with extensor tendon subluxation due to rheumatoid arthritis.
Methods
From 2018 to 2022, reconstruction was performed in 10 patients (31 fingers), with UD due to rheumatoid arthritis and a minimum of 2-year follow-up. The mean age was 57 years, and the mean follow-up period was 4.5 years. Ulnar drift was assessed using the Fearnley classification and included 17 stage 1 cases and 14 stage 2 fingers. A half-slip tendon was created just above the metacarpal head. An anchor was driven into the center of rotation of the metacarpophalangeal (MCP) joint on the radial side of the metacarpal bone, and the half-slip tendon was sutured and fixed. If limitations were observed in the flexion of the MCP joint, the extensor tendon was step-cut, and the half-slip tendon was fixed via an interlacing suture to the step-cut distal extensor tendon. We investigated the patient’s background and range of motion. The Disabilities of the Arm, Shoulder, and Hand questionnaire and the Michigan Hand Outcomes Questionnaire of patient-reported outcome measures were scored as functional outcomes.
Results
At a mean of 54 months after the operation, the average extension in the MCP joint improved from −12° (range: −80° to 28°) before surgery to 1.5° (range: −40° to 20°) at the final follow-up (P < .05), whereas the average flexion had no remarkable change. The average active arc of motion of the operated MCP joint was significantly increased to 95° (range: 60°–120°) compared with 82° (range: 34°–118°) before surgery (P < .05). The Disabilities of the Arm, Shoulder, and Hand questionnaire and the Michigan Hand Outcomes Questionnaire scores improved significantly. No recurrence of UD, such as a decreased Fearnley stage, was documented.
Conclusions
We present good results with no recurrence using a dynamic tenodesis technique as a functional reconstruction for UD with finger extensor tendon subluxation caused by rheumatoid arthritis, with a particular focus on joint preservation via soft tissue reconstruction.
Type of study/level of evidence
Therapeutic IV.
Key words: Centralization, Extensor tendon subluxation, Rheumatoid arthritis, Ulnar drift
Ulnar subluxation of the extensor tendon at the metacarpophalangeal (MCP) joint and the resulting ulnar drift (UD) of the fingers are caused by rheumatoid arthritis (RA), and these abnormalities may cause various disorders that affect activities of daily living and appearance.1 Although often encountered in rheumatology clinics and in those who undergo silicone implant arthroplasty, there are some problems, such as early implant fractures and high revision rates. Their postoperative results warrant further improvement.2,3
Subluxation of the extensor tendon occurs when the extensor tendon that is normally centered over the metacarpal head in both flexion and extension dislocates ulnarly with MCP joint flexion. Subluxation usually occurs on the ulnar side, and the abnormality can be caused by idiopathic, traumatic, or RA, and is caused mainly by attrition or rupture of the radial sagittal band.4 In diseases such as RA and systemic lupus erythematosus, which attenuate the radial sagittal band due to MCP joint arthritis, extensor tendon subluxation is one of the causes of UD from the index finger to the little finger.
Advancements in early diagnosis and outstanding drug therapy, such as biologic agents and Janus kinase inhibitors, have dawned a new era for the treatment of finger deformities caused by RA. Even in RA, where joint destruction is the main characteristic of the disease, joint-preserving surgery has become a viable option.5 It is desirable to establish a technique to reliably correct ulnar deviation via soft tissue reconstruction without relying on linked silicone implants, leaving the patient’s own bone and joint intact. We present the outcomes of a functional reconstruction technique that we call dynamic tenodesis for finger extensor tendon subluxation and UD caused by RA, with a particular focus on joint preservation via soft tissue reconstruction.
Materials and Methods
Full ethical approval was granted for this study and the cohort from the institutional review board of our hospital. This retrospective study was conducted in accordance with the Declaration of Helsinki 1964 and its later amendments. All patients provided oral and written informed consent at each evaluation.
