Percutaneous desmotomy of digits for stiffness from fixed edema

A simple technique, not previously described, has been successful in achieving increased motion of contracted metacarpophalangeal and proximal interphalangeal joints of the hand. The procedure involves percutaneous sectioning of collateral ligaments followed by joint manipulation. Experience with 65 stiff joints treated by this minimally invasive technique followed by physical therapy revealed an average final gain of 28 degrees for metacarpophalangeal joints and 19 degrees for proximal interphalangeal joints. Mean follow-up was 13 months. This compares favorably to the more aggressive technique of open arthrolysis, thus offering a simple and effective treatment alternative.     

Dupuytren's fasciectomies in 60 consecutive digits using lidocaine with epinephrine and no tourniquet

Dupuytren's contracture is a common hand problem. Its treatment, other than percutaneous fasciectomy, is an outpatient operation performed with the patient under regional or general anesthesia. If local anesthetics are used, they are used without epinephrine, and an arm or forearm tourniquet is essential. Multiple reviews have described the safety of local anesthetics with epinephrine in the digits. This study is a retrospective review of operations performed by the same surgeon in the hospital (43 digits) versus the office using local anesthetics with epinephrine and no tourniquet (60 digits). Results and complications were compared and tabulated. The hospital and epinephrine groups were comparable regarding preoperative measurements. Postoperative improvement in extension at the metacarpophalangeal and proximal interphalangeal joints was similar in both the hospital and epinephrine groups. Complications, including digital nerve and artery injuries, infections, and hematomas, were similar between the groups. There were no cases of digital necrosis or gangrene in the epinephrine group, even though one patient sustained a transection of a digital artery at the proximal interphalangeal joint. Because of the similarities in results and complications, there does not seem to be an advantage to performing Dupuytren's excisions with full arm tourniquet and outpatient admission in many cases. Local anesthetics with epinephrine are safe in the treatment of Dupuytren's contracture, although both the use of digital epinephrine and the use of mechanical tourniquets carry the potential for complications. Visibility is similar to that for facial or head and neck surgery and is aided by the use of loupe magnification. The old dogma against its use in the fingers is refuted, as seen by the results in these 60 consecutive Dupuytren's fasciectomies and the results of other authors.     

Rheumatoid arthritis and Dupuytren's contracture

Of four patients with rheumatoid arthritis and Dupuytren's contracture, two were not aware of the presence of Dupuytren's contracture. When both diseases coexist, the presence of rheumatoid hand deformities, especially flexion and ulnar deviation of the metacarpophalangeal joints, may mask the flexion deformity caused by Dupuytren's contracture. Careful clinical examination should rule out the presence of a pathologic fascial cord. When reconstructive surgery is indicated for the rheumatoid hand in the presence of advanced Dupuytren's contracture, staged surgery would be appropriate and reconstruction of Dupuytren's contracture should precede other surgery.     

Optimizing the correction of severe postburn hand deformities by using aggressive contracture releases and fasciocutaneous free-tissue transfers

Severe postburn hand deformities were classified into three major patterns: hyperextension deformity of the metacarpophalangeal joint of the fingers with dorsal contracture of the hand, adduction contracture of the thumb with hyperextension deformity of the interphalangeal joint, and flexion contracture of the palm. Over the past 6 years, 18 cases of severe postburn hand deformities were corrected with extensor tenotomy, joint capsulotomy, and release of volar plate and collateral ligament. The soft-tissue defects were reconstructed with various fasciocutaneous free flaps, including the arterialized venous flap (n = 4), dorsalis pedis flap (n = 3), posterior interosseous flap (n = 3), first web space free flap (n = 3), and radial forearm flap (n = 1). Early active physical therapy was applied. All flaps survived. Functional return of pinch and grip strength was possible in 16 cases. In 11 cases of reconstruction of the dorsum of the hand, the total active range of motion in all joints of the fingers averaged 140 degrees. The mean grip strength was 16.5 kg and key pinch was 3.5 kg. In palm reconstruction, the wider contact area facilitated the grasping of larger objects. In thumb reconstruction, key-pinch increased to 5.5 kg and the angle of the first web space increased to 45 degrees. Jebsen's hand function test was not possible before surgery; postoperatively, it showed more functional recovery in gross motion and in the dominant hand. Aggressive contracture release of the bone,joints, tendons, and soft tissue is required for optimal results in the correction of severe postburn hand deformities. Various fasciocutaneous free flaps used to reconstruct the defect provide early motion, appropriate thinness, and excellent cosmesis of the hand.     

