17 Management of Complications of Ligament Repair of Thumb and Finger Joints
Mike Ruettermann
Abstract
Iatrogenic nerve injury, wound healing problems, and wound infections, including osteomyelitis, can occur in the short term after operative treatment. Mid-term complications comprise nerve compression due to scarring, stiffness, and persistent instability of the joint. Long-term recurrence of instability after months or years of intensive use after a successful primary repair is a possible complication and does resemble chronic gamekeeper’s thumb. Chronic pain is mostly caused by cartilage damage.
An easily reproducible pull-out tendon graft technique for secondary RCL as well as UCL reconstruction for the metacarpophalangeal (MCP) joint of the thumb is presented. With slight modifications regarding the soft tissue dissection, this pull-out tendon graft technique can also be used for severe instabilities of PIP joints.
The most common complications of volar plate injuries and their conservative and surgical treatments are stiffness and instability, leading to subluxation and in the long run secondary arthritis.
Diagnostic pearls are presented as well as technical tips. Foreign body materials, like bone anchors, interference, or locking screws, are discussed regarding their value in secondary cases. Finally, differential indications for secondary surgery with regard to specific joints are detailed.
Keywords: complications, radial/ulnar collateral ligament repair, stiffness/instability MCP/PIP/DIP joint, subluxation thumb/finger joint
17.1 Introduction
The primary treatment of injuries of ligament lesions of the small joints of the thumb and fingers, such as metacarpophalangeal (MCP), proximal, and distal interphalangeal (PIP and DIP) joints, is in most cases nonoperative, especially when there is no extensive instability: less than 30 degrees of laxity or less than 20 degrees more laxity compared to the contralateral side with a discrete end point to the joint opening. Also, volar plate injury is mostly treated nonoperatively, unless there is gross instability.
The nonoperative treatment is generally done by splinting or buddy taping, ideally without immobilizing other joints that are not affected. For volar plate injuries, a dorsal extension block is added in cases of dorsal subluxation. For the ulnar collateral ligament (UCL) lesion of the MCP joint of the thumb, a Stener lesion1 has to be ruled out because the retracted part cannot heal. Stability of the UCL should be tested in 40 degrees of flexion, as, otherwise, the volar plate will stabilize the joint such that a relevant lesion of the collateral ligament could be missed clinically.2 A Stener lesion is possible in case of complete UCL injuries of the MCP joint of the thumb, without a clinical end point on valgus stress. It needs to be ruled out by ultrasound or magnetic resonance imaging (MRI) if one does not operate anyway. Nonoperative treatment will not lead to sufficient healing and stability if the distally avulsed ligament is retracted behind the adductor aponeurosis like in a Stener lesion. The distally avulsed ligament cannot get into contact with its insertion at the base of the proximal phalanx without surgical readaptation.
17.2 Indications for Surgery
If nonoperative treatment does not lead to sufficient stability or there is extensive instability including (sub)luxation in the first place, surgery is indicated. Other indications for primary surgical repairs are an open injury or the Stener lesion as mentioned above. Bony ligament avulsions, which include a relevant part of the joint surface and lead to instability of the joint, should be treated as fractures. Reposition and fixation of a significant bony fragment will correct the joint instability.
Surgical repair of the ligamentous injury is either done by suturing of the ligaments in cases of intrasubstance injuries, which are rare, or by reattachment of the ligament with or without a bony fragment at the side of bony fracture. This is the distal attachment at the base of the proximal phalanx in the majority of cases.
In volar plate injuries of the PIP joints, there is mostly no need to fix a bony fragment, unless it is a relevant part of the joint surface and would be classified as a fracture rather than a volar plate lesion.3 In cases of severe luxation with significant instability or patient incompliance with regard to postoperative immobilization, temporary fixation of the joint with a K-wire may be indicated.
This chapter deals with the management of complications of surgical ligament repair of thumb and finger joints. Fractures, as well as dislocations caused by a fracture, are beyond the scope of this chapter and are discussed in Chapter 7.
Most injuries happen to the stable hinge joints, like the PIP joints, in the form of dislocations caused by hyperextension due to a ball striking a fingertip. These dislocations can be dorsal, lateral, or volar, and most of them can be treated nonoperatively. UCL lesions of the thumb are ten times more common than radial collateral ligament (RCL) injuries.4
Notwithstanding which ligament of which joint has to be treated, complications can be classified according to when they appear postoperatively as short-, medium-, and long-term complications.