We applied this procedure to the case in which the extensor tendon dislocated to the ulnar side due to RA, causing ulnar deviation. Contraindications were defined as when the shape of the joint surface was not maintained or when ankylosis occurred due to joint destruction. Cases with severe joint pain, extensor tendon dislocation due to trauma or infection other than RA, and collagen diseases such as systemic lupus erythematosus were excluded. In cases where joint pain was not the main complaint and the MCP joint was congruent or could be easily reduced, this technique was generally applied, regardless of whether there was erosion or narrowing of the joint space. A total of 31 fingers in 10 patients (all with RA) were followed up for more than 2 years after surgery. The index/middle fingers were operated on in two cases. There were five index/middle/ring finger cases and three index/middle/ring/little finger cases. All patients were women, with a mean age at the time of surgery of 57 years (range: 48–70). The mean follow-up time was 4.5 years (range: 2‒6.4 years). Preoperative radiographs revealed the following Larsen grades with respect to the operated joint: grade I, n = 3; grade II, n = 3; grade III, n = 2; and grade IV, n = 2. Ulnar drift was assessed using the Fearnley classification and included 17 stage 1 cases and 14 stage 2 fingers. The Fearnley classification method was first reported in 1951 and is frequently used for the evaluation of UD in RA.6 This method divided hands with UD into three stages: (1) voluntarily correctable, (2) passively correctable, and (3) fixed. Surgery may be indicated for hands classified as stage 1 or 2. Because stage 3 is a fixed deformity with an ulnar deviation that cannot be passively corrected, the condition requires the use of an artificial joint. Therefore, this condition was excluded from this series.
The disease activity in patients with RA was evaluated using the simple disease activity index, which was calculated by the tender joint count, swollen joint count, global assessment by patients and evaluators, and C-reactive protein.7 Tender and/or swollen joints were evaluated for 28 joints, including the proximal interphalangeal and MCP joints of the fingers, in addition to the wrist, elbow, shoulder, and knee joints.
All patients with RA were included in this study. In all patients, the simple disease activity index was 11 or less with low disease activity. Rheumatoid arthritis was well controlled in all patients.
Surgical anatomy
The extensor tendon has a structure that maintains stable tracking and tension with the sagittal band of both the radial and ulnar sides on the metacarpal head when the MCP joint flexes and extends. The sagittal band is divided into superficial and deep layers.1,8,9 In idiopathic extensor tendon subluxation, the superficial layer is ruptured, and the connection with the deep layer is broken. During finger flexion, the superficial layer together with the entire extensor tendon slips down from the deep layer, leading to subluxation. In our previous study, finger deformities progressed in patients with RA, even when the disease was well controlled.10 Rheumatoid arthritis-induced extensor tendon subluxation occurs when the radial sagittal band degenerates, weakens, and causes UD. When the extensor tendon is completely dislocated ulnarly and deviates palmarly from the center of rotation of the MCP joint, it becomes a flexion force of the MCP joint when extending the fingers, and eventually becomes impossible to reduce, with considerable limitations in MCP joint extension, leading to UD (Fig. 1).11
Figure 1.
Schema of extensor tendon subluxation and ulnar drift (left hand). The extensor tendon subluxation is due to the attenuation of the radial sagittal band, resulting in ulnar drift. Left: normal; Right: ulnar drift. ∗Extensor digitorum communis, †Lateral band, ‡Sagittal band.
Therefore, the reconstruction of the radial side of the sagittal band is believed to be important for the correction of extensor tendon subluxation and UD due to RA. Many methods have been reported for the reconstruction of the radial side of the sagittal band for extensor tendon subluxation; however, unlike other types of extensor tendon subluxation, RA-induced subluxation often involves severe soft tissue degeneration in the early stage.12 The conventional technique of suturing the reconstructive ligament to the soft tissue of the ruptured sagittal band is associated with a risk of recurrence even in traumatic rupture of the sagittal band.13 Especially in RA, soft tissue balance may be easily disrupted by synovitis. The reconstruction of the sagittal band in RA may favor tenodesis over soft tissue-to-soft tissue balancing. Moreover, with the progression of extensor tendon subluxation, the extensor tendon cannot undergo active reduction owing to its muscle contracture.14 In such cases, with the reconstruction of the sagittal band alone, we have experienced that the centralized extensor tendon becomes taut, limiting finger flexion. It is necessary to manually centralize the extensor tendon prior to surgery, and if there is a limitation of MCP joint flexion, to reconstruct the sagittal band and simultaneously lengthen the shortened extensor tendon. Next, we describe a dynamic tenodesis technique in which the efficacy of the procedure is not dependent on the integrity, quality, or healing of the native soft tissues and allows earlier mobilization to achieve functional motion.