A note on the Mulder-Landsmeer phenomenon.

Mulder-Landsmeer phenomenon (inability to activiely straighten the interphalangeal joints fully when the metacarpophalangeal joint of a finger is passively held in maximal hyperextension) was confirmed in the normally hypermobile South Indian fingers. A powerful but limited de-extension of the proximal phalanx was noticied, in normagers, during completion of interphalangeal extension when the metacarpophalangeal joint was passively held in maximal hyperextension...     

Matrix metalloproteinases and tissue inhibitors of metalloproteinases in sera and tissue of patients with Dupuytren's disease

Dupuytren's contracture is a fibroproliferative disorder characterized by progressive deposition of mature collagen fibers. In other fibrotic diseases affecting organs such as the liver, lung, heart, and skin, matrix metalloproteinases (MMPs) and their natural inhibitors, the tissue inhibitors of metalloproteinases (TIMPs), play an important role. In this study, serum concentrations of MMP-1, MMP-2, MMP-9, TIMP-1, and TIMP-2 were determined in 22 patients (five women and 17 men; average age, 67 +/- 11 years) with Dupuytren's disease using an enzyme-linked immunosorbent assay. Tissue samples were obtained for standard histological and immunohistochemical analyses. Sera and samples of palmar fascia from 20 patients (13 women and seven men; average age, 60 +/- 15 years) who had undergone hand surgery for carpal tunnel syndrome were used as the control group. Statistical analysis was performed using the Mann-Whitney test. Patients with Dupuytren's contracture presented with a TIMP-1 concentration of 437 +/- 160 ng/ml, a significantly higher TIMP-1 concentration than that seen in the control patients, who had a concentration of 321 +/- 70 ng/ml (p < 0.05). Patients with a proliferative active disease (n = 14) had a significantly higher TIMP-1 concentration (525 +/- 136 ng/ml) than patients (n = 8) with a contracture in the late involutional and residual phase (286 +/- 41 ng/ml; p < 0.05). There were no significant differences in the TIMP-2, MMP-1, MMP-2, and MMP-9 serum concentrations between patients with palmar fibromatosis and the control group. Patients with Dupuytren's disease had a significantly lower MMP-to-TIMP ratio (1.1 +/- 0.3; p < 0.05) than the control group (1.5 +/- 0.35). Patients with an active palmar fibromatosis presented a significantly (p < 0.05) reduced ratio (1 +/- 0.2) compared with those in later phases (1.4 +/- 0.3). TIMP-1 and TIMP-2 could be detected in tissue of patients with Dupuytren's contracture, with an accumulation in proliferative areas. MMPs could be detected locally in Dupuytren's tissue in a few patients, with less positive staining than for TIMPs. In the control group, there was just little or no staining for TIMPs and MMPs. The data indicate that the physiological balance between MMPs and their natural inhibitors is disturbed in patients with a proliferative active Dupuytren's disease. The decrease in the systemic MMP-to-TIMP ratio can cause increased synthesis and deposition of collagen, leading to palmar fibromatosis.     

