Reoperative Aesthetic & Reconstructive Plastic Surgery

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Incision choice varies for Dupuytren disease, with the Bruner-type zigzag incision
remaining popular for primary procedures, but if recurrent disease involves the skin
(as it often does) along the central longitudinal digit, dissection of the Bruner skin
ap from the Dupuytren band may render the tip of the ap ischemic. Therefore
the Bruner incision is preferable if the skin is not involved, as with a retrovascular
fascial cord. In recurrent disease with skin involvement one author (W.H.M.)
prefers a direct longitudinal approach along the most prominent cord usually using
a No. 69 Beaver blade to tediously dissect thin skin from its adherence to the
Dupuytren band, and using Z-plasty closure as described by Hueston.This often re-
sults in Z-plasty limbs with scars at their bases from the previous surgery. Scarred
tissue is less mobile and the aps must be thicker, but aps with scars at their base
will survive.
This patient had a third Dupuytren contracture across the MP joint. Dots show the
scar from a previous PIP release and incision planned directly over the Dupuytren
cord.The proper digital nerves dissected from the cord are lifted by the forceps, and
the incision is then closed with a Z-plasty.The patient’s motion is shown 2 weeks
postoperatively (below, right).

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Reoperative Hand Surgery
The value of resecting the skin (dermatofasciectomy) and placing a full thickness
graft must be measured against the greater morbidity of decreased sensation in the
graft,34 longer immobilization and probable decreased amplitude of motion. One
series reported an 82% incidence of some type of recurrence in grafted patients
who had dermatofasciectomy for recurrent problems,11 probably re ecting the bi-
ologic destiny of the patients rather than the result of a surgical technique. In the
most severe PIP contractures, in which capsulotomy is needed, dermatofasci-
ectomy with skin graft is not a rational option because the skin graft must be placed
directly over the tendon and a cross- nger ap is preferable. After prolonged severe
xed exion contracture, one can anticipate attenuation of the extensor mechanism
and sometimes when the volar joint has not shortened (volar plate and collateral
ligament) there is inability to actively extend the PIP joint, when it can still be pas-
sively extended. In these circumstances, one author (W.H.M.) has chosen to use
temporary K-wire xation with the PIP joint in full extension following fasciec-
tomy and remove this at approximately 10 to 12 days, providing an in ammatory
interval for the extensor mechanism to remodel (see p. 1872). After K-wire re-
moval the digit is splinted in extension at rest when not engaged in active exion
therapy.This strategy appears to result in remodeling of the extensor mechanism in
these patients with better chance to recover active extension.
Some authors (V.R.M.) prefer the Bruner zigzag incision approach when the MP
or PIP contractions are 30 degrees or less, and longitudinal incision with Z-plasty
for more severe contractures. Others (W.H.M.) prefer a Hueston-type “limited fas-
ciectomy” technique for almost all cases with incisions over the Dupuytren cords,
directly removing all of the apparently involved fascia under loupe control, and to
leave normal-appearing fascial bands alone, other than a cuff removed with the
edge of the resected portion and closure by multiple Z-plasties. Others disagree, and
suggest excision of uninvolved “normal” fascial bands might reduce recurrence, es-
pecially in the diathesis patient with expected recurrence. Given that the perivas-
cular cells seem the most likely culprits to become the myo broblasts and broblasts
of Dupuytren contracture,35 it seems naive to believe we will alter the course by
prophylactic resection of apparently uninvolved normal fascial bands. Preoperative
established Dupuytren cords that pose no functional dif culty, however, can be ex-
pected to contract in the future, so they should be resected whenever Dupuytren
surgery is done elsewhere in the hand.
Surgeons differ in their preference regarding tourniquet release. One author
(W.H.M.) prefers to release the tourniquet before closing any wounds, achieving
hemostasis with bipolar cautery, and if there is any persistent bleeding, use a drain
(rarely).This also provides opportunity to assess the vascularity of all of the Z-plasty
aps and any reoperated nger that had severe contracture (often with temporary
PIP K-wire xation). If there is inadequate perfusion of a ap, a graft or some al-
ternative ap can be used; if the ngertip remains white, the K-wire must be re-
moved and the PIP joint exed until the pulp again becomes pink (rarely neces-
sary). Marcaine can be injected along the proximal hand nerves to provide
prolonged postoperative pain relief and reduce the likelihood of a pain syndrome.

