Had to post the body of the note separately as it had to many characters to put together!
DESCRIPTION OF PROCEDURE: The patient was placed supine on the operating table, and an arm board
was utilized. Prior to the surgery and after she was asleep, I injected the subcutaneous and deeper tissues
with approximately 20 mL of 1% lidocaine with 1:100,000 epinephrine to allow for hemostasis as the tourniquet
time was anticipated to be more than 2 hours given the multiplicity of digits needing reconstruction. In addition,
the patient was given tranexamic acid and antibiotics (2 g of IV Ancef) prior to tourniquet inflation. A time-out
was called after the surgical site was prepped and draped, and the tourniquet was inflated to 260 mmHg. The
tourniquet time was exactly 2 hours, and it was only inflated once.
I made a transverse incision just proximal to the metacarpophalangeal joints, left hand, curving slightly ulnarly
over the metacarpal head with the anticipated excision of the rheumatoid nodule which was bothersome on the
ulnar aspect above the joint. It appeared to be a rheumatoid nodule, presumably related to the capsule of the
metacarpophalangeal joint. Following the incision and hemostasis with electrocautery, I carefully identified the
dorsal sensory nerve branches as well as veins and small arteries and released them in a such a way so that
they could be retracted between the metacarpal heads and on the ulnar side retracted ulnar to the 5th underneath.
At this time, I made incision on the ulnar aspect of the extensor tendon through the ulnar sagittal
band to release it in order to move it radially so that it could be retracted out of harm's way, and also this was
part of the extensor malalignment correction. At this time, I also identified the ulnar intrinsic tendon which was
contributing to the deformity and placed a small mosquito underneath it distally and carefully released it, with
care being taken to avoid the neurovascular structure. I then incised the capsule longitudinally and T'd it
distally so that good flaps could be used to repair the capsule over the implant in the end. At this point, I
performed a synovectomy to evaluate the joint, and then, after hyperflexing it and completely identifying the
metacarpal head, I released the ulnar and radial collateral ligament from the metacarpal head origin proximally,
keeping the attachment distal on the phalanx. I marked the radial collateral ligament with a suture tag for later
repair. Having released the joint, it was then possible to evaluate both the metacarpal head and the base of
the proximal phalanx.
At this time, I resected the metacarpal head at the level of the collateral ligament origin. The initial cut was
slightly distal to this, but a second cut was made as it was noted to be too distal. The cut was made
perpendicular to the shaft. After making the cut, I then released the volar plate of the proximal phalanx with a
Freer and a knife so that it could be brought up and evaluated and worked on. Having done soft tissue
releases and making the metacarpal head cut, I evaluated the space which was about a centimeter or so about
the desired space for the implant.
I then opened the base of the distal phalanx with an awl after making a small hole with a tiny bur and then
broached it up to a size 4. I then broached the metacarpal to a 4. I then evaluated the size of the implant and
the space, and it seemed a bit loose and also the size of the implant seemed a bit small, and I, therefore,
trialed a size 5 which seemed to fit much better and was much more stable with full flexion and extension,
without buckling. I, therefore, chose to utilize a size 5 implant for the index. The extensor tendon was
centralized, and the metacarpal was ready for the final implant. However, before doing this, I elected to move
on to the long digit.
Almost an identical procedure for the long digit was done, identifying the extensor tendon initially and then
releasing it on its ulnar side from the ulnar sagittal band and then retracting it ulnarly to expose the capsule
which was then incised, and then a synovectomy was done. Collateral ligaments were released, radial
collateral ligament tagged, and then, after hyperflexing and visualizing the joint and visualizing the proximal
phalanx, I then released the volar plate and opened the canal of the distal phalanx with a tiny bur and then
started with an awl and then broached it to a size 4. I then broached the canal of the metacarpal which also
received a size 4 nicely. I then trialed with a size 4, and it appeared to be a good fit with full extension and
flexion, without buckling. Unlike the index digit, which was a bit loose with the size 4, it fit very nicely with
respect to the long digit. It also appeared that the index metacarpal shaft was slightly larger than the long, and
this made sense. Therefore, a size 4 was chosen. As in the index, the final implant would be done at the end.