Epidermal growth factor in Dupuytren's disease

The aim of this article was to show the participation of epidermal growth factor (EGF) in the pathogenesis of Dupuytren's disease (palmar contracture). The concentration of EGF in specimens obtained from 68 patients with Dupuytren's contracture and 14 controls was examined immunochemically with the use of enzyme-linked immunosorbent assay. The determined EGF concentration in pathologic aponeurosis with symptoms of Dupuytren's disease (median, 6.29 ng/g; range, 1.67 to 63.09 ng/g) showed significantly different values (p = 0.036) in comparison with the control group (median, 10.1 ng/g; range, 5.13 to 39.81 ng/g). The changes in EGF concentration were shown in tested groups of pathologic tissues that were formed according to the clinical stage of disease progression. The significantly lower concentration than that seen in the control group characterizes tissues with first and third degrees of palmar contracture progression (p = 0.025 and p = 0.018, respectively). In the group of patients with second-degree disease progression, the EGF level increased transiently. Nevertheless, in comparison with the other groups, the difference was not significant. The group with the fourth degree of the disease showed EGF concentrations that resembled the control values. The authors conclude that significant differences in levels of EGF concentration between contractured and normal fasciae may suggest the participation of this cytokine in the pathogenesis of Dupuytren's disease.     

Collateral ligaments of the distal sesamoid bone in the digit of Equus: re-evaluating midstance function

The distal forelimb of the horse has a complex array of ligaments that play a critical role in determining function of the digit and are often associated with the initiation of foot pathologies. The collateral ligaments of the distal sesamoid bone (CLDS) play an important role in digit stabilization near the end of foot contact and there is also limited evidence to suggest that the CLDS stabilize the proximal interphalangeal joint (PIPJ) during weight bearing. By virtue of their anatomical attachments where the ligaments pass dorsal to the axis of rotation of the PIPJ, it is reasonable to assume that the CLDS prevent flexion of the PIPJ during weight bearing or midstance in a moving horse. To test this functional hypothesis, forelimb specimens from three mixed-breed horses were loaded in compression in a materials testing frame. Limb loading was applied with the CLDS intact and following transection. Average PIPJ angle and metacarpophalangeal joint (MCPJ) angle at maximum load (approximately 3000 N) were calculated from angular changes of proximal and middle phalanges and the third metacarpal, which were compared between intact and transected trials. PIPJ angles were found to be the same (175 degrees) at maximum load for intact and transected trials. The proximal and middle phalanges rotated together remaining aligned, regardless of the CLDS condition. Contrary to expectation, however, the combined proximal and middle phalanges unit rotates less relative to the third metacarpal under load after transection, indicating less digit extension at the metacarpophalangeal (fetlock) joint without the influence of CLDS. Since the mechanical properties of the fetlock joint are unchanged by CLDS transection, observed proximal and middle phalanx motion is dependent on increased rotation of the distal phalanx after transection. The original hypothesis was not supported and the results suggest that at midstance the CLDS function primarily to stabilize the articulation of the middle phalanx about the distal phalanx to limit distal interphalangeal joint extension during weight bearing. Establishing the functional role of the CLDS may help to better understand the biomechanical consequences of ligament injuries and diseases of the pastern.     

A method for early diagnosis of reduced mobility of hand joints in diabetes mellitus type I

The study aimed at elaborating the technique of an early diagnosis of cheiroarthropathy. The study involved 170 patients with diabetes mellitus type I aged between 16 and 45 years and disease duration ranging from 1 year to 33 years. Advanced cheiroarthropathy with shining waxy skin was diagnosed in 41 patients (group I). No lesions characteristic for cheiroarthropathy was diagnosed in 122 patients (group II) while in 7 patients (group III) only skin lesions without contractures were noted. Proliferative retinopathy was significantly more frequent (p less than 0.001) in the group with cheiroarthropathy--39% to 8%. Mean age of patients of group I is 31.5 +/- 5.9 years, in group II--31.0 +/- 6.6 years. Duration of diabetes mellitus is 17.8 +/- 6.2 and 9.6 +/- 7.2 years respectively (p less than 0.05). An angle of metacarpophalangeal joint of the V finger extension was measured in all patients with goniometer. A significant difference was noted in both groups: 34.4 +/- 8.08 degrees and 56.5 +/- 7.1 degrees, respectively (p less than 0.01). Mathematic models were designed basing on the value of measured angle and duration of the disease. These models facilitate possible risk of cheiroarthropathy. Systematic measurements of metacarpophalangeal joint extension seems valuable means of early diagnosis of diabetic cheiroarthropathy and follow-up of such patients.     