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Usually a bulky compressive dressing is used with immobilization in a “functional”
position with the MP joints exed, the IP joints extended, the wrist splinted in
extension and the ngertips exposed. Other surgeons (V.R.M.) choose to leave the
tourniquet elevated until after closure and compressive dressing, reasoning that this
might decrease hematoma formation, but remove the dressing early to start an im-
mediate postoperative mobilization program.
POSTOPERATIVE CARE
While hand surgeons may differ in details of their initial postoperative manage-
ment, they agree that commitment to an extensive and individualized hand therapy
program is an essential feature of successful Dupuytren’s postoperative manage-
ment. It is a mistake to conceptualize that any standard protocol will t all patients,
because people do not heal identically. There is a remarkably varied healing re-
sponse to Dupuytren surgery, with some patients developing profound stiffness af-
ter what does not seem a dif cult dissection, and others recovering full motion
with minimal hand therapy in spite of challenging surgery for recurrent disease.
Some factors causing healing response differences are predictable, like the age of the
patient, the degree and location of recurrent contracture, compliance, and insurance
rationing of hand therapy. In this day of insurance pressure to standardize care and
limit resources, we must resist pressures to make the patient t the protocol.To ac-
cept inadequate therapy for the patient who needs more than the HMO allows is
to validate the insurance industry’s untenable position that all people heal identi-
cally. In reality, there are dramatic differences and the hand therapists must individ-
ualize accordingly. Perhaps the most profound example of individualized wound re-
sponse is in the patient with RSD/CRPS, who after simple Dupuytren surgery,
carpal tunnel release, or minor hand injury may nd an in amed, severely painful,
stiff, osteoporotic, functionless dystrophic hand, bringing into sharp focus our in-
ability to comprehend the intrinsic individual factors that have a biologic impact on
wound healing.Therefore we must carefully monitor each patient and modify their
management according to the individual response.
One author (W.H.M.) prefers to rest his postoperative Dupuytren’s patients for 4 or
5 days with the hand elevated in its compressive dressing. If there is any signi cant
complaint, the bandage is removed, the hand inspected, and whatever necessary
measures are taken to make the patient comfortable (which may be just caring at-
tention). After this rest interval hand therapy starts with initial attention toward
gaining full motion in all unoperated digits and recovery of exion in the operated
digits as soon as possible (which varies), always resting in extension (especially at
night) when flexion is improving. Otherwise, dynamic splinting is used in
whichever direction ( exion or extension) is needed. Therapy requirements may
vary from only one or two weeks to frequent visits for as much as 3 months, de-
pending on the individual patient’s response. The other author (V.R.M.) prefers
postoperative continuous passive motion, initiated in the immediate postoperative
interval, while the patient’s block is still effective, and continued as long as the block
lasts. After the block wears off, the patient begins active exion and extension ex-

ercises and is discharged with the continuous passive motion unit, especially to be
worn at night while the patient is sleeping, or until after the rst week of therapy.
The patient is then rested in a static extension splint at night unless full extension
cannot be obtained, then a dynamic outrigger is used at night. In similar fashion, the
hand therapy program and splints vary thereafter with the individual patient’s re-
sponse.
It is interesting that both authors of this chapter have done several hundred
Dupuytren cases, and in spite of differences in management in a large number of
cases, neither has had a single patient develop RSD/CR PS (which statistically
should be at least 20 to 50 cases). Certainly there have been some patients who
had more of what appeared to be sympathetic instability, stiffness, edema and even
disproportionate pain compared to others, but with increased hand therapy atten-
tion did not progress into a chronic pain syndrome. One cannot help but speculate
that the attention and support of the physician and therapist to reduce the patient’s
anxiety and restore con dence and hope of healing may have obviated develop-
ment of a pain disorder in some of these cases.
COMPLICATIONS
Repeat surgery for Dupuytren contracture carries a greater risk for joint stiffness
and nerve injury than primary operations, as well as wound healing problems.31,36
Sennewald37 reported only a 1.3% incidence of nerve laceration in 77 patients at
primary Dupuytren surgery, but a 29% incidence of nerve injury in 26 operations
for recurrent disease. Furthermore, patients with recurrent Dupuytren contracture
are the most likely group who will need additional Dupuytren surgery in the fu-
ture.Their understanding of the need for careful monitoring and early repeat sur-
gery is an essential feature to reduce complications.
RHEUMATOID ARTHRITIS
By the nature of rheumatoid arthritis (RA), a connective tissue disease, reoperation
in the hands of RA patients is the rule, and long-term favorable relationships de-
velop with these patients, who learn to present their hand problems to their sur-
geon.
RA patients are among the most appreciative patients the hand surgeon
ever encounters.This may be a product of the disproportionate grati-
tude experienced by a patient with chronic disease who for once is
able to see improvement instead of deterioration after medical inter-
vention.
The key to successful rheumatoid hand surgery is the individualization of each pa-
tient’s functional needs, whether it is for greater mobility, stability, alignment, or
pain relief.These goals are not always compatible, and the need varies greatly with
each patient’s hand functional use. However, when the patient’s greatest need is
1879
Chapter 46
Reoperative Hand Surgery

