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Collateral Ligament Reconstruction of the Proximal Interphalangeal Joint

2015; Elsevier BV; Volume: 41; Issue: 1 Linguagem: Inglês

10.1016/j.jhsa.2015.10.007

1531-6564

Julian Carlo, Paul C. Dell, Rob Matthias, Thomas W. Wright,

Tendon Structure and Treatment

Proximal interphalangeal joint collateral ligament injuries are common; however, chronic instability of this joint is rare. In such cases, however, there is no consensus on optimal management. Various repairs and reconstructions have been devised, although the literature on outcomes remains scant. We present a method of reconstruction of the proximal interphalangeal joint collateral ligament using a distally based slip of the flexor digitorum superficialis tendon. Proximal interphalangeal joint collateral ligament injuries are common; however, chronic instability of this joint is rare. In such cases, however, there is no consensus on optimal management. Various repairs and reconstructions have been devised, although the literature on outcomes remains scant. We present a method of reconstruction of the proximal interphalangeal joint collateral ligament using a distally based slip of the flexor digitorum superficialis tendon. Proximal interphalangeal (PIP) joint collateral ligament injuries are common work- or sports-related injuries.1Redler I. Williams J.T. Rupture of a collateral ligament of the proximal interphalangeal joint of the fingers: analysis of eighteen cases.J Bone Joint Surg Am. 1967; 49: 322-326PubMed Google Scholar Injuries may range from sprains and partial tears to complete tears and result in pain, swelling, stiffness, and instability of the joint. Lasting instability of the PIP joint is rare; stiffness rather than instability is the more common outcome. Therefore, most surgeons would agree that acute partial and complete injuries can be managed nonoperatively with good results, although some report persistent dysfunction in these patients.2Ali M.S. Complete disruption of collateral mechanism of proximal interphalangeal joint of fingers.J Hand Surg Br. 1984; 9: 191-193Crossref PubMed Scopus (22) Google Scholar Short-term surgical management of these injuries by reattaching the collateral ligament has also yielded good results.2Ali M.S. Complete disruption of collateral mechanism of proximal interphalangeal joint of fingers.J Hand Surg Br. 1984; 9: 191-193Crossref PubMed Scopus (22) Google Scholar, 3Kato N. Nemoto K. Nakajima H. Motosuneya T. Fujikawa K. Primary repair of the collateral ligament of the proximal interphalangeal joint using a suture anchor.Scand J Plast Reconstr Surg Hand Surg. 2003; 37: 117-120Crossref PubMed Scopus (8) Google Scholar, 4Kato H. Minami A. Takahara M. Oshio I. Hirachi K. Kotaki H. Surgical repair of acute collateral ligament injuries in digits with the Mitek bone suture anchor.J Hand Surg Br. 1999; 24: 70-75Crossref PubMed Scopus (39) Google Scholar Chronic injuries may be amenable to repair, with outcomes noted to be excellent in 2 little finger PIP joints.5Tuncay I. Ege A. Reconstruction of chronic collateral ligament injuries to fingers by use of suture anchors.Croat Med J. 2001; 42: 539-542PubMed Google Scholar However, most chronic injuries are associated with degeneration, fibrosis, and shrinkage of the collateral ligament, which makes the tissue unsuitable for repair. In this case, collateral ligament reconstructions using a free tendon have been devised.6Mantovani G. Pavan A. Aita M.A. Argintar E. Surgical reconstruction of PIP joint collateral ligament in chronic instability in a high performance athlete: case report and description of technique.Tech Hand Up Extrem Surg. 2011; 15: 87-91Crossref PubMed Scopus (3) Google Scholar, 7Lee J.I. Jeon W.J. Suh D.H. Park J.H. Lee J.M. Park J.W. Anatomical collateral ligament reconstruction in the hand using intraosseous suture anchors and a free tendon graft.J Hand Surg Eur Vol. 2012; 37: 832-838Crossref PubMed Scopus (5) Google Scholar Mantovani et al6Mantovani G. Pavan A. Aita M.A. Argintar E. Surgical reconstruction of PIP joint collateral ligament in chronic instability in a high performance athlete: case report and description of technique.Tech Hand Up Extrem Surg. 2011; 15: 87-91Crossref PubMed Scopus (3) Google Scholar described passing a palmaris longus tendon autograft in a U-fashion through drill holes in the middle and proximal phalanges. They secured the reconstruction with 2 suture anchors on the contralateral side and reconstructed the accessory portion of the collateral with the remaining suture limb. Lee et al7Lee J.I. Jeon W.J. Suh D.H. Park J.H. Lee J.M. Park J.W. Anatomical collateral ligament reconstruction in the hand using intraosseous suture anchors and a free tendon graft.J Hand Surg Eur Vol. 2012; 37: 832-838Crossref PubMed Scopus (5) Google Scholar described a 