Extrinsic flexor muscles generate concurrent flexion of all three finger joints

The role of the forearm (extrinsic) finger flexor muscles in initiating rotation of the metacarpophalangeal (MCP) joint and in coordinating flexion at the MCP, the proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints remains a matter of some debate. To address the biomechanical feasibility of the extrinsic flexors performing these actions, a computer simulation of the index finger was created. The model consisted of a planar open-link chain comprised of three revolute joints and four links, driven by the change in length of the flexor muscles. Passive joint characteristics, included in the model, were obtained from system identification experiments involving the application of angular perturbations to the joint of interest. Simulation results reveal that in the absence of passive joint torque, shortening of the extrinsic flexors results in PIP flexion (80°), but DIP (8°) and MCP (7°) joint extension. The inclusion of normal physiological levels of passive joint torque, however, results in simultaneous flexion of all three joints (63° for DIP, 75° for PIP, and 43° for MCP). Applicability of the simulation results was confirmed by recording finger motion produced by electrical stimulation of the extrinsic flexor muscles for the index finger. These findings support the view that the extrinsic flexor muscles can initiate MCP flexion, and produce simultaneous motion at the MCP, PIP, and DIP joints.     

Dermatan sulfate remodeling associated with advanced Dupuytren's contracture

Dermatan sulfate (DS) widespread as a component of extracellular matrix proteoglycans, is characterized by great bio-reactivity and remarkable structural heterogeneity due to distinct degrees of sulfation and glucuronosyl epimerization and different polymerization degrees. However, DS metabolism under various biological conditions is poorly known. Dupuytren's contracture is a benign fibromatosis leading to complex remodeling of the palmar fascia structure and properties. However, it remains unclear whether the disease affects the structure of DS, which is the major tissue glycosaminoglycan. Thus the aim of the study was to examine the structure of the total DS in Dupuytren's fascia. DS chains were extracted from 5 samples of normal fascia and 7 specimens of Dupuytren's tissue by papain digestion followed by fractionation with cetylpyridinium chloride. Then, DS structure analysis was performed comprising the evaluation of its molecular masses and sensitivity to hyaluronidase and chondroitinase B. Dupuytren's contracture is associated with significant remodeling of DS chain structure revealed by (1) a distinct profile of chain molecular masses characterized by the appearance of long size components as well as the increase in the content of small size chains; (2) a different glucuronosyl epimerization pattern connected with the enhanced content of glucuronate disaccharide blocks; (3) chain oversulfation. These structural alterations in total DS may modify the GAG interactions especially affecting collagen fibrillogenesis and growth factor availability. Thus, Dupuytren's contracture associated DS remodeling may promote the phenomena typical for advanced disease: apoptosis and reduction in cell number as well as the appearance of dense pseudotendinous collagen matrix.     

Finger joint force minimization in pianists using optimization techniques

A numerical optimization procedure was used to determine finger positions that minimize and maximize finger tendon and joint force objective functions during piano play. A biomechanical finger model for sagittal plane motion, based on finger anatomy, was used to investigate finger tendon tensions and joint reaction forces for finger positions used in playing the piano. For commonly used piano key strike positions, flexor and intrinsic muscle tendon tensions ranged from 0.7 to 3.2 times the fingertip key strike force, while resultant inter-joint compressive forces ranged from 2 to 7 times the magnitude of the fingertip force. In general, use of a curved finger position, with a large metacarpophalangeal joint flexion angle and a small proximal interphalangeal joint flexion angle, reduces flexor tendon tension and resultant finger joint force.     

Treatment of complex interphalangeal joint fractures with dynamic external traction: a series of 20 cases

Data are reported for a series of 20 patients who were treated with the pins and rubbers traction system for fractures of the proximal interphalangeal joints of the long fingers. This technique allows fracture reduction with external dynamic traction and immediate active mobilization. Two patients in the series were lost to follow-up monitoring. For two others, the pins and rubbers traction system needed to be removed early (during the first week) because of intolerance or infection. Sixteen patients who were reexamined after minimal follow-up periods of 1 year demonstrated a mean active range of motion of 85.9 degrees for the injured joint; only one patient experienced intermittent pain.     

