Patients should identify functional goals for the elective procedure and the therapist must ensure the goals are foremost in the therapy treatment program.
A comprehensive, custom-designed rehabilitation program is essential for an excellent, functional outcome.
Effective edema control serves as the chief priority the initial three weeks following surgery to effectively limit pain, allow greater range-of-motion, and limit the formation of scar tissue.
Custom-fabricated orthoses, both for immobilization and mobilization purposes, play an integral role in a successful outcome.
Specific tendon gliding exercises are essential for maximizing tendon excursion and limiting tendon adherence when tenolyses are performed in conjunction with the capsulectomy.
A review of the literature shows that some of the earliest metacarpophalangeal (MCP) joint capsulectomy procedures were performed by Shaw in 1920 and Fowler and Pratt in the 1940s. This reconstructive procedure was often performed secondary to severe hand trauma from war injuries. Since then, other authors have written on the subject. Most of the publications have a limited review of the surgical procedure and the outcomes.
Some of the early articles cited in the literature for proximal interphalangeal (PIP) joint capsulectomies were by Curtis in 1966, Rhode and Jennings in 1971, Sprague in 1976, and Young and colleagues in 1978. The elective procedure was offered to patients to enhance functional performance of the hand.
There are limited written works on the rehabilitation for MCP joint and PIP joint capsulectomies. Laseter, , Gorman, and Saunders published the most thorough reviews of therapy after these procedures. Laseter contributed comprehensive chapters on the subject in the second and third editions of this textbook. Other authors have briefly addressed the postoperative therapy.
Dorsal MCP Joint Capsulectomy
This procedure is recommended primarily for stiff joints in which the surfaces of the head of the metacarpal and base of the proximal phalanx of the MCP joint are relatively normal and the anatomic relationship of the bones has been preserved. However, other authors believe that the procedure can be performed even when radiographs reflect considerable joint damage.
Dorsal MCP joint capsulectomies are indicated when the MCP joint has an extension contracture with significant functional limitation in MCP joint flexion secondary to thickening and contracture of the dorsal capsule, adhesions of the extensor tendons over the dorsum of the hand or the MCP joint, contracture of the collateral ligaments (primarily the cord portion), and skin contracture or scarring over the dorsum of the hand as seen with burns.
Some of the more common diagnoses requiring dorsal capsulectomy are metacarpal fractures, proximal phalanx fractures (primarily at the base), soft tissue or bony crush injuries of the hand, nerve palsies, zone V and VI extensor tendon repairs, Volkmann’s contracture, burns, skin contractures, and distal radius fractures with secondary pain and residual stiffness of the hand.
A number of authors believe that it is unlikely that the procedure will add valuable function to the hand when 60 to 75 degrees of active and/or passive range of motion (ROM) already has been achieved before capsulectomy. Through the years, I have observed a large number of patients with 50 to 60 degrees of passive MCP joint flexion before surgery who ultimately obtained significant improvement in functional use of the hand after the procedure. This has been particularly true when limitation with the MCP joint involves the ring and small fingers. Restoring flexion of the ring and small fingers is invaluable for maximizing hand function.
The chief medical contraindication to this procedure is arthritis. The procedure is not indicated to improve ROM in a digit limited by arthritis. In addition, patients who are not highly motivated and do not have specific functional goals for the procedure would not be favorable candidates for this elective procedure. This contraindication would be true of all elective surgical procedures for which intensive postoperative rehabilitation is necessary after the surgery.
Anatomy of the MCP Joint
A thorough understanding of the bony and soft tissue anatomy at the MCP joint level is essential for appreciating the surgical procedure and establishing an effective postoperative treatment regimen ( Fig. 68-1 ).
The MCP joint is a diarthrodial joint with two freedoms of motion in flexion and extension and abduction and adduction. Unlike the PIP and distal interphalangeal (DIP) joints, which have a consistent degree of stability throughout the arc of motion, the MCP joint has a relatively significant amount of lateral and rotational mobility, which is at its greatest in extension and is relatively eliminated in full flexion. This is because of its bony anatomy and surrounding soft tissue structures.