1880
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
correctly interpreted, the functional result can be gratifying for both patient and
surgeon. Happily, the need for major rheumatoid reconstruction has diminished in
recent years because of substantial improvement in medical management.The fun-
damentals for surgical correction, however, remain the same.
BIOLOGIC MECHANISM OF R HEUMATOID
HAND DEFORMITY
The precise mechanism causing rheumatoid hand deformity continues to be de-
bated, but all investigators agree that the connective tissue disease is characterized
by chronic in ammation of mesenchymal tissue, with macrophages present, stim-
ulating both increased collagen synthesis as well as increased collagen degradation
activity. In such a setting of increased collagen synthesis and increased collagen
degradation, there should be predominantly “new” uncrosslinked collagen present
in a similar fashion as seen in early (3 to 6 weeks) wound healing. Under these cir-
cumstances of increased collagen turnover we know collagen will structurally re-
spond to stress with slippage of the collagen subunits, as demonstrated in healing
wound stress response by Arem and Madden.5 In their model, signi cant collagen
structural alteration was produced using tension between 3 and 12 weeks, but not
altered after 12 weeks as a result of mature crosslinking. Wounds that were not
stressed remained unchanged, and there were no differences in collagenase, total
collagen or strength between the two groups, only the structural appearance al-
tered with elongation of the wounds under stress.The difference in the rheumatoid
patient compared with a patient with a healing wound is that in the RA patient
later stages (crosslinking) do not occur, because the in ammation is now chronic.
Under these circumstances, collagen metabolism is out of balance in response to the
normal forces of activities of daily living.Whereas the normal combination of sta-
bility and mobility of collateral ligaments and joint capsules allow us force and mo-
tion, chronic in ammation places these structures in a “warm butter” category, sus-
ceptible to elongation from normal forces that otherwise would not alter these
structures.What are the normal forces of the hand? With exion there is an ulnar
force at the MP joint, as described by Flatt,38 related to the anatomic fact that an ul-
nar inclination exists between phalanges in relation to the line of the metacarpals,
greatest in the index, causing increased ulnar forces in normal grip. Furthermore,
such normal activities as opening a jar or a doorknob produces forces in an ulnar
direction. Meanwhile, the powerful intrinsic muscle-tendon unit creates a volar
force over the metacarpophalangeal joint of the ngers that Flatt characterized as
three times the force of pinch of the ngertip.38 Thus the most common rheuma-
toid hand deformity is ulnar deviation and volar subluxation at the MP joint level
in response to normal forces in a malleable hand. As the digit ngertips relocate ul-
narly, the wrist compensates by radial deviation, and the extensor tendons and
sometimes the exor tendons migrate between the MP joints and the greater the
ulnar deviation the greater the moment arm, increasing the deviating force. Evi-
dence for this mechanism of deformity is one author’s (W.H.M.) observations of
characteristic ulnar drift in a Papago Indian’s dominant rheumatoid hand, while