Surgical technique
A transverse incision distal to the MCP joint is used to expose the extensor tendons as well as the radial and ulnar sagittal bands while preserving any dorsal sensory nerves. The extensor hood and entire sagittal bands should be exposed distally and proximally (Material 1, available online on the Journal’s website at https://www.jhsgo.org). Marked laxity of the sagittal band on the radial side and extensor tendon subluxation on the ulnar side can be confirmed. Then, while preserving the neurovascular bundle on the volar side, the palmar side is sufficiently released up to the lumbrical muscle and flexor tendon sheath. The intrinsic muscles and lateral bands on the ulnar side usually exhibit contracture and shortening. These patients should either undergo a step-cut or slide lengthening in addition to resection if there is severe shortening. The amount of lateral band lengthening was determined by the intrinsic tightness test to confirm the tension of proximal interphalangeal joint flexion by placing the MCP joint in extension while the extensor tendon is manually reduced above the metacarpal head.15 Next, we confirmed whether the MCP joint can achieve full flexion while the extensor tendon is manually reduced above the metacarpal head. If there is a limitation of MCP joint flexion, the extensor tendon requires step lengthening from the distal radial to the proximal ulnar side just above the metacarpal head (Fig. 2). A 1.4 mm JuggerKnot (Zimmer Biomet) is driven into the center of rotation of the MCP joint on the radial side of the metacarpal, that is, the attachment of the collateral ligament on the radial side. The half-slip tendon on the distal ulnar side is sutured and fixed such that the extensor tendon is completely centralized (Fig. 3). The half-slip tendon of the proximal radial side is fixed using an interlacing suture to the step-cut distal extensor tendon at a position where the MCP joint can achieve full flexion (Fig. 4). These techniques allow both secure extensor tendon stabilization with tenodesis and physiological gliding to be obtained simultaneously to act as a dynamic tenodesis.
Figure 2.
Schema and surgical findings (left hand). Expose the extensor tendon and the radial and ulnar sagittal bands and step-cut the extensor tendon from the distal radial to proximal ulnar side just above the metacarpal head. ∗Extensor digitorum communis. †Lateral band. ‡Sagittal band.
Figure 3.
An anchor is driven into the center of rotation of the MCP joint on the radial side of the metacarpal and the half-slip tendon on the distal ulnar side is sutured and fixed.
Figure 4.
The half-slip tendon of the proximal radial side is fixed using an interlacing suture to the step-cut distal extensor tendon.
If there is no limitation in passive MCP joint flexion while the extensor tendon is manually reduced above the metacarpal head, a half-slip tendon is created just above the metacarpal head on the proximal ulnar side (Fig. 5A; Material 2, available online on the Journal’s website at https://www.jhsgo.org). A 1.4 mm JuggerKnot is driven into the radial collateral ligament attachment, and the distal ulnar half-slip tendon is sutured and fixed at a position in which the extensor tendon is completely centralized (Fig. 5B).
Figure 5.
Schema of the case. There is no limitation in MCP joint flexion while the extensor tendon is manually reduced. A A half-slip tendon is created just above the metacarpal head on the proximal ulnar side. B An anchor is driven into the radial collateral ligament attachment, and the distal ulnar half-slip tendon is sutured and fixed at a position in which the extensor tendon is completely centralized.
When centralizing a dislocated extensor tendon, the intertendinous connections should not be released and should play a role in supporting the radial side of each tendon to assist in its centralization.
Postoperative management
All fingers should be fixated at night with a volar splint that spans from the distal forearm to the proximal phalanx. During the day, a dynamic splint is created to perform passive extension and active flexion (Video 1, available online on the Journal’s website at https://www.jhsgo.org). The splint is forearm-based and consists of an outrigger bar with rubber bands attached to the proximal fingers. At 4 weeks after surgery, the inline splint is replaced by active extension training. At 8 weeks after surgery, the splint should be worn during work. Depending on the type of work, the splint is worn until approximately 3 months after surgery.
Pearls, pitfalls, and complications
In this technique, the half-slip extensor tendon is fixed to the bone; thus, the possibility that the extensor tendon could be obstructed from sliding may be of concern. The reconstructed sagittal band, along with the glide of the extensor tendon on the radial side of the MCP joint, can achieve isometric motion as a result of fixating the half-slip tendon by driving the anchor into the center of rotation of the MCP joint on the radial side of the metacarpal (the attachment of the collateral ligament on the radial side) to obtain good fixation and gliding simultaneously (Fig. 6), which act as a dynamic tenodesis.13
Figure 6.
Lateral view of the MCP joint. The reconstructed sagittal band (green line) can achieve isometric motion as dynamic tenodesis by driving the anchor into the center of rotation of the MCP joint (red circle) and obtaining good fixation and gliding simultaneously.