17.2.1 Short-Term Complications and Their Treatment
These can affect tissues in the anatomical area of the procedure and resemble general hand surgery complications.
Intraoperative complications like iatrogenic nerve injury of the branch of the dorsal radial superficial nerve on the dorsoulnar side of the thumb, for example, should ideally be noticed immediately and microsurgically repaired directly. This is also important in cases of injuries of palmar finger nerves during repairs of ligaments or volar plates.
Postoperative hematomas or wound healing problems should be treated accordingly if they have a relevant extend.
Wound infections can be overcome by rest and topical antiseptic treatment if detected early. In advanced infection, debridement and antibiotic treatment may be necessary. Special care must be taken when K-wires have been used for temporary fixation of the joint. If there is any risk of osteomyelitis, the hardware needs to be removed and the osteomyelitis treated. If this complication is not taken seriously and treated accordingly, the joint will get infected, leading to long-term complications with joint damage resulting in pain, stiffness, etc.
Nerve compression due to scarring can occur in the course of wound healing, especially after wound healing problems, hematomas, or wound infections. In most cases, conservative scar treatment with massage and silicone application solves the problem. In persistent cases, corticosteroid injections into the scarred area might help; otherwise, surgical neurolysis is indicated.
Missed sharp nerve injuries require microsurgical repair or proximal resection and translocation in muscle or bone. If direct repair is feasible after resection of the neuroma, it should be done. In case of defect with a distance, the approach should be based on the anatomical location and the patient’s wishes. A detailed discussion of the options with the patient and informed consent are mandatory in these cases.
The approach with the best cost-benefit ratio for the patient should be chosen.
If, for example, direct repair of the distal dorsoulnar branch of the thumb, which comes of the superficial radial nerve, is not feasible, it should be denervated proximally. For an injury of the palmar ulnar digital nerve of the thumb, microsurgical interposition of a nerve graft is indicated if the thumb is otherwise functional.
17.2.2 Mid-Term Complications and Their Treatment
After healing of the ligament repair in a cast or splint, there is frequently stiffness, which generally can be improved by exercises and hand therapy. Additionally, dynamic splints may lead to further improvement of the range of motion.
If these measures do not lead to a sufficient function, and there is no further progress, surgical revision may be indicated if the patient is motivated.
Depending on the primary injury, especially on which other structures, such as flexor or extensor tendons, have been affected, there needs to be a precise evaluation of the problem.
In cases of a passively mobile joint with limited active flexion or extension, tenolysis of the extensor or flexor tendon, respectively, could be the next step. This should be done after complete maturation of the scar tissues. Beforehand a corticosteroid injection could be given if the area of the scarring can clinically be identified.
A surgical revision in wide-awake local anesthesia without tourniquet (WALANT) is helpful, as the results can be actively verified during the procedure.
If the tendons are gliding, but the joint itself is contracted despite consequent hand therapy and dynamic splinting, a surgical approach with stepwise arthrolysis is an option. The long-term results of arthrolysis, especially of the PIP joints, are less predictable than those of tenolysis.
The most important mid-term complication is persistent instability of the joint due to insufficient primary repair/healing. This can be caused not only by short-term complications, like infection, but also by inadequate quality of the remnants of the ligament in cases of direct suturing of intrasubstance lesions.
Insufficient healing to the periosteum in cases of a distal avulsion can also cause this problem, which happens if a Stener lesion is treated conservatively.
Another reason may be the formation of a pseudarthrosis when a small bony fragment fixed at the repair site is not healed. This might happen if the bone part is fixed in malposition; it is rotated in a way that the cortical bone or the joint surface is in contact with the cancellous bone at the fracture site. Secondary fixation can be considered, but this is a technically demanding procedure as the bony fragment is often small, but needs to be debrided, repositioned, and fixed adequately. Since that is not feasible in many cases, excision of the small bone fragment and reinsertion or reconstruction of the ligament are advisable.
In most cases of failed primary surgical repair of a collateral ligament, there are not sufficient remnants of the ligament in a secondary procedure. Often a reconstruction with an augmentation or replacement graft is necessary.
However, in most cases a reconstruction with a graft is necessary. The reference standard graft is the palmaris longus tendon if this is available. Another option is a graft taken from the flexor carpi radialis tendon, mostly as a partial lengthwise split. Other tendons can be used, too, but this has to be weighed up against the downsides of the specific donor-site morbidity. Alternatively, a piece of extensor retinaculum can be used as a graft for augmentation of the ligament’s remnants but is not easy to harvest or handle as a pull-out graft. Other options are artificial grafts that are available as ligament augmentation. Their use has to be weighed against the extra costs and possible reaction to foreign body material.
