extra-articular and extratendineous palmar tenodesis for ...€¦ · extra-articular and...

SFCM- GEM 2019Paris

No conflict of interest to disclose

Florent METAIRIE, My-Van NGUYEN, Marc LEROY, Étienne GAISNE, Philippe BELLEMÈRE 1

Extra-articular and extratendineouspalmar tenodesis for the treatment of

reducible swan-neck deformity: Clinical results

Prise en charge des déformations en col-de-cygne souples par ténodèse palmaire en 8 extra-articulaire extra-tendineuse : Résultats cliniques

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Swan-neck deformity• Postraumatic

• Chronic mallet finger• Chronic PIP palmar plate attenuation

• Imbalance ext/flech causes• RA• Neurological

• Spasticity, Cerebral palsy, Parkinson, • Constitutional joint laxity

• Hypermobility, Marfan, Elhers Danlos

• Iatrogenic• PIP arthroplasty• FDS release ( tendon transfert )

SFCM - GEM 2019 - PARIS 2

• Snapping finger = Functional impairment +++


• Various technics described• Capsulodesis (Bate)

• Tenotomy (Fowler)

• Tenodesis• Using Extensor lateral band : Zancolli-Tonkin

• Using FCS : Littler

• Using PL : « SORL » Littler-Thompson


Treatments options for Reducible SND

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• Various technics described• Capsulodesis (Bate)

• Tenotomy (Fowler)

• Tenodesis• Using Extensor lateral band : Zancolli-Tonkin

• Using FCS : Littler

• Using PL : « SORL » Littler-Thompson

• More recently• Palmar ringing (De Soras Hand Surg &

Rehab 2017 )

Treatments options for Reducible SND


• Invasive procedures: • Opening

• Tendon sheath

• Joint

• Bones tunnel

• Tendon sacrifice


Leading to risk of : - Sencondary deformation- Stiffness


Extra-articular and extratendinous palmartenodesis: Principe of the technique• Goretex CV/O thread:

• non absorbable (ePTFE)

• tensile strength = 5.27 kg

SFCM - GEM 2019 - PARIS

Palmar crossed tenodesisDouble SORL like

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• To assess resistance of the technique• Looking for:

• Weight leading to failure

• Weight leading to loss of inducedflessum

• Causes of failure

• 35 tenodesis on cadavers

• Results :• Mean « Failure weight » 7,5Kg [1 -25]. • Loose of induced flessum for 1,97 Kg [1 - 6]. • Mean induced Stretching of 5,4 mm [0 -

10].

• Causes of failure:• Breaking of A2 anchor point : 23 (65,7%), • Knot loosening: 3 ( 8,57%)• Thread rupture : 2 (5,71%)• Checkreins breaking: 3 ( 8,57%) ,• Loosening of synthetic material: 4 (11,42%)

Preliminary Cadaveric Study


Cf E-Poster SFCM-GEM 2019


Methods:

• Retrospective monocentric study

• 10 fingers / 8 patients ( 3♂/5♀)

• With reducible SND + Snapping finger

• Multiple etiologies: • 3 chronical mallet fingers

• 3 constitutional joint laxity

• 2 rhumatoid

• 2 post PIP Arthroplasty

• Surgeries betwen 2016 and 2018



Assesments

• Clinical examination

• Independant examinator

• ROM Assesments of PIP and DIP • Pre-op and post -op• Correction of PIP hyperextension& DIP flessum

• Surgery satisfaction : • Snapping finger recurrence ? • Deformity recurrence?• Knot tolerance ?


preop 1 year postop

9

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• Mean Age 43,4 years

• Mean Follow Up : 29.7 Months [M5-M39].

• Mean pre-op PIP hyperextension = 30.5° [15°-40°]

• Mean DIP flessum

= 35.5° [20°-65°].

N° Age(Y)

Etiology Last FU(Months)

Hyperextension PIP pre-op

(°)

Flessum DIP pre-

op(°)

174

PIP Tactys M36 15 20

272

PIP Tactys M24 30 25

350

Rhumatoid M24 40 50

450

Rhumatoid M24 30 65

527

Mallet Finger M5 30 40

616

Hypermobility M39 35 25

749

Mallet Finger M31 20 40

843


943


1016

Mallet finger M38 35 50

Mean 43,4 M 29,7 30,5 35,5

FU = Follow Up

Results (1)

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• PIP hyperextension decrease of 22.5°(p=0,001)

• DIP Flessum improvement of 27°(p1 year): Recurrence of Snapping finger • Post mallet finger • Hypermobility

• 1 CRPS

• 1 knot sensation without discomfort

• No surgical revision yet

Before Surgery After Surgery p=

Hyperextension PIP

30,5 8 0,001*

Flessum DIP 35,5 8,5 0,0003*

N %

Recidive SND5 over10 50%

Recidive snapping2 over 10 20%

Results (2)

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• 2 failures: • Young patients,

• One brutal : wire rupture ? • One progressive : loosening of the tenodesis ?/

progressive failure of the anchorage?

• Anchorage at A2 Level

• Limits: • small number of patients • Learning curve++


Discussion

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Conclusion – Take Home Messages

• Pros : • Spare flexor and extensor tendons

• Spare PIP joint

• Can be used on all etiologies of reducible SND

• Cons: • Learning curve ++

• Technical tips & tricks : • Solid anchorage at A2 level ( periost & A2

insertion)

• tightening & crushing of the knot+++ (suture material (empty))


Does not burn the bridges

Palmar crossed tenodesisDouble SORL like

Extra-articular and extra-tendinous palmar tenodesis

Thank you !14

N° Age Etiology Last FUHyperextension PIP pré op

Flessum DIP pré op

Flexion PIP post op

Hyperextension post op PIP

∆ PIPROM DIP post op

∆ DIPRecidive of SND

Récidive of snapping

1 74PIP Tactys 36 15 20 30 30 -15-15//35 5+ -2 72PIP Tactys 24 30 25 70 0 300//40 25- -3 50RA 24 40 50 90 10 30-10//70 40+ -4 RA 24 30 65 90 5 25-15//70 50+ -5 27Mallet Finger 5 30 40 70 0 300//50 20- -6 16Hyperlaxité 39 35 25 100 0 350//70 25+ +7 49Mallet Finger 31 20 40 90 0 200//70 40- -

8 43Hypermobility 38 40 20 90 0 0-5//70 15- -

9 Hypermobility 38 30 20 90 10 0-10//70 10- -

11 16Mallet Finger 38 35 50 90 25 10-30//70 20+ +

Mean 43,375 29,7 30,5 35,5 81 8 16,5 25


extra-articular and extratendineous palmar tenodesis for ...€¦ · extra-articular and...

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