If the extensor tendon requires lengthening, there will be no complications involving postoperative flexion or extension lag as long as the tendon is sutured in a sufficiently flexed position at its maximum tension.
In order to obtain good postoperative results, it is important to restore the balance of soft tissues. In particular, the MCP joint should be sufficiently released on the ulnar side of the sagittal band in addition to the palmar side to release adhesions and contractures.
For extensor tendon subluxation and UD due to collagen diseases such as systemic lupus erythematosus and systemic sclerosis, it may be better to use this technique in combination with an artificial ligament, as the deformity may recur due to soft tissue degeneration.16
Clinical evaluation and statistical methods
The clinical evaluations included the active range of motion (ROM) for the MCP joints, patient-reported disability according to the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH), and the Michigan Hand Outcomes Questionnaire (MHQ).17 Active ROM was measured by an hand therapist. To compare the preoperative and postoperative clinical outcomes, statistical analyses were performed via paired t tests. Statistical significance was defined as a P value of less than .05. Statistical analyses were performed in an exploratory manner without a priori sample size estimation or formal power analysis, given the retrospective nature of this case series and the limited number of patients. Therefore, the P values reported should be interpreted descriptively rather than inferentially.
Results
The average extension in the MCP joint improved from −12° (range: −80° to 28°) before surgery to 1.5° (range: −40° to 20°) at the final follow-up (P < .05), whereas the flexion in the MCP joint worsened in four fingers despite showing no remarkable change in the average angle from 95° (range: 80°–114°) to 94° (range: 80°–110°; P = .3). The average active arc of motion of the operated MCP joint was significantly increased to 95° (range: 60°–120°) compared with 82° (range: 34°–118°) before surgery (P < .05).
Elongation of the extensor tendon with the step-cut and interlacing suture was necessary in seven fingers of three patients. In other cases, full flexion of the MCP joints was achieved without the step-cut of the tendon.
The Michigan Hand Outcomes Questionnaire and Disabilities of the Arm, Shoulder, and Hand questionnaire scores also improved significantly at the final follow-up (Table), especially in the Michigan Hand Outcomes Questionnaire score (total, mean improvement = 29.9). No late recurrence of UD, such as a decreased Fearnley stage, or major complications were documented.
Table.
MHQ and DASH Scores∗
| Functional Evaluation Domains | Preoperative Mean (Range) |
Final Follow-Up Mean (Range) |
P Value |
|---|---|---|---|
| DASH | 23.2 (2.8–45.5) | 10.8 (1.7–25) | <.05 |
| MHQ overall | 50 (25–100) | 88.3 (65–100) | |
| MHQ ADL | 58.3 (25–95) | 88.3 (70–100) | |
| MHQ work | 59.2 (25–100) | 87.5 (55–100) | |
| MHQ pain | 26.7 (0–60) | 13.3 (0–30) | |
| MHQ aesthet | 50 (18.8–87.5) | 86.5 (5–100) | |
| MHQ satisf | 52 (25–100) | 87.5 (41.7–100) | |
| MHQ total | 57.1 (30.3–97.1) | 87.5 (60.3–98.1) |
ADL, activities of daily living; DASH, Disabilities of the Arm, Shoulder, and Hand questionnaire; MHQ, Michigan Hand Outcomes Questionnaire.
The six MHQ domains (overall hand function: overall, activities of daily living: ADL, work performance: work, aesthetics: aesthe, and patient satisfaction: satisf) are scored from 0 to 100, with 100 being the best possible ability. The pain domain is scored from 0 to 100, where 0 indicates no pain. The total MHQ score was calculated as the mean of all six domains (after converting pain from a “best score of 0” scale to a “best score of 100” scale).
Case illustration and case series results
This study represents the case of a 46-year-old woman (Figure 7, Figure 8). The disease duration of RA was approximately 20 years, and the Steinbrocker classification was stage II on x-ray and class I in function. Although the disease showed low activity due to the use of biologics, the UD progressed slowly in both hands, which interfered with activities of daily living. Although there was no limited ROM, extensor tendon subluxation was observed in the index, middle, ring, and little fingers of both hands. The drift angle of the middle finger of the MCP joint was 30° with mild subluxation, but bone destruction was not observed. Swan-neck deformities were observed from the index finger to the little finger on both hands and were classified as type I according to the Nalebuff classification (Fig. 7).10 The operation was performed from the dorsal side of the MCP joint. The surroundings of the MCP joint were sufficiently released, a half-slip tendon of the extensor tendon was created, and the tendon was fixed to the center of the radial collateral ligament attachment on the radial side of the medial head with a JuggerKnot Soft Anchor 1.4 mm short (Zimmer Biomet). From the second postoperative day, a dynamic splint was created and used during the daytime to perform passive extension and active flexion. At night, the splint was fixed with a volar splint that extended from the distal forearm to the proximal phalanx. At 4 weeks after surgery, we switched from a volar splint to an inline splint and from passive to active extension training. At 8 weeks after surgery, the splint was worn only during work. At 49 months after surgery, there was no recurrence of ROM limitations, extensor tendon subluxation, UD, or restrictions in activities of daily living (Fig. 8; Material 3, available online on the Journal’s website at https://www.jhsgo.org).