The bony anatomy of the metacarpal head is configured slightly differently in each of the metacarpals. The metacarpal heads have a smooth and asymmetrical shape. In the index finger, the metacarpal joint surface rotates in a slightly ulnar direction, whereas the ring and small finger metacarpal heads are rotated slightly radially, which allows the fingers to converge toward the middle finger with a common resting point for grasping. This is an important anatomic relationship to be observed with fabrication of dynamic flexion orthoses for the MCP joints. Within the joint itself, the spherical convex contour of the metacarpal head articulates with the concave articular surface of the proximal phalanx. As flexion occurs at the MCP joint, the potential for direct contact between the two bones increases. In part, this is because the surface of the metacarpal head is twice as wide on the volar surface compared with the dorsal portion.
The ligamentous support of the MCP joint is composed of a main collateral ligament and an accessory collateral ligament arising eccentrically off the metacarpal head on the radial and ulnar sides of the joint. The main collateral ligament (cord portion) originates on the metacarpal head and inserts on the volar and lateral base of the proximal phalanx. The accessory collateral ligament originates on the metacarpal head and inserts primarily into the volar (palmar) plate. The main collateral ligaments are redundant in MCP extension and taut in MCP flexion. As the MCP joint flexes, these ligaments must stretch over the wide tubercles and volar base of the metacarpal head. The main collateral ligament in particular becomes increasingly taut as the MCP joint reaches 45 degrees of flexion ( Fig. 68-2 ).
The volar plate, or palmar plate, is a fibrocartilaginous structure on the volar surface of the MCP joint. Distally, the structure is firmly secured to the proximal phalanx and is reinforced by fibers from the accessory collateral ligaments. Proximally, its attachment with the metacarpal head is loosely secured. This permits the laxity necessary for MCP joint hyperextension. The deep transverse metacarpal ligament acts as an added soft tissue support structure for the volar plate and MCP joint.
The dorsal capsule consists of dense connective tissue. The structure is relatively redundant in extension and becomes taut in flexion. The capsule serves as a support structure for the MCP joint.
In extension, the MCP joint inherently maintains stability through the intrinsic muscles. To a lesser degree, added stability is provided through the extrinsic flexors and extensors crossing the MCP joint. Both the extrinsic and intrinsic muscles assist with active flexion and extension at the MCP joint level ( Fig. 68-3 ).
Tendon excursion of the extensor digitorum communis (EDC) is important to keep in mind, particularly when an extensor tenolysis accompanies the MCP joint capsulectomy , ( Table 68-1 ). With the proper exercises, maximum excursion of the EDC can be obtained, thereby preventing adherence of the EDC to adjacent soft tissue and/or bony structures.
|Bunnell et al., 1956 57||15 mm||16 mm||11 mm||12 mm|
Beyond the EDC, it is valuable to recognize the added contribution of the extensor indicis proprius (EIP) and extensor digiti quinti (EDQ). Both of these muscles are innervated by the radial nerve.
Hand surgeons should consider including an assessment by the hand therapist as part of the initial evaluation process for patients referred with hand stiffness. The therapist can evaluate the patient’s past therapy regimen and determine whether additional therapy can positively influence the stiff MCP joints and potentially eliminate the need for surgery. Conversely, the therapist can reinforce the need for the elective procedure through the objective evaluation and assessment of the patient’s therapy program.
The preoperative assessment should include (1) the patient’s pertinent medical history; (2) active and passive ROM of all digits and the wrist; (3) evaluation for possible intrinsic tightness and extrinsic extensor tightness; (4) manual muscle testing of the extrinsic flexors, extensors, and intrinsic muscles; (5) the patient’s current pain level and history of pain; (6) integrity of the skin; (7) notation of any previous infection and risk of recurrence; (8) functional performance level of the hand in activities of daily living (ADL), along with vocational and avocational activities; and (9) the patient’s desired functional goals of surgery.