the nondominant hand had MP radial deviation.This Native American was a bas-
ket weaver who held her basket with the nondominant hand resting in her lap in
a radially deviated posture, while weaving was done with the dominant hand using
normal forces.
1881
Chapter 46
Reoperative Hand Surgery
Mike Brown, OTR, CHT, shared a similar case in a textile worker with rheumatoid
arthritis whose right hand remained axially aligned after enduring chronic radial
force as she moved the material pushing with the ulnar side of her right hand.
Meanwhile, normal ulnar forces used for gripping led to ulnar deviation in her left
hand.
Flatt38 also described two patients he had seen with radial deviation, both of whom
had similar occupational forces he held responsible. Hueston and Wilson39 pub-
lished a description of a man with ulnar palsy from a gunshot wound to his elbow;
this patient later developed dorsal rather than volar MP joint subluxation in the
palsied hand and volar subluxation in his uninjured side after he developed RA and
had no intrinsic force to pull the proximal phalanx forward.
The importance of this concept to the reconstructive surgeon is to recognize the
need to balance the forces in the rheumatoid hand as much as possible, recogniz-
ing the susceptibility of recurrent deformity with future stress forces in these pa-
tients.This can be accomplished by axial alignment and tendon transfers to better
balance the forces in the hand, along with lifestyle alterations that might diminish
forces. One of the most effective means to realign the forces at the MP joint is re-
placement arthroplasty, sometimes with cross-intrinsic tendon transfer.
ARTHROPLASTY
Both interpositional and cemented total joint arthroplasties are often used to treat
hand deformities caused by rheumatoid arthritis, with silicone rubber most com-
monly used because it is dependable and predictable.40,41

1882
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
Metacarpophalangeal (MP) Joint Arthroplasty
Studies by Vahvanen and Viljakka43 and by Blair et al44 have shown that within 4
years after silicone rubber interpositional arthroplasty, patients had range of mo-
tion in the MP joint that varied from 34 to 43 degrees (averaging 40 degrees).Vah-
vanen and Viljakka found that 27 of 32 patients had signi cant pain relief follow-
ing Swanson Silastic replacement arthroplasty in the MP joints, and 28 of the 32
had cosmetic improvement as well. Most studies showed no signi cant improve-
ment in grip or pinching strength following replacement arthroplasty, although ax-
ial alignment generally produced better function and pain relief, and patient satis-
faction was high.
The degree of recurrent ulnar deviation following Swanson arthroplasty has been
variously reported as ranging from 11% to 43%.43 Ulnar deviation of a milder de-
gree (less than 10 degrees) occurs even more frequently. Patients with RA are par-
ticularly susceptible to gradual ulnar deviation following a Swanson arthroplasty if
the wrist is unbalanced with radial deviation deformity of the carpus and meta-
carpals in relation to the radius,45-50 or if the exor tendons are ulnarly translocated
at the MP joint level.
Indications for Cross-Intrinsic Transfer at MP Arthroplasty
The concept of
cross-intrinsic tendon transfer from the ulnar side of the index, middle and ring
digits to the radial side of the adjacent digit at the time of MP replacement arthro-
plasty has been advocated as a means to reduce the incidence of recurrent ulnar
drift (see p. 1886).
Moran et al51 compared the incidence of recurrent ulnar drift and the electrical
functional activity of intrinsic muscles of patients who had only intrinsic release
with those with intrinsic transfer at the time of MP replacement arthroplasty.They
found signi cantly greater recurrent ulnar deviation in those patients with only in-
trinsic release and these patients had random insertional electric activity of the re-
leased intrinsic muscles no longer functioning with intrinsic activity. This is com-
monly seen late in other muscles with cut tendons that contract spontaneously
without function. Conversely, the electrical activity of the transferred intrinsic mus-

cles directly correlated with hand functional intrinsic muscle activities, such as
pinching and extension, indicating that there is an intrinsic muscle force to dis-
courage recurrent ulnar deviation.
1883
Chapter 46
Reoperative Hand Surgery
At MP arthroplasty, the long extensor tendons are recentralized, but the exor ten-
dons are not.When there has been ulnar exor translocation with MP ulnar drift,
these tendons still cause signi cant postoperative ulnar force with nger exion;this
can be counterbalanced by cross-intrinsic transfer. In patients without ulnar exor
tendon translocation, intrinsic transfer may provide too much radial force and lead
to late radial deviation.This is simple to ascertain on preoperative examination by
centralizing the digits in extension using radial pressure on the fth digit, then hav-
ing the patient ex into a st. If there is signi cant ulnar force as the patient exes,
it is clear that exor tendon translocation exists at the MP level, and cross-intrinsic
tendon transfer is indicated with either MP joint replacement arthroplasty or syn-
ovectomy to reduce recurrent ulnar drift.
However, cross-intrinsic tendon transfer can
cause postoperative MP radial deviation in the
wrong patient. Radial deviation is shown fol-
lowing MP replacement arthroplasties and cross-
intrinsic transfer in this patient, who did not
have ulnar flexor tendon translocation at the
MP level preoperatively. The intrinsic transfers
caused a radial overpull and deviation.
To determine whether cross-intrinsic transfers are needed because of exor tendon
ulnar translocation, the digits are pushed into axial alignment while in extension,
then are actively exed. If the digits strongly push in an ulnar direction, there is
exor tendon translocation, as in this patient, who needs intrinsic transfer.

