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• W2000621517 abstract "Joint contractures are a common complication of hand trauma. The conventional treatment consists of arthrolysis, tenolysis and occasionally arthrodesis. Frequently, this does not achieve a good result, particularly when there has been a long delay in presentation. Progressive lengthening of a joint by distraction (joint distraction) allows the release of joint contractures even in cases of failure of traditional methods.We present a case of a delayed (20 years) work related traumatic flexion deformity of the PIP joint of the left index and middle fingers. This was the result of a complete division of both flexor tendons of both fingers.The range of movements, both active and passive, was limited to 90/100° in the index finger and 95/100° in the middle finger. Following joint distraction using our lengthening device (Antão™, Portugal) the patient was able to achieve an active and passive range of movements of 10/100° for the PIP joint of the index finger and 40/100° of the middle.This clinical case shows the simplicity and application of our technique for the correction of joint contractures. Joint contractures are a common complication of hand trauma. The conventional treatment consists of arthrolysis, tenolysis and occasionally arthrodesis. Frequently, this does not achieve a good result, particularly when there has been a long delay in presentation. Progressive lengthening of a joint by distraction (joint distraction) allows the release of joint contractures even in cases of failure of traditional methods. We present a case of a delayed (20 years) work related traumatic flexion deformity of the PIP joint of the left index and middle fingers. This was the result of a complete division of both flexor tendons of both fingers. The range of movements, both active and passive, was limited to 90/100° in the index finger and 95/100° in the middle finger. Following joint distraction using our lengthening device (Antão™, Portugal) the patient was able to achieve an active and passive range of movements of 10/100° for the PIP joint of the index finger and 40/100° of the middle. This clinical case shows the simplicity and application of our technique for the correction of joint contractures. Joint contractures are a common complication of hand trauma and can have several causes related to contractions or adhesions of the tendons, thickening of the synovium, contracture of the ligaments or joint capsule, insufficient skin cover or scarring and bone block or exostosis within the joint.1Curtis R.M. Management of the stiff hand.in: Lamb D.W. Hooper G. Kuczynski K. The practice of hand surgery. Blackwell Scientific Publications, Oxford1989: 351-360Google Scholar The conventional treatment consists of performing a combination of arthrolysis, tenolysis and occasionally, as a last resort, arthrodesis or replacement. Frequently this does not achieve a good result,2Koller R. Choi M.S. Bayer G.S. Millesi H. Analysis of change in finger function after flexor tenolysis.Handchir Mikrochir Plast Chir. 1996; 28: 204-209Google Scholar, 3Ghidella S.D. Segalman K.A. Murphey M.S. Long-term results of surgical management of proximal interphalangeal joint contracture.J Hand Surg [Am]. 2002; 27: 799-805Google Scholar particularly when there is a long delay since the injury. The surgical release of a digital joint contracture can cause excessive stretching of the neurovascular structures resulting in damage to these elements. In addition there can be a lack of skin cover. Progressive lengthening by distraction can prevent such complications, and does not result in permanent tissue modifications,4Gil-Albarova J. Melgosa M. Gil-Albarova O. Canadell J. Soft tissue behaviour during limb lengthening: an experimental study in lambs.J Pediatr Orthop B. 1997; 6: 266-273Google Scholar allowing the release of joint contractures even in cases of failure of traditional methods. The use of such techniques for the release of post-traumatic joint contractures (not as sequelae of burn) has not been widely reported in western literature.6Kasabian A. McCarthy J. Karp N. Use of a multiplanar distracter for the correction of a proximal interphalangeal joint contracture.Ann Plast Surg. 1998; 40: 378-381Google Scholar, 7van Roermund P.M. van Valburg A.A. Duivemann E. van Melkebeek J. Lafeber F.P. Bijlsma J.W. et al.Function of stiff joints may be restored by Ilizarov joint distraction.Clin Orthop. 1998; : 220-227Google Scholar Joint distraction techniques were first reported by Kolontay and Miloslavskii5Kolontai I. Miloslavskii F.A. Distraction tendoplasty in injuries of the flexor tendons of the fingers at the level of the osteo-fibrous synovial canal.Ortop Travmatol Protez. 1987; : 1-3Google Scholar in 1987 in the former Soviet Union. This paper shows the efficacy of a technique of joint distraction, employed by the authors, through the presentation of a clinical case. With the patient in the supine position and under loco-regional anaesthesia, a threaded, self-tapping half-pin is inserted bicortically into the bone, proximal to the joint(s) to be distracted and another distal to the joint(s), using a drill. The pins should be passed perpendicular to the axis of joint movements and should have a diameter of at least 1.5 mm. When the goal is to lengthen a proximal interphalangeal (PIP) joint, stabilisation of the distal interphalangeal (DIP) joint should be performed with a Kirschner wire, to avoid contracture of this joint. The lengthening device (Antão™, Portugal) is assembled onto the two previously applied pins. The lengthening of the device starts immediately. It should be adjusted daily, up to the maximum tolerated length, which is determined by the appearance of moderate pain and pale skin. Once the desired length has been achieved, the device and the pins are removed. This is usually done in the outpatient clinic and without the need for any anaesthesia. The patient should initiate mobilisation of the lengthened joint immediately. A 40-year-old male was admitted to the emergency service