3-limbed reconstruction using a palmaris longus autograft secured with 3 suture anchors, but they reported on only 2 PIP joints. Lane8Lane C.S. Reconstruction of the unstable proximal interphalangeal joint: the double superficialis tenodesis.J Hand Surg Am. 1978; 3: 368-369Abstract Full Text PDF PubMed Scopus (19) Google Scholar reported using both limbs of the flexor digitorum superficialis (FDS) passed through drill holes on the proximal phalanx to reconstruct the collateral ligament and volar plate with the entire FDS tendon, addressing volar plate and collateral insufficiency.Drawing on described reconstructions of the central slip with a distally based slip of FDS,9Ahmad F. Pickford M. Reconstruction of the extensor central slip using a distally based flexor digitorum superficialis slip.J Hand Surg Am. 2009; 34: 930-932Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar we performed PIP collateral ligament reconstructions using a distally based slip of the FDS tendon routed through a drill hole in the base of the middle phalanx and secured with a single suture anchor.We have found that this reconstruction offers advantages over previously described techniques. This technique avoids the need for a free tendon graft and additional incisions required for tendon harvest. Another advantage of the technique is that the FDS insertion serves as a strong anchor point distally. Having only one point of fixation with a suture anchor at the ligament origin site simplifies the reconstruction, minimizes potential points of failure, and requires fewer anchoring implants. The technique is versatile. Although we describe a midaxial approach, the technique can also be performed via a volar approach. Several fixation options are possible (suture anchor, interference screw, pull-out stitch, and local tissue). It is possible to combine the technique with silicone PIP arthroplasty, extending indications to include unstable joints with degenerative joint disease.Indications and ContraindicationsIndications for PIP collateral ligament reconstruction include chronic, symptomatic instability of any finger PIP joint resulting from collateral ligament deficiency that has otherwise failed nonoperative management with placement of an orthosis or immobilization. Static coronal plane deformity may be addressed as long as it is passively correctible. Contraindications to ligament reconstruction include advanced arthrosis, fixed joint deformity, instability owing to articular or bony deformity, or instability resulting from inflammatory conditions. In these situations arthrodesis is a viable option, although concurrent silicone implant arthroplasty and collateral ligament reconstruction may be an alternative.Surgical AnatomyThe PIP joint is a bicondylar hinge joint. It is stabilized on the radial and ulnar sides by a collateral ligament complex composed of proper and accessory portions. Cadaver studies have shown that the proper collateral ligament originates from a crescent-shaped area just dorsal and proximal to the concavity on either side of the head of the proximal phalanx. It travels longitudinally and also fans volarly to insert broadly on the lateral aspect of the middle phalanx base.10Allison D.M. Anatomy of the collateral ligaments of the proximal interphalangeal joint.J Hand Surg Am. 2005; 30: 1026-1031Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar The accessory collateral ligament is a thin structure lying volar to the proper portion and inserting on the volar plate. The volar plate forms the floor of the joint. Superficial to the collateral ligament is the transverse retinacular ligament, a band of fascia joining the conjoint lateral band tendon and the flexor tendon sheath.Surgical TechniqueA midaxial approach to the PIP joint is performed, centered on the side of the deficient collateral ligament. Inadequate quality or length of the collateral ligament to allow anatomic repair indicates irreparability of the collateral ligament. The remaining ligament is released to allow inspection of the joint. On the contralateral side of the joint, another midaxial incision is centered over the PIP joint. The neurovascular bundle is identified and protected. A window is made between the A2 and A4 pulleys. Both slips of the FDS tendon are identified (Fig. 1A). Dissection is carried proximally and distally to separate the slips. The FDS slip contralateral to the deficient collateral ligament is pulled distally and cut proximally, leaving a 3- to 4-cm distally based slip (Fig. 1B). An incision can be added between the A1 and A2 pulleys for additional tendon length if needed. The slip is retrieved distally. A hole is drilled transversely from the base of the middle phalanx at the insertion of the deficient collateral to the opposite side of the base of the middle phalanx (Fig. 1C). A 2.5- to 3.0-mm drill bit usually