Name:
Flexor Digitorum Superficialis Tenodesis for Swan Neck Deformity Reconstruction
Description:
Flexor Digitorum Superficialis Tenodesis for Swan Neck Deformity Reconstruction
Thumbnail URL:
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Duration:
T00H10M59S
Embed URL:
https://stream.cadmore.media/player/066f764c-060d-48fd-ba82-adc6239ec801
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/066f764c-060d-48fd-ba82-adc6239ec801/v-005678.mp4?sv=2019-02-02&sr=c&sig=HonH9M9cxq1eg2qKUmp8SiF1Lu2ODnZ3d%2B7q8kkqnFc%3D&st=2024-11-23T12%3A01%3A46Z&se=2024-11-23T14%3A06%3A46Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
KANU GOYAL: Hello this is Kanu Goyal and this is a video on FDS Tenodesis for Swan Neck Deformity Correction. I am at the Ohio State University in the Division of Hand and Upper Extremity Surgery and I did this video, the surgery with one of our current residents, Craig Luplow, and the video was assembled and edited by one of our medical students, Parth Vaghani.
KANU GOYAL: I have nothing to disclose that's relevant to this video and topic. So in brief, swan neck deformities can be characterized by PIP joint hyperextension and DIP joint flexion that can occur at rest or with digital extension. And it's more commonly seen in patients with rheumatoid arthritis. Up to 50% of patients may have this type of deformity Can be post traumatic, such as with a PIP injury that leads to hyperextension and volar plate rupture.
KANU GOYAL: And it can be secondary to some baseline ligamentous laxity, as you would see with Ehlers-Danlos syndrome. As I said, it can occur secondary to PIP volar plate injury and laxity. Sometimes it's associated with volar subluxation on MCP joint. In less common cases, it's related to FDS rupture. It can be seen in an intrinsic tightness, of course, and in a chronic mallet finger as well. So what are the indications for swan-neck deformity correction?
KANU GOYAL: Well, if it's symptomatic and it can be symptomatic for several reasons but probably the best indication is when there is snapping of the digit when the patient attempts to go from full digital extension to full flexion. Contraindications to the surgery if there's severe PIP stiffness or joint incongruity or deformity, those would be two reasons to think again before performing a reconstruction for a swan neck deformity correction.
KANU GOYAL: So this particular case is a 66-year-old woman. History of rheumatoid arthritis, non-smoker, nondiabetic. She had four digits that were symptomatic to her with snapping. All of them had a swan neck deformity about 20 to 30 degrees of passive inactive PIP hyperextension, and after treatment discussions she elected for surgery.
KANU GOYAL: She had tried the silver ring splints or a splint that prevented PIP hyperextension with good temporary control. However, she did not want to wear splints long term. We had discussed doing all four fingers simultaneously versus doing two digits at a time, and she elected to do two digits at a time, mainly because she wanted to be unencumbered with two of the fingers during the rehab process at any single moment.
KANU GOYAL: Here are some radiographs of her hand that demonstrate minimal arthritic changes at the PIP joint and without any arthritic changes or with any signs of incongruity. Here is a clinical video of the patient's digits pre operatively, full digital extension, we can all see the swan neck appearance of the digits, about 15 to 20 degrees there for several of those digits.
KANU GOYAL: And as you'll see here, when she attempts to make a fist, several of the digits will snap at the PIP joint. There's this unnatural finger motion when she is attempting to make a fist. So we brought her to the OR for this particular case, we used local anesthesia with monitored anesthesia care.
KANU GOYAL: I made a Bruner incision, as you see there, across the P1 proximal phalanx extending just a little bit distal over the PIP joint and up to the distal palmar crease. Here, I've opened up the sheath proximal to the A-2 pulley. identified the FDS tendon, divided one of the slips as proximal as I could and then flipped it distally
KANU GOYAL: to secure it to itself, as you see there. So again, this is a distally based FDS slip and it repaired it to itself using a non absorbable 4-0 braided suture and I put usually one stitch in and I check the tenodesis but also the passive PIP extension,
KANU GOYAL: and if I have it sitting at around 10 to 15 degrees, 15 degrees or so, I'm pretty happy with it. And then I secure it further with usually a running cross hitch stitch where I go up and down the length and I cross it on the way back up, thereby providing a very secure repair, but also without too much strangulation of the tendon. So we did it for the index finger, and here we are,
KANU GOYAL: this is the same operation that's been done for the middle finger. Identify the FDS tendon, proximal to the A-2 pulley, divided as proximal as possible and then flip it distally and secure it to itself. Now, in this case, if you don't get enough length of the FDS tendon for whatever reason, you can pass it through a small window within the A-2 pulley,
KANU GOYAL: and that's what I did here. And here I am just checking to see that I'm happy with my tenodesis of the PIP joint. And you could see that each of those digits are at about 15 degrees. And that's it. And then you wash it up, close the skin, put a splint, and typically we apply a splint that, it's a little bulky to begin with, but then we have the patient come back within a few days and then she starts some gentle finger flexion while limiting PIP extension,
KANU GOYAL: and I, and I usually use a larger splint to start with; a hand based dorsal PIP blocking splint for four weeks and then we transition to figure of eight splints for an additional four weeks. Now, this young lady, she had four digits that were swan necking and we did discuss doing all four digits at the same time but I thought it would be easier for her if we did two digits at a time
KANU GOYAL: so we spaced the index and middle fingers. We did the index and middle first and then eight weeks later, we did the ring and small and it went well. She did not have too much swelling or pain after surgery and she had a good outcome. So here she is about two months out from the ring and small fingers tenodesis and you can see all the digits are about 10 to 15 degrees at the PIP joint.
KANU GOYAL: She has near full flexion at the 8 week mark. Some important pearls, it's important to obtain adequate surgical exposure for this operation. I would avoid making small incisions. I think the, the surgical repair of the FDS tenodesis is going to be much cleaner if you have the proper exposure and you can pass the FDS at the proximal edge or through the A-2 pulley depending on the available tendon length.
KANU GOYAL: When we divide the FDS tendons slip proximally, I do make an effort to try to divide it's attachments to its neighboring FDS tendon slip. I think this probably helps the active flexion of the remaining FDS slip. Pitfalls; if you capture FDP tendon when suturing tenodesis in place, that can clearly cause loss of active flexion and then not tensioning the FDS tenodesis appropriately.
KANU GOYAL: I personally aim for about 15 degrees as it gives me a little bit of cushion in case it stretches out postoperatively. Here is some literature on this topic. Brulard reported the outcomes of 23 rheumatoid swan neck deformities in 8 patients. Treated similar to the way you've just seen on this video with the slip FDS tendon. However sutured to the A-2 pulley, which is a very reasonable way to approach it and it was corrected by an average of 33 degrees and then the flexion also gained in this patient population of an average of 26 degrees.
KANU GOYAL: Another paper compared FDS tenodesis with the bone anchor versus direct suture to the A-2 pulley and they showed then there was an eight degree reduction in PIP hyperextension was found in eight fingers operated using a bone anchor but a 12 degree reduction in those that sutured it to the soft tissue, so a pretty negligible clinical difference. You could suture the tendon directly to the A-2 pulley if you like
KANU GOYAL: and I've done that before. I, I think it's a little bit more secure if you secure it to itself. And I find that it's a little bit less likely you will accidentally capture the FTP tendon because you can see what you're suturing it to directly. And that is the video, I appreciate you watching it and if there's any questions or comments, please don't hesitate to reach out to us at the Ohio State University.
KANU GOYAL: Thank you.