because of a full-thickness flame burn of the dorsum of the right hand. Besides the burn, the physical examination revealed the presence of a flexion deformity of the PIP joints of the index and middle fingers of the left hand, secondary to a flexor tendon injury 20 years previously (a work-related accident). Primary repair was performed at that time. The patient developed a flexion deformity post-operatively and underwent tenolysis 6 months after the repair, without improvement. The range of both active and passive motion was 90/100° at the index finger and 95/100° at the middle finger, with restriction of some basic activities (Fig. 1). The DIP joints had an active and passive range of 0/70° at the index finger and 0/40° at the middle finger. The superficial and deep flexor tendons of both fingers functioned independently. The clinical and radiographic (Fig. 2) examination excluded the existence of a true ankylosis from bony fusion or block. We treated him with our technique of joint distraction and lengthened the PIP joint of both fingers simultaneously (Fig. 3). The degree of lengthening achieved on a day-to-day basis was limited by pain rather then skin perfusion.Figure 3Pre-operative view—devices assembled.View Large Image Figure ViewerDownload Hi-res image Download (PPT) After 20 days the device was removed and the patient began active and passive mobilisation. The range of motion achieved, both active and passive, was 10/100°, for the PIP joint of the index finger and 30/100° for the middle finger. A decrease in the range of motion of the DIP joints of both fingers was noted and was probably related to the immobilisation period of this joint with the K-wire. The patient was reviewed at 3, 6 and 9 months after surgery. He maintained an improved range of motion, both active and passive, of the PIP joints of 10/100° in the index finger and 40/100° in the middle finger (Figure 4, Figure 5, Figure 6). The DIP joint of the index finger recovered to the previous range of 0/70°, both active and passive, but the DIP joint of the middle finger remained limited to 0/15°, both active and passive. The independent function of the superficial and deep flexor tendons of both fingers was maintained. The patient reported improvement of his functional ability, as well as better aesthetic appearance.Figure 5Result. Six months post-operatively.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6Result. Six months post-operatively.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Lengthening techniques for the soft tissues of the hand appear sporadically in the literature and have mostly been used for the correction of burn contractures. Description of such techniques for the correction of tendon and joint contractures is rare.5Kolontai I. Miloslavskii F.A. Distraction tendoplasty in injuries of the flexor tendons of the fingers at the level of the osteo-fibrous synovial canal.Ortop Travmatol Protez. 1987; : 1-3Google Scholar, 6Kasabian A. McCarthy J. Karp N. Use of a multiplanar distracter for the correction of a proximal interphalangeal joint contracture.Ann Plast Surg. 1998; 40: 378-381Google Scholar, 7van Roermund P.M. van Valburg A.A. Duivemann E. van Melkebeek J. Lafeber F.P. Bijlsma J.W. et al.Function of stiff joints may be restored by Ilizarov joint distraction.Clin Orthop. 1998; : 220-227Google Scholar, 8Miguleva I. Treatment of complications of plastic surgery on the tendons of finger flexors.Khirurgiia (Mosk). 1996; : 92-96Google Scholar, 9Korshunov V.F. Filimonov A.L. The treatment of multiple contractures of the fingers.Vestn Khir Im I I Grek. 1992; 148: 52-55Google Scholar There are many mechanical factors that may limit the excursion of a joint; it is, therefore, important to perform an accurate clinical10Bunnell S. Doherty E.W. Curtis R.M. Ischemic contracture, local, in the hand.Plast Reconstr Surg. 1948; 3: 424Google Scholar and radiographic examination of the hand to determine the precise cause. In our opinion, the technique presented here is useful for the release of joint contractures related to contractions or adhesions of the tendons, contracture of the ligaments or the joint capsule, inadequate skin cover or scarring. When the joint contracture is related to bony block or exostosis within the joint, other techniques should be employed. In the presented case the limitation of motion was attributed to adhesions of the flexor tendons and contracture of the ligaments and capsule of the affected joints. The progressive distraction of the joint allowed the lengthening of the contracted structures and at the same time caused the rupture of the flexor tendon adhesions, without causing any damage to neural or vascular structures. The patient presented 20 years after his injury and after the conclusion of his case by the insurance company, having received due compensation. He recovered a very good range of motion of the index finger and only a good range of motion of the middle finger because of residual flexion deformity at the PIP joint. It is important to stress that the range of motion was almost the same at 3, 6 and 9 months after surgery, which confirms the durability of the technique in the short and medium term. Special attention should be paid to early movement of the DIP joints in order to avoid loss of range due to the immobilisation period. The technique we present here uses a simple distraction device that is easy to assemble and adjust, as well as being relatively cheap (approximately 75€) compared to other devices usually employed. The low cost, low morbidity and simplicity of application under loco-regional anaesthesia make this an alternative to the classic techniques used, either as a first line therapeutic option or as a last resort when other techniques have failed. The authors wish to thank Dr Martin Vesely and Dr Dylan Murray for their help with the manuscript." @default.
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• W2000621517 title "Correction of long term joint contractures of the hand by distraction. A case report" @default.
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