Fist position for skin grafting on the dorsal hand: I. Analysis of length of the dorsal hand surgery in hand positions.

In skin grafting for reconstruction of burns and contracture deformities of the dorsal hand, the hand is kept in a proper position to provide the greatest amount of skin and to avoid the secondary functional deformity. The safe position has been commonly used for immobilizing the hand, but this is to protect the hand function rather than to provide maximal surface for skin grafting. Split-thickness skin graft contracts up to 30 to 50 percent of the original size owing to secondary contraction. If insufficient skin is grafted, contracture deformity of the dorsal hand may occur. To graft the greatest amount of skin on the dorsal hand, the hand should be kept preoperatively in a position flexing all joints of the wrist, metacarpophalangeal joints, and interphalangeal joints and maximally stretching the dorsal hand (a fist position). We studied the surface length of the dorsal hand between the wrist, the metacarpophalangeal joint, and the eponychium in the anatomic, safe, and fist positions of the right hand in 60 adults. Difference of total length between the anatomic and safe positions was not statistically significant (p > 0.05). The total length in a fist position was significantly increased in comparison with the other two positions (p < 0.05). In a fist position compared with the safe position, the increase in length of the dorsal surface of the proximal hand was 11 to 20 percent except in the thumb, and the increase in length of the dorsal surface of the finger was 12 to 17 percent. The increase in total length of a fist position was about 9 mm (7 to 8 percent) in the thumb and 20 to 32 mm (14 to 18 percent) in the index to little fingers. It suggests that the safe position fails to provide an increased dorsal hand surface area for skin grafting compared with the anatomic position. The greatest amount of skin can be grafted in a fist position. Hand immobilization in a fist position for 7 to 9 days after skin grafting has not resulted in irrevocable joint stiffness in our experience. If injury of the deep structures is not present, the hand should be immobilized in a fist position before skin grafting on the dorsal hand.     

Kinematic evaluation of the finger’s interphalangeal joints coupling mechanism—variability,flexion–extension differences,triggers, locking swanneck deformities,anthropometric correlations

The human finger contains tendon/ligament mechanisms essential for proper control. One mechanism couples the movements of the interphalangeal joints when the (unloaded) finger is flexed with active deep flexor. This study’s aim was to accurately determine in a large finger sample the kinematics and variability of the coupled interphalangeal joint motions, for potential clinical and finger model validation applications. The data could also be applied to humanoid robotic hands. Sixty-eight fingers were measured in seventeen hands in nine subjects. Fingers exhibited great joint mobility variability, with passive proximal interphalangeal hyperextension ranging from zero to almost fifty degrees. Increased measurement accuracy was obtained by using marker frames to amplify finger segment motions. Gravitational forces on the marker frames were not found to invalidate measurements. The recorded interphalangeal joint trajectories were highly consistent, demonstrating the underlying coupling mechanism. The increased accuracy and large sample size allowed for evaluation of detailed trajectory variability, systematic differences between flexion and extension trajectories, and three trigger types, distinct from flexor tendon triggers, involving initial flexion deficits in either proximal or distal interphalangeal joint. The experimental methods, data and analysis should advance insight into normal and pathological finger biomechanics (e.g., swanneck deformities), and could help improve clinical differential diagnostics of trigger finger causes. The marker frame measuring method may be useful to quantify interphalangeal joints trajectories in surgical/rehabilitative outcome studies. The data as a whole provide the most comprehensive collection of interphalangeal joint trajectories for clinical reference and model validation known to us to date.     