1884
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
Surgical Techniques: Swanson Arthroplasty
A transverse dorsal incision is
made over the metacarpal heads, which may be curved over each metacarpal head
to increase tissue coverage over the prosthesis and render the scar less conspicuous
than a straight one, resulting in a better cosmetic effect, as seen in the right hand of
this patient after replacement arthroplasties and intrinsic transfers.
Right preoperative hand before
replacement arthroplasty with
cross-intrinsic transfers
Left
Right postoperative
Use of wavy scar makes the incision inconspicuous
The initial exposure showing the ulnar translocated extensors is demonstrated.The
subcutaneous tissues are then dissected from the underlying extensor mechanism
for 2 cm proximal and distal to the joint to expose the heads of the metacarpals. If
intrinsic tendon transfer is planned, the distal lateral band on the ulnar side of each
digit, except the fth, is divided, and incision continued proximally along the ulnar
side of the long extensor tendon, releasing the ulnar sagittal band and joint capsule.
When no intrinsic transfer is planned, each joint can be entered through a longi-
tudinal incision in the extensor hood along the ulnar border of the displaced exten-
sor tendon with the ulnar sagittal band released longitudinally for approximately
3 cm. The ulnarly subluxed central tendon can then be dissected with the exten-
sor hood from the underlying joint capsule, holding the digit extended, and pre-
serving the hood and the attached extensor, providing opportunity to later reef the
extensor hood and tendon to centralize and shorten it to compensate for the resec-

tion of the metacarpal head.The metacarpal may be transected with a bone cutter
or microsagittal saw the level of the metaphyseal are, and the joint capsule is re-
sected with the metacarpal head from its attachment to the proximal phalanx.The
bone is cut perpendicular to the longitudinal axis of the metacarpal, and the prox-
imal phalangeal base is attened by removing osteophytes to a point that the bony
surface is level.
1885
Chapter 46
Reoperative Hand Surgery
A small opening can be made in the subchondral bone, then a square Riordan rasp
is used with the oscillating head to rapidly create a square hole to accept the square
shape of the stem of the prosthesis and to discourage rotation in the phalanx. A
larger hole is made into the metacarpal shaft as seen above (right).
The largest silicone rubber prosthesis that will t into the intramedullary canal is
used. After the appropriate size is chosen, the base of the proximal phalanx may
have to be additionally rasped to t the stem of the corresponding trial prosthesis,
which is placed using instruments, not the gloved hand.The proximal phalanx must
align with the dorsum of its respective metacarpal. If necessary, a No. 69 Beaver
blade can be used to circumferentially dissect the subperiosteum around the base of
the proximal phalanx until the palmar aspect of the proximal phalangeal base can be
stacked onto the dorsum of the respective metacarpal.This provides adequate lax-
ity for the prosthesis with full exion and extension. Some surgeons (V.R.M.) re-
construct the collateral ligaments, suturing this to drill holes in the distal
metacarpal, whereas others (W.H.M.), feel ligament reconstruction is unnecessary
if adequate splinting alignment is maintained postoperatively.

1886
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
The wound is irrigated and any excess bone debris removed. Smooth forceps are
used to inset the appropriate-sized Swanson prosthesis. Care should be taken to
avoid any cuts or tears in the prosthesis, since this can increase the risk of particu-
late silicone and thus cause synovitis. After the prosthesis is inserted, the MP joint
is held in extension to avoid accidental displacement until wound closure is com-
pleted.
If intrinsic tendons are to be transferred, they must be dissected from their attach-
ment to the volar plate on the ulnar side of the donor digit;then after transfer they
are woven along the adjacent radial lateral band and secured with a couple of 4-0
permanent mattress