suffices. A Hewson suture passer (Smith and Nephew, London, UK) is used to pull the slip through the drill hole (Fig. 1D, E). Next, a Mini QUICKANCHOR Anchor (Mitek Inc., Westwood, MA) is placed at the anatomic origin site of the collateral ligament on the head of the proximal phalanx. The tendon slip is manually tensioned and secured at the anchor site using the anchor permanent suture in a horizontal mattress fashion (Fig. 1F). Range of motion (ROM) may be evaluated and coronal stability tested. If PIP silicone implant arthroplasty is necessary owing to degenerative joint disease, bone cuts and medullary canal preparation are performed for the arthroplasty followed by placement of the drill hole through the base. The tendon is transferred and the silicone implant is trialed. Additional canal preparation may be necessary or implant resizing may be required to allow both the trial and tendon to fit. After the final implant is inserted, the tendon is repaired as previously described.Postoperative ManagementAfter surgery, the finger is immobilized in full extension in an orthosis. At 2 to 3 weeks, sutures are removed, a digital gutter splint is fashioned to protect the reconstruction, and gentle active ROM exercises are begun. At 6 weeks, the orthosis is worn only for nighttime use and ROM exercises are advanced. At 12 weeks, the orthosis can be discontinued and activities of daily living may be resumed.Pearls and PitfallsThe technique is versatile and can be completed through a volar approach if necessary and with various fixation options such as a suture anchor, interference screw, pull-out stitch, or suture to local tissue. Care should be taken when performing the drill hole to avoid intra-articular placement, and the hole should be initiated from the collateral insertion for accuracy of placement.ComplicationsThere may be several complications. Stiffness can result and may be related to dissection required for surgery, non-atomic ligament reconstruction, or immobilization. Weakness in flexion, diminished flexion, or swan neck deformity can result from FDS tendon harvest,11Brandsma J.W. Ottenhoff-De Jonge M.W. Flexor digitorum superficialis tendon transfer for intrinsic replacement. Long-term results and the effect on donor fingers.J Hand Surg Br. 1992; 17: 625-628Crossref PubMed Scopus (41) Google Scholar although this complication is likely minimized by retaining one FDS slip. Failure of the reconstruction is another possibility. In an unpublished study, we investigated the mechanical strength of this reconstruction in 10 cadaver fingers. Reconstructions were performed as described and the reconstructions were stressed until failure. The average load to failure of the reconstruction was 36 N, similar in strength to other published metacarpophalangeal or PIP collateral reconstructions.12Dzwierzynski W.W. Pintar F. Matloub H.S. Yoganandan N. Biomechanics of the intact and surgically repaired proximal interphalangeal joint collateral ligaments.J Hand Surg Am. 1996; 21: 679-683Abstract Full Text PDF PubMed Scopus (9) Google Scholar Most failures occurred at the suture–tendon junction and none of the fingers fractured at the drill hole site.Clinical CaseA 72-year-old woman with an index finger PIP joint fracture-dislocation treated with open reduction internal fixation approximately 8 years previously presented with pain and stiffness. Examination showed an ROM of 20° to 50° and a static coronal plane deformity of 20° with additional gross instability to coronal stress. Radiographs showed osteoarthritic joint changes, static coronal deformity, and previous hardware (Fig. 2A, B). She underwent hardware removal and the reconstruction as described earlier, tendon fixation provided by a 2.0-mm screw for interference fixation and the addition of a silicone implant arthroplasty (Fig. 3A, B). She was immobilized for 3 weeks followed by a dorsal-blocking and ulnar gutter orthosis for 3 weeks. At the 3-month follow-up, ROM was 10° to 50°. She had persistent ulnar deviation at the PIP joint but alignment was improved and the joint was stable to coronal stress (Fig. 4). She had minimal pain and was satisfied with the outcome.Figure 2A Anteroposterior and B lateral radiographs before surgery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3A Anteroposterior and B lateral radiographs after surgery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4Patient making a fist 3 months after surgery.