Characterization of implants from Dupuytren's contracture tissue into the nude (athymic) mouse

Dupuytren's contracture tissues were obtained from six patients as excess surgical material. Pieces of these tissues (a total of 38 implants) were placed into subcutaneous pockets in the suprascapular area of nude (athymic) mice. The objective was to determine whether the implant tissues would be maintained in the mouse with the characteristics of Dupuytren's tissue. The implants were removed for study at 14-179 days after implantation. Microvascular anastomosis between implant and host skin was established within the first 14 days. Histologic character and electron microscopic structure of the implants did not change during the course of the study. The implants became reduced in size with time. However, neither the spatial pattern of collagen nor the appearance of fibroblast cells changed. The original high levels of chondroitin-4-sulfate were significantly decreased in the 66- to 179-day postimplantation group, but were not significantly different from the values for normal fascial bands. The hyaluronic acid of the implants increased significantly with time of implantation, but never reached the level found in the normal fascial bands. The use of implants into nude mice may be useful for further experimental studies of Dupuytren's contracture.     

Measurement of finger joint angles and maximum finger forces during cylinder grip activity

Finger joint angles and finger forces during maximal cylindrical grasping were measured using multi-camera photogrammetry and pressure-sensitive sheets, respectively. The experimental data were collected from four healthy subjects gripping cylinders of five different sizes. For joint angles, an image analysis system was used to digitize slides showing markers. During the calibration of the camera system, both the nonlinear least square and the direct linear transform methods were applied and compared, the former providing the fewer errors; it was used to determine joint angles. Data were collected from the pressure-sensitive grip films by using the same image analysis system as used in the collection of the joint angle data. The method of using pressure-sensitive sheets provided an estimation of the weighted centre of the phalangeal forces. Results indicate that finger flexion angles at the metacarpophalangeal and proximal interphalangeal joints gradually increase as cylinder diameter decreases, but that at the distal interphalangeal joint the angle remains constant throughout all cylinder sizes. It was also found that most of the radio-ulnar deviation and the axial rotation angles at the finger joints deviate from zero, but the deviations are small. For the force measurement, it was found that total finger force increases as cylinder size decreases, and the phalangeal force centres are not located at the mid-points of the phalanges. The data obtained in this experiment would be useful for muscle force predictions and for the design of handles.     

Second toe wrap-around flap

The microsurgical second toe wrap-around technique is an ideal treatment option for reconstruction of the distal half of the finger with circumferential loss of skin and nail associated with an uninjured proximal interphalangeal joint and an intact insertion of the flexor digitorum superficialis tendon. Follow-up of 13 flaps in 10 patients from 1986 to 1989 demonstrates rapid and adequate functional recovery as well as satisfactory aesthetic appearance in all patients.     

Dupuytren's disease.

Dupuytren''s disease is an extremely common malady, affecting as many as 3% of the general population. Presenting features are variable and include simple asymptomatic palmar nodules or refractory contractures of the interphalangeal joints. Substantial associations with knuckle pads, plantar nodules, and Peyronie''s disease are noteworthy. Although a strong familial tendency is present, the precise pathologic mechanism is unknown. Treatment is frequently unnecessary, but when indicated it includes a variety of surgical alternatives. An appropriately timed referral to a surgical specialist before irreversible contracture of the interphalangeal joints can prevent a permanent loss of function. When surgical intervention is not elected, careful and regular follow-up is necessary to detect early joint contracture.     

Static and dynamic human flexor tendon–pulley interaction

The aim of the study was to investigate the influence of a preceding flexion or extension movement on the static interaction of human finger flexor tendons and pulleys concerning flexion torque being generated. Six human fresh frozen cadaver long fingers were mounted in an isokinetic movement device for the proximal interphalangeal (PIP) joint. During flexion and extension movement both flexor tendons were equally loaded with 40 N while the generated moment was depicted simultaneously at the fingertip. The movement was stopped at various positions of the proximal interphalangeal joint to record dynamic and static torque. The static torque was always greater after a preceding extension movement compared to a preceding flexion movement in the corresponding same position of the joint. This applied for the whole arc of movement of 0–105°. The difference between static extension and flexion torque was maximal 11% in average at about 83° of flexion. Static torque was always smaller than dynamic torque during extension movement and always greater than dynamic torque during flexion movement. The kind of preceding movement therefore showed an influence to the torque being generated in the proximal interphalangeal joint. The effect could be simulated on a mechanical finger device.