An example of a secondary collateral ligament reconstruction with a palmaris longus tendon graft for the UCL of the MCP joint of the thumb is described in detail below.
Complications of Volar Plate Injuries
Most volar plate injuries of the MCP and PIP joints are treated conservatively in the first place. If closed reposition is not feasible, open reposition is performed. The most common complications of conservative and surgical treatment are stiffness and instability, leading to subluxation and subsequently could lead to osteoarthritis.
Stiffness is treated with hand therapy and dynamic splinting. If there is a remaining functional flexion contracture without arthritic changes in the joint, an arthrolysis is indicated in a motivated patient. This is ideally done via mid-axial incisions. A stepwise approach with a release of the collateral ligaments, the checkrein ligaments, and the proximal part of the volar plate is the method of choice. The joint should be straight at the end of the procedure without a tendency to spontaneous flexion. Otherwise, more extensive dissection of remaining adhesions is needed. Instability is hardly ever seen; recurrent flexion contracture is more likely.
Consequent exercises and splinting are mandatory after arthrolysis.
Instability with dorsal luxation can be treated by reinsertion of the volar plate, for which one or two suture-bone anchors can be used. With these, the proximal part of the volar plate can be fixed to the head of the proximal phalanx in most cases. An additional K-wire for temporary fixation of the joint protects the repair. It can be removed after about 4 weeks. Dorsal splinting to prevent reluxation should be continued until the volar plate has healed, at least 8 weeks in cases of complete instability.
17.2.3 Long-Term Complications and Their Treatment
A recurrence of instability after months or years with intensive use after a successful primary repair does resemble chronic gamekeeper’s thumb. It can be treated like persistent instability of the joint.
If chronic pain develops over time, this is mostly caused by cartilage damage. Pain progresses faster in cases where the ligament repair is not stable enough and leads to laxity and subluxation of the joint with consequent accelerated cartilage damage. Treatment is the same as for any other form of posttraumatic osteoarthritis.
If conservative treatment does not provide sufficient relief, surgery is indicated.
If the pain due to cartilage damage is not yet severe and persistent, a ligament reconstruction could be performed. Arthrodesis is the most promising option regarding pain relief, as arthroplasty in joints with already injured collateral ligaments results in more complications.5 Depending on the affected joint, arthrodesis can be performed with K-wires, cerclages, screws, or plates. But not all patients are happy with an arthrodesis of, for example, their thumb MCP joint as this can lead to difficulties with one or more specific activities, especially in young, more demanding patients. Adequate preoperative information and realistic expectations are essential.6
In joints that are less prone to strain, like the PIP joints of the ring- and little finger, arthroplasty is an alternative. (Especially new generation) Silicone spacers do have some intrinsic stability and can be used, but the results in posttraumatic cases with ligament injuries are less rewarding and lasting than those in primary arthritis.
17.3 Operative Technique
17.3.1 Preferred Method of Secondary Ligament Reconstruction of the Radial/Ulnar Collateral Ligament of the Thumb MCP Joint
Multiple methods of repair of the collateral ligaments of the MCP of the thumb have been described, but none has been shown to be superior.7 The original method described by Littler’s group8 is technically demanding. It makes it difficult to precisely place the distal tunnel, which is important with regard to joint movement.9
An alternative method is a pull-through tendon graft with two oblique transverse tunnels: one in the distal first metacarpal and one in the base of the proximal phalanx of the thumb (Fig. 17‑1).
Fig. 17.1 Normal ulnar collateral ligament complex (view of the thumb metacarpophalangeal joint from the ulnar side): (a) in extension, (b) in flexion. pUCL = proper ulnar collateral ligament (tight in flexion with a maximum around 40 degrees) and aUCL = accessory ulnar collateral ligament (tight in extension). Red dots: the ideal position of the bone tunnels for the pull-out tendon graft.
Related posts:
Complications: What They Do to the Patient
Debunking Complex Regional Pain Syndrome/Sudeck/Reflex Sympathetic Dystrophy
Flexor Tendon Repair in Zone 2: Prevention and Management of Complications by Hand Therapy
Management of Complications Following Open Reduction and Plate Fixation of Distal Radius Fractures
Treatment of Complications after Scapholunate Ligament Repair
Management of Complications of Extensor Tendon Surgery
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