Figure 7.
Preoperative findings. Digits could extend incompletely due to extensor tendon subluxation and ulnar drift.
Figure 8.
Postoperative findings of the left hand. Her right hand has not yet undergone surgery. Extensor tendon subluxation and ulnar drift are reduced completely.
Discussion
Ulnar drift of the finger is often encountered in the treatment of RA. The prevalence rate at 10 years after the onset of RA is reported to be 30% to 45%, and patients may experience difficulty in gripping.10 Furthermore, aesthetic complications are often found with deformity progression. The Fearnley classification is widely used to assess stages of UD according to reducibility, wherein stage 1 is indicated for conservative treatment and stages 2 and 3 are indicated for surgical treatment; however, the type of surgical treatment must not be determined by staging but rather the condition of the joint, tendon, and ligament.18 The evaluation and pathological conditions of this classification system are incongruous and unsuitable for determining the treatment policy. Therefore, we developed a new scoring classification system for UD to evaluate the degree of subluxation, drift in the MCP joint, bone destruction, and reducibility of subluxation.19,20 This classification reflects the pathophysiology of UD and is confirmed to exhibit a linear correlation with functional evaluation. From this evaluation, we believe that UD causes a decline in function with the progression of the deformity, even without strong pain. Intervention at the earliest possible stage is important from the perspective of preventing functional deterioration.
Extensor tendon subluxation is generally most common in the middle finger.13,21 This may be due to the third metacarpal head, which is the apex of the lateral arch of the hand; thus, when the MCP joint is in flexion, the most strain is placed on the sagittal band of the middle finger MCP joint, which provides fixation of the extensor tendon in the center.22 In RA, extensor tendon subluxation is often observed in multiple fingers and starts from the middle finger and progresses to the index, ring, and little fingers.13 The greatest amount of tension is induced on the extensor tendon of the middle finger, and when it dislocates, the intertendinous connection and index finger are pulled to the ulnar side to cause subluxation of the extensor indicis tendon. In contrast, the intertendinous connection between the middle and ring fingers becomes lax, and the extensor tendon of the ring finger loses support on the radial side and dislocates to the ulnar side. The same is true for the little finger.
Because there is no adjacent finger on the radial side of the index finger, the radial collateral ligament becomes lax and is prone to dysfunction. Therefore, even if the extensor tendon is centralized, the index finger MCP joint may remain unstable in the ulnar direction. In this case, the half-slip tendon that is anchored at the center of rotation of the radial side of the metacarpal distally is folded and sutured again with appropriate tension to the extensor tendon on the proximal phalanx. With this technique, radial stability can be easily reconstructed simultaneously, and complete joint stability and mobility can be obtained at the same time. For the index finger, centralization seems easier by using the extensor indicis proprius located on the ulnar side.
In this case series, postsurgical outcomes indicated an improvement in the extension of the MCP joint; however, there was a mild reduction in the flexion angle. The metacarpal head exhibits a “cam-shaped” profile, where the distance between its center and the dorsal cortex is shorter than that between the center and the articular surface. The motion of the MCP joint follows an elliptical trajectory, potentially contributing to the decrease in the flexion angle. However, the “dynamic tenodesis” trajectory of the reconstructed ligament is confined to the distal dorsal quarter of the metacarpal; thus, we consider the impact to be minimal.