A capsulectomy is excision of a capsule and, in this case, a joint capsule. The Latin derivation is capsule, meaning “the joint capsule,” and ectomy, meaning “cutting, excision.” Thus, with a capsulectomy, there is surgical excision of a portion of the joint capsule along with the soft tissue structures intricately associated with the joint. Capsulotomy, on the other hand, is an incision, but not excision or removal, of soft tissue structures. It is not uncommon, however, for these terms to be used interchangeably.
A thorough understanding of the operative procedure is essential to effectively manage the postoperative therapy. A number of authors have described their surgical approach for MCP joint dorsal capsulectomies. The reader is referred to Chapter 66 for a complete description of the surgical management for MCP joint contractures. The following is an overview of one surgical approach for dorsal MCP joint capsulectomies. ,
A longitudinal incision is made along the dorsal aspect of the affected joint or joints ( Fig. 68-4A , online).
The extensor hood is incised, and the extensor tendon is either retracted laterally to the joint or split longitudinally to gain visual exposure of the joint ( Fig. 68-4B , online).
The synovium and the dorsal capsule are exposed and excised ( Fig. 68-4C , online).
The collateral ligaments are excised in a balanced fashion along the cord portion just beneath and on both sides of the tubercle of the metacarpal head. The distal portion of the cord is left attached to the accessory portion of the collateral ligament ( Fig. 68-4D , online).
As passive flexion is attempted, if the MCP joint opens like a book instead of the proximal phalanx gliding along the head of the metacarpal (as seen with normal joint biomechanics), then a periosteal elevator or curved dissector is passed around the volar aspect of the metacarpal head to free the adhesions between the metacarpal head and the volar plate ( Fig. 68-4E , online). This will correct the problem.
The wound is closed. If the extensor tendon has been split longitudinally, it is reapproximated and sutured before skin closure.
In cases of extensive dissection, consideration may be given to placing drains along the surgical area to enhance drainage and secondarily reduce postoperative edema, risk of hematoma, and ultimate scar-tissue formation.
In severe cases in which a certain degree of rebound or tendency to resist passive flexion occurs, consideration may be given to percutaneous pinning of the joint in flexion for a limited time before initiating therapy.
A bulky compressive dressing is evenly applied, positioning the MCP joints in 45 to 75 degrees of flexion.
If postoperative pain is a concern (based primarily on the patient’s history of pain after the initial injury or surgery), consideration may be given to postoperative transcutaneous electrical nerve stimulation (TENS) along the appropriate peripheral nerve distribution.
If an extensor tenolysis is needed, the tenolysis would be performed before the capsulectomy. In some cases, extensor tendon adhesions may be the primary restriction to passive flexion, and an extensor tenolysis alone may prevent the need for capsulectomy.
To establish an effective postoperative course of rehabilitation, the therapist and surgeon should thoroughly discuss the patient’s surgery. The therapist must have a complete understanding of the extent of surgery performed, any residual limitations to full passive flexion, potential concerns related to joint stability, and any additional surgical procedures (e.g., tenolysis, intrinsic releases). Based on this information, the initial postoperative therapy program can be established.
An objective examination should be performed during each treatment session after surgery. It is critical to monitor active and passive ROM, edema with circumferential measurements along the distal palmar flexion crease or along the MCP joints, pain with a visual analog scale or by rating the pain on a scale of 0 to 10, and the wound (size and appearance). The objective examination is essential to monitor the patient’s progress and the effectiveness of each treatment method.
As part of the initial examination, the therapist should have a full understanding of the patient’s goals and objectives for the surgery. With this information, the therapist can effectively design the rehabilitation program prioritizing these goals.