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Proximal interphalangeal (PIP) joint collateral ligament injuries are common work- or sports-related injuries.1Redler I. Williams J.T. Rupture of a collateral ligament of the proximal interphalangeal joint of the fingers: analysis of eighteen cases.J Bone Joint Surg Am. 1967; 49: 322-326PubMed Google Scholar Injuries may range from sprains and partial tears to complete tears and result in pain, swelling, stiffness, and instability of the joint. Lasting instability of the PIP joint is rare; stiffness rather than instability is the more common outcome. Therefore, most surgeons would agree that acute partial and complete injuries can be managed nonoperatively with good results, although some report persistent dysfunction in these patients.2Ali M.S. Complete disruption of collateral mechanism of proximal interphalangeal joint of fingers.J Hand Surg Br. 1984; 9: 191-193Crossref PubMed Scopus (22) Google Scholar Short-term surgical management of these injuries by reattaching the collateral ligament has also yielded good results.2Ali M.S. Complete disruption of collateral mechanism of proximal interphalangeal joint of fingers.J Hand Surg Br. 1984; 9: 191-193Crossref PubMed Scopus (22) Google Scholar, 3Kato N. Nemoto K. Nakajima H. Motosuneya T. Fujikawa K. Primary repair of the collateral ligament of the proximal interphalangeal joint using a suture anchor.Scand J Plast Reconstr Surg Hand Surg. 2003; 37: 117-120Crossref PubMed Scopus (8) Google Scholar, 4Kato H. Minami A. Takahara M. Oshio I. Hirachi K. Kotaki H. Surgical repair of acute collateral ligament injuries in digits with the Mitek bone suture anchor.J Hand Surg Br. 1999; 24: 70-75Crossref PubMed Scopus (39) Google Scholar Chronic injuries may be amenable to repair, with outcomes noted to be excellent in 2 little finger PIP joints.5Tuncay I. Ege A. Reconstruction of chronic collateral ligament injuries to fingers by use of suture anchors.Croat Med J. 2001; 42: 539-542PubMed Google Scholar However, most chronic injuries are associated with degeneration, fibrosis, and shrinkage of the collateral ligament, which makes the tissue unsuitable for repair. In this case, collateral ligament reconstructions using a free tendon have been devised.6Mantovani G. Pavan A. Aita M.A. Argintar E. Surgical reconstruction of PIP joint collateral ligament in chronic instability in a high performance athlete: case report and description of technique.Tech Hand Up Extrem Surg. 2011; 15: 87-91Crossref PubMed Scopus (3) Google Scholar, 7Lee J.I. Jeon W.J. Suh D.H. Park J.H. Lee J.M. Park J.W. Anatomical collateral ligament reconstruction in the hand using intraosseous suture anchors and a free tendon graft.J Hand Surg Eur Vol. 2012; 37: 832-838Crossref PubMed Scopus (5) Google Scholar Mantovani et al6Mantovani G. Pavan A. Aita M.A. Argintar E. Surgical reconstruction of PIP joint collateral ligament in chronic instability in a high performance athlete: case report and description of technique.Tech Hand Up Extrem Surg. 2011; 15: 87-91Crossref PubMed Scopus (3) Google Scholar described passing a palmaris longus tendon autograft in a U-fashion through drill holes in the middle and proximal phalanges. They secured the reconstruction with 2 suture anchors on the contralateral side and reconstructed the accessory portion of the collateral with the remaining suture limb. Lee et al7Lee J.I. Jeon W.J. Suh D.H. Park J.H. Lee J.M. Park J.W. Anatomical collateral ligament reconstruction in the hand using intraosseous suture anchors and a free tendon graft.J Hand Surg Eur Vol. 2012; 37: 832-838Crossref PubMed Scopus (5) Google Scholar described a 3-limbed reconstruction using a palmaris longus autograft secured with 3 suture anchors, but they reported on only 2 PIP joints. Lane8Lane C.S. Reconstruction of the unstable proximal interphalangeal joint: the double superficialis tenodesis.J Hand Surg Am. 1978; 3: 368-369Abstract Full Text PDF PubMed Scopus (19) Google Scholar reported using both limbs of the flexor digitorum superficialis (FDS) passed through drill holes on the proximal phalanx to reconstruct the collateral ligament and volar plate with the entire FDS tendon, addressing volar plate and collateral insufficiency. Drawing on described reconstructions of the central slip with a distally based slip of FDS,9Ahmad F. Pickford M. Reconstruction of the extensor central slip using a distally based flexor digitorum superficialis slip.J Hand Surg Am. 2009; 34: 930-932Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar we performed PIP collateral ligament reconstructions using a distally based slip of the FDS tendon routed through a drill hole in the base of the middle phalanx and secured with a single suture anchor. We have found that this reconstruction offers advantages over previously described techniques. This technique avoids the need for a free tendon graft and additional incisions required for tendon harvest. Another advantage of the technique is that the FDS insertion serves as a strong anchor point distally. Having only one point of fixation with a suture anchor at the ligament origin site simplifies the reconstruction, minimizes potential points of failure, and requires fewer anchoring implants. The technique is versatile. Although