Ulnar drift is the most commonly encountered deformity in the daily clinical practice of RA patients and has multifactorial causes, such as the slope of the metacarpal head, carpal rotation, intrinsic tightness, vector pull of the extrinsic flexor and extensor tendons, and pull of the abductor digiti minimi from the force nucleus.11 Various techniques have been used for reconstruction.12 Crossed intrinsic transfer is one of the most popular techniques.23,24 The transferred tendons no longer follow their natural anatomical course, which may alter the normal dynamics of finger movement. As a result, a potential disadvantage of this technique is that it is easy to cause a restriction of the ROM of the fingers. A notable advantage of the dynamic tenodesis technique described in this study is that it reproduces physiological movements and has almost no ROM limitations. In recent years, it has become possible to suppress the progression of bone destruction by controlling synovitis, but ulnar deviation with mild joint destruction has become more common due to soft tissue degeneration.5 When soft tissues such as ligaments, tendons, and joint capsules degenerate and the radial sagittal cord relaxes, extensor tendon subluxation occurs, which is the main cause of ulnar deviation. Many methods have been reported for sagittal cord reconstruction, but there are a few reports on the postoperative results of correcting UD by reconstructing extensor tendon dislocations for RA. In RA, long-term inflammation causes strong soft tissue degeneration, and we believe that a more reliable sagittal cord reconstruction is necessary. The sagittal cord to be reconstructed must function as a ligament that reliably centralizes the extensor tendon. In order to obtain reliable braking of the extensor tendon, we perform a reconstruction technique that uses the bone as the fulcrum rather than the soft tissue.25 Our technique closely resembles the pant-over-vest repair, which involves releasing the sagittal band on the ulnar side and repairing the radial side over the tendon to maintain a dorsal position. Although the pant-over-vest repair reproduces a more physiological movement, the dynamic tenodesis technique demonstrates advantages in terms of soft tissue degeneration and recurrence of ulnar deviation in RA.
This study has several limitations and weaknesses. This study is limited by the small sample size and the lack of a priori power analysis. Therefore, statistical comparisons should be interpreted with caution as exploratory findings rather than definitive evidence of treatment effects. Furthermore, the follow-up period was short for patients with variably progressive diseases such as RA. This technique focuses on the centralization of extensor tendon dislocations by reconstructing the sagittal cord. It is not suitable for ulnar deviations due to active synovitis, considerable insufficiency of the radial collateral ligament, or carpal deformity. We believe that our favorable results may be related to the fact that the included cases were limited to patients with low disease activity who were able to undergo joint-sparing procedures.
This dynamic tenodesis technique can easily and reliably reconstruct soft tissues and preserve joints, which is suitable for modern RA treatment. In addition, since this technique can be used in combination with artificial joints, we believe that it can lead to further reliable reconstruction when used as one of the primary surgical techniques for UD.
Conflicts of Interest
No benefits in any form have been received or will be received related directly to this article.
Supplementary Data
Dynamic splint. A forearm-based dynamic splint was created to perform passive extension and active flexion. The splint consists of an outrigger bar with rubber bands attached to the proximal fingers.
Video of surgical diagram (left hand). The extensor tendon is step cut just above the metacarpal head and an anchor is driven into the radial side of the metacarpal bone. The half-slip tendon on the distal ulnar side is sutured and fixed. The half-slip tendon of the proximal radial side is fixed to the step-cut distal extensor tendon.
If no limitation is observed in MCP joint flexion while the extensor tendon is manually reduced, a half-slip tendon is created on the proximal ulnar side. An anchor is driven into the radial collateral ligament attachment, and the half-slip tendon is sutured and fixed at a position in which the extensor tendon is completely centralized.
Pre-operative findings (left side). Digits extend incompletely due to extensor tendon subluxation and ulnar drift. Post-operative findings (right side). Digits can perform full flexion and extension due to reduced extensor tendon subluxation and ulnar drift.
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Associated Data
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Supplementary Materials
Dynamic splint. A forearm-based dynamic splint was created to perform passive extension and active flexion. The splint consists of an outrigger bar with rubber bands attached to the proximal fingers.
Video of surgical diagram (left hand). The extensor tendon is step cut just above the metacarpal head and an anchor is driven into the radial side of the metacarpal bone. The half-slip tendon on the distal ulnar side is sutured and fixed. The half-slip tendon of the proximal radial side is fixed to the step-cut distal extensor tendon.
If no limitation is observed in MCP joint flexion while the extensor tendon is manually reduced, a half-slip tendon is created on the proximal ulnar side. An anchor is driven into the radial collateral ligament attachment, and the half-slip tendon is sutured and fixed at a position in which the extensor tendon is completely centralized.
Pre-operative findings (left side). Digits extend incompletely due to extensor tendon subluxation and ulnar drift. Post-operative findings (right side). Digits can perform full flexion and extension due to reduced extensor tendon subluxation and ulnar drift.