I repeated the same procedure for the ring digit, identifying the extensor tendon, releasing the extensor tendon
along its ulnar side, and releasing the ulnar sagittal bands followed by the ulnar intrinsic release and then
incised the capsule and did a synovectomy. I then cut the metacarpal head, released the collateral ligaments,
opened the proximal phalanx with an awl, and then broached it and then broach the metacarpal side. For the
ring digit, a size fit the best and had the best combination of motion and stability, and therefore, a size 3 was
chosen.
Finally, I turned to the small digit, and the same procedure was done, identifying the extensor tendon, releasing
it ulnarly, and retracting it radially. I released the abductor digiti quinti and then incised the capsule after
identifying it and did a synovectomy. I then released the collateral ligaments, tagging the radial collateral
ligament, and then cut the metacarpal head, released the volar plate from the proximal phalanx, and then
broached the proximal phalanx distally and the metacarpal head proximally and sized it to a size 3. Size 3 fit
well with good stability and motion.
metacarpal.
At this point, I began working on the index digit. Digits were done one at a time for the most part. I started with
the index, identifying the extensor tendon proximally and tracing it distally. The extensor tendon was ulnar to
the MP joint and was not easily identified at first, but once it was traced, I identified the central tendon well
ulnar to the ulnar head. The radial sagittal band was noted to be quite attenuated. There was a lot of synovitis
At this time, I worked my way back and implanted the size 3 MP silicon implant (DJO Ortho, originally called
Swanson implant). Prior to implanting the implant, I made a drill hole in the dorsoradial aspect of the
metacarpal for reattachment of the radial collateral ligament and placed a suture through this. A modified
Bunnell suture was placed in the radial collateral ligament, and after inserting the implant, I then tied it,
resulting in excellent stability with ulnar deviated stress as well as excellent motion. The capsule was then
repaired over the implant, and the implant was noted to be very stable with passive motion from 0° to 90° or
more. I then reefed the radial sagittal band that was patulous and stretched to help stabilize the extensor
tendon and maintain its position directly over the MP joint.
I then irrigated and inserted the size 3 ring silastic implant, repairing the radial collateral ligament as described
for the small digit, repairing the capsule, and reefing the radial sagittal band in the same way using several 4-0
PDS figure-of-eight sutures, and it centralized the tendon nicely.
I repeated the same procedure for the long digit and the index digit as described above.
Following this, I took final pictures with findings as above, showing satisfactory alignment and positioning.
There was excellent stability of all implants and good motion. It should be noted that the tourniquet was
deflated just as I finished implanting the last implant of the index. Another 45 minutes to an hour was utilized
for combination of excising the rheumatoid nodule, irrigation, hemostasis, injection of more local (20 mL of
0.25% Marcaine with epinephrine), C-arm x-rays, and application of a splint.
The rheumatoid nodule was approached through the same ulnar incision, and I carefully released it away from
subcutaneous tissue. It was unclear what the origin was, possibly the capsule which had been dissected free
of tissue at the time of exposure. The nodule was about a centimeter to a centimeter and a half wide and was
grayish tissue, appearing like a rheumatoid nodule. It was not sent for pathology as it clearly appeared to be
benign and related to the rheumatoid arthritis. There did not appear to be any infection present. A final check
prior to closure revealed that all extensor tendons were centralized over the MP joints for each digit with full
flexion and extension. Pulling on the extensor tendons manually also straightened the fingers for the most part
with mild PIP lags of about 10° to 15°, presumably due to chronic tendon dysfunction.
A splint was applied on the volar aspect after closure with interrupted 4-0 Vicryl and 5-0 subcuticular Prolene
augmented with Steri-Strips. The splint extended from the midforearm level to a point just short of the PIP
joints, holding the MP joints in extension but allowing PIP flexion.