Control of postoperative edema during the initial 10 to 14 days after surgery is of great importance ( Fig. 68-5 ). Effective edema management is key to a successful outcome. During the initial inflammatory phase and, more important, during the fibroplasia phase of wound healing, the fibroblasts and fibrin lay down collagen, affecting the suppleness of the soft tissue structures and forming restrictive adhesions. Effective edema management minimizes the formation of adhesions, decreases the pressure and resistance to passive joint motion, and favorably influences the orientation of collagen fibers as active and passive ROM exercises are incorporated in the therapy program.
When excessive edema is present, there is heightened pain and increased risk of wound separation and subsequent infection. It is critical to effectively manage the edema so that it will not interfere with the course of rehabilitation.
One particularly effective method for controlling postoperative edema in the hand and forearm is a carefully and evenly applied light compressive dressing ( Fig. 68-6 , online). The dressing is changed at each therapy visit and is worn for the initial 10 to 14 days after surgery. Once the light compressive dressing is discontinued, elastic stockinettes may be worn on the hand and forearm along with an edema glove to assist with managing persistent edema.
In addition to the light compressive dressings and elastic stockinettes, elevation and interdigital massage (between the metacarpals and along the length of the volar and dorsal aspects of the hand) are effective for managing the boggy edema often noted after surgery. With the massage, it is important to avoid direct contact with the sutures and to avoid skin separation along the suture line.
To manage digital edema, finger socks or Coban are applied and worn between exercise sessions ( Fig. 68-7 , online). The edema at this level will generally subside within 2 to 3 weeks.
In most instances, wound care can be accomplished through the use of postoperative light compressive dressings. The dressings serve as the sterile barrier between the wound and contaminants in the environment. When possible, the Xeroform, which is often placed over the sutures before the bulky dressing is applied, is left in place to provide added wound protection ( Fig. 68-8 , online).
Occasionally, when extensive surgery is required, significant dorsal edema may create a limited degree of wound separation. These wounds generally have an uneventful course and heal readily by secondary intention.
On occasion, a hematoma will occur. In these instances, it is important to express the hematoma to prevent an environment for infection. With the use of sterile technique, hematomas may be manually expressed by slightly separating the sutured skin edges and gently rolling a 4 × 4-inch sterile gauze pad with light pressure along the skin to express the hematoma or the hematoma may be aspirated by the physician with a needle and syringe. After expression of the hematoma, the wound must be monitored carefully for signs of infection. A course of prophylactic antibiotics is not uncommon.
In traumatic injuries in which extensive surgical dissection is necessary (i.e., combined capsulectomies and tenolyses in multiple digits), a Hemovac drain may be placed in the surgical area for 1 to 3 days to allow drainage and evacuation of the residual bleeding. This is valuable in reducing the risk of the development of a hematoma and excessively dense scar tissue postoperatively.
Effective edema management is one means for controlling the postoperative pain associated with MCP joint capsulectomies. In addition, TENS has proven to be beneficial in reducing postoperative pain ( Fig. 68-9 , online). High-rate, conventional TENS settings, with electrode placement along the peripheral nerve distribution of the surgical area, has repeatedly proven effective in the authors experience.
The surgeon may choose to use an in-dwelling pain catheter to control the postoperative pain along with a regimen of oral narcotics for the initial days after surgery.
The bulky compressive dressing should be removed within the initial 24 to 48 hours after surgery to initiate ROM exercises. It is important to begin the exercises before the close of the inflammatory phase of wound healing and before active participation of the fibroblasts in laying the framework for the formation of new collagen. Initiating early controlled motion will aid in the alignment and orientation of the newly forming collagen and will ultimately affect the final arc of motion.
Important to include in the postoperative exercise regimen are the following active, active-assisted, and passive ROM exercises ( Fig. 68-10 ):
Composite flexion and extension of the digits
MCP joint flexion/extension with the interphalangeal (IP) joints extended
MCP joint flexion/extension with the IP joints flexed
Abduction/adduction of the digits