we describe a midaxial approach, the technique can also be performed via a volar approach. Several fixation options are possible (suture anchor, interference screw, pull-out stitch, and local tissue). It is possible to combine the technique with silicone PIP arthroplasty, extending indications to include unstable joints with degenerative joint disease. Indications and ContraindicationsIndications for PIP collateral ligament reconstruction include chronic, symptomatic instability of any finger PIP joint resulting from collateral ligament deficiency that has otherwise failed nonoperative management with placement of an orthosis or immobilization. Static coronal plane deformity may be addressed as long as it is passively correctible. Contraindications to ligament reconstruction include advanced arthrosis, fixed joint deformity, instability owing to articular or bony deformity, or instability resulting from inflammatory conditions. In these situations arthrodesis is a viable option, although concurrent silicone implant arthroplasty and collateral ligament reconstruction may be an alternative. Indications for PIP collateral ligament reconstruction include chronic, symptomatic instability of any finger PIP joint resulting from collateral ligament deficiency that has otherwise failed nonoperative management with placement of an orthosis or immobilization. Static coronal plane deformity may be addressed as long as it is passively correctible. Contraindications to ligament reconstruction include advanced arthrosis, fixed joint deformity, instability owing to articular or bony deformity, or instability resulting from inflammatory conditions. In these situations arthrodesis is a viable option, although concurrent silicone implant arthroplasty and collateral ligament reconstruction may be an alternative. Surgical AnatomyThe PIP joint is a bicondylar hinge joint. It is stabilized on the radial and ulnar sides by a collateral ligament complex composed of proper and accessory portions. Cadaver studies have shown that the proper collateral ligament originates from a crescent-shaped area just dorsal and proximal to the concavity on either side of the head of the proximal phalanx. It travels longitudinally and also fans volarly to insert broadly on the lateral aspect of the middle phalanx base.10Allison D.M. Anatomy of the collateral ligaments of the proximal interphalangeal joint.J Hand Surg Am. 2005; 30: 1026-1031Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar The accessory collateral ligament is a thin structure lying volar to the proper portion and inserting on the volar plate. The volar plate forms the floor of the joint. Superficial to the collateral ligament is the transverse retinacular ligament, a band of fascia joining the conjoint lateral band tendon and the flexor tendon sheath. The PIP joint is a bicondylar hinge joint. It is stabilized on the radial and ulnar sides by a collateral ligament complex composed of proper and accessory portions. Cadaver studies have shown that the proper collateral ligament originates from a crescent-shaped area just dorsal and proximal to the concavity on either side of the head of the proximal phalanx. It travels longitudinally and also fans volarly to insert broadly on the lateral aspect of the middle phalanx base.10Allison D.M. Anatomy of the collateral ligaments of the proximal interphalangeal joint.J Hand Surg Am. 2005; 30: 1026-1031Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar The accessory collateral ligament is a thin structure lying volar to the proper portion and inserting on the volar plate. The volar plate forms the floor of the joint. Superficial to the collateral ligament is the transverse retinacular ligament, a band of fascia joining the conjoint lateral band tendon and the flexor tendon sheath. Surgical TechniqueA midaxial approach to the PIP joint is performed, centered on the side of the deficient collateral ligament. Inadequate quality or length of the collateral ligament to allow anatomic repair indicates irreparability of the collateral ligament. The remaining ligament is released to allow inspection of the joint. On the contralateral side of the joint, another midaxial incision is centered over the PIP joint. The neurovascular bundle is identified and protected. A window is made between the A2 and A4 pulleys. Both slips of the FDS tendon are identified (Fig. 1A). Dissection is carried proximally and distally to separate the slips. The FDS slip contralateral to the deficient collateral ligament is pulled distally and cut proximally, leaving a 3- to 4-cm distally based slip (Fig. 1B). An incision can be added between the A1 and A2 pulleys for additional tendon length if needed. The slip is retrieved distally. A hole is drilled transversely from the base of the middle phalanx at the insertion of the deficient collateral to the opposite side of the base of the middle phalanx (Fig. 1C). A 2.5- to 3.0-mm drill bit usually suffices. A Hewson suture passer (Smith and Nephew, London, UK) is used to pull the slip through the drill hole (Fig. 1D, E). Next, a Mini QUICKANCHOR Anchor (Mitek Inc., Westwood, MA) is placed at the anatomic origin site of the collateral ligament on the head of the proximal phalanx. The tendon slip is manually tensioned and secured at the anchor site using the anchor permanent suture in a horizontal mattress fashion (Fig. 1F). Range of motion (ROM) may be evaluated and coronal stability tested. If PIP silicone implant arthroplasty is necessary owing to degenerative joint disease, bone cuts and medullary canal preparation are performed for the arthroplasty followed by placement of the drill hole through the base. The tendon is transferred and the silicone implant is trialed. Additional canal preparation may be necessary or implant resizing may be required to allow both the trial and tendon to fit. After the final implant is inserted, the tendon is repaired as previously described. A midaxial approach to the PIP joint is performed, centered on the side of the deficient collateral ligament. Inadequate quality or length of the collateral ligament to allow anatomic repair indicates irreparability of the collateral ligament. The remaining ligament is released to allow inspection of the joint. On the contralateral side of the joint, another midaxial incision is centered over the PIP joint. The neurovascular bundle is identified and protected. A window is made between the A2 and A4 pulleys. Both slips of the FDS tendon are identified (Fig. 1A). Dissection is carried proximally and distally to separate the slips. The FDS slip contralateral to the deficient collateral ligament is pulled distally and cut proximally, leaving a 3- to 4-cm distally based slip (Fig. 1B). An incision can be added between the A1 and A2 pulleys for additional tendon length if needed. The slip is retrieved distally. A hole is drilled transversely from the base of the middle phalanx at the insertion of the deficient collateral to the opposite side of the base of the middle phalanx (Fig. 1C). A 2.5- to 3.0-mm drill bit usually suffices. A Hewson suture passer (Smith and Nephew, London, UK) is used to pull the slip through the drill hole (Fig. 1D, E). Next, a Mini QUICKANCHOR Anchor (Mitek Inc., Westwood, MA) is placed at the anatomic origin site of the collateral ligament on the head of the proximal phalanx. The tendon slip is manually tensioned and secured at the anchor site using the anchor permanent suture in a horizontal mattress fashion (Fig. 1F). Range of motion (ROM) may be evaluated and coronal stability tested. If PIP silicone implant arthroplasty is necessary owing to degenerative joint disease, bone cuts and medullary canal preparation are performed for the arthroplasty followed by placement of the drill hole through the base. The tendon is transferred and the silicone implant is trialed. Additional canal preparation may be necessary or implant resizing may be required to allow both the trial and tendon to fit. After the final implant is inserted, the tendon is repaired as previously described. Postoperative ManagementAfter surgery, the finger is immobilized in full extension in an orthosis. At 2 to 3 weeks, sutures are removed, a digital gutter splint is fashioned to protect the reconstruction, and gentle active ROM exercises are begun. At 6 weeks, the orthosis is worn only for nighttime use and ROM exercises are advanced. At 12 weeks, the orthosis can be discontinued and activities of daily living may be resumed. After surgery, the finger is immobilized in full extension in an orthosis. At 2 to 3 weeks, sutures are removed, a digital gutter splint is fashioned to protect the reconstruction, and gentle active ROM exercises are begun. At 6 weeks, the orthosis is worn only for nighttime use and ROM exercises are advanced. At 12 weeks, the orthosis can be discontinued and activities of daily living may be resumed. Pearls and PitfallsThe technique is versatile and can be completed through a volar approach if necessary and with various fixation options such as a suture anchor, interference screw, pull-out stitch, or suture to local tissue. Care should be taken when performing the drill hole to avoid intra-articular placement, and the hole should be initiated from the collateral insertion for accuracy of placement. The technique is versatile and can be completed through a volar approach if necessary and with various fixation options such as a suture anchor, interference screw, pull-out stitch, or suture to local tissue. Care should be taken when performing the drill hole to avoid intra-articular placement, and the hole should be initiated from the collateral insertion for accuracy of placement. ComplicationsThere may be several complications. Stiffness can result and may be related to dissection required for surgery, non-atomic ligament reconstruction, or immobilization. Weakness in flexion, diminished flexion, or swan neck deformity can result from FDS tendon harvest,11Brandsma J.W. Ottenhoff-De Jonge M.W. Flexor digitorum superficialis tendon transfer for intrinsic replacement. Long-term results and the effect on donor fingers.J Hand Surg Br. 1992; 17: 625-628Crossref PubMed Scopus (41) Google Scholar although this complication is likely minimized by retaining one FDS slip. Failure of the reconstruction is another possibility. In an unpublished study, we investigated the mechanical strength of this reconstruction in 10 cadaver fingers. Reconstructions were performed as described and the reconstructions were stressed until failure. The average load to failure of the reconstruction was 36 N, similar in strength to other published metacarpophalangeal or PIP collateral reconstructions.12Dzwierzynski W.W. Pintar F. Matloub H.S. Yoganandan N. Biomechanics of the intact and surgically repaired proximal interphalangeal joint collateral ligaments.J Hand Surg Am. 1996; 21: 679-683Abstract Full Text PDF PubMed Scopus (9) Google Scholar Most failures occurred at the suture–tendon junction and none of the fingers fractured at the drill hole site. There may be several complications. Stiffness can result and may be related to dissection required for surgery, non-atomic ligament reconstruction, or immobilization. Weakness in flexion, diminished flexion, or swan neck deformity can result from FDS tendon harvest,11Brandsma J.W. Ottenhoff-De Jonge M.W. Flexor digitorum superficialis tendon transfer for intrinsic replacement. Long-term results and the effect on donor fingers.J Hand Surg Br. 1992; 17: 625-628Crossref PubMed Scopus (41) Google Scholar although this complication is likely minimized by retaining one FDS slip. Failure of the reconstruction is another possibility. In an unpublished study, we investigated the mechanical strength of this reconstruction in 10 cadaver fingers. Reconstructions were performed as described and the reconstructions were stressed until failure. The average load to failure of the reconstruction was 36 N, similar in strength to other published metacarpophalangeal or PIP collateral reconstructions.12Dzwierzynski W.W. Pintar F. Matloub H.S. Yoganandan N. Biomechanics of the intact and surgically repaired proximal interphalangeal joint collateral ligaments.J Hand Surg Am. 1996; 21: 679-683Abstract Full Text PDF PubMed Scopus (9) Google Scholar Most failures occurred at the suture–tendon junction and none of the fingers fractured at the drill hole site. Clinical CaseA 72-year-old woman with an index finger PIP joint fracture-dislocation treated with open reduction internal fixation approximately 8 years previously presented with pain and stiffness. Examination showed an ROM of 20° to 50° and a static coronal plane deformity of 20° with additional gross instability to coronal stress. Radiographs showed osteoarthritic joint changes, static coronal deformity, and previous hardware (Fig. 2A, B). She underwent hardware removal and the reconstruction as described earlier, tendon fixation provided by a 2.0-mm screw for interference fixation and the addition of a silicone implant arthroplasty (Fig. 3A, B). She was immobilized for 3 weeks followed by a dorsal-blocking and ulnar gutter orthosis for 3 weeks. At the 3-month follow-up, ROM was 10° to 50°. She had persistent ulnar deviation at the PIP joint but alignment was improved and the joint was stable to coronal stress (Fig. 4). She had minimal pain and was satisfied with the outcome.Figure 3A Anteroposterior and B lateral radiographs after surgery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4Patient making a fist 3 months after surgery.View Large Image Figure ViewerDownload Hi-res image Download (PPT) A 72-year-old woman with an index finger PIP joint fracture-dislocation treated with open reduction internal fixation approximately 8 years previously presented with pain and stiffness. Examination showed an ROM of 20° to 50° and a static coronal plane deformity of 20° with additional gross instability to coronal stress. Radiographs showed osteoarthritic joint changes, static coronal deformity, and previous hardware (Fig. 2A, B). She underwent hardware removal and the reconstruction as described earlier, tendon fixation provided by a 2.0-mm screw for interference fixation and the addition of a silicone implant arthroplasty (Fig. 3A, B). She was immobilized for 3 weeks followed by a dorsal-blocking and ulnar gutter orthosis for 3 weeks. At the 3-month follow-up, ROM was 10° to 50°. She had persistent ulnar deviation at the PIP joint but alignment was improved and the joint was stable to coronal stress (Fig. 4). She had minimal pain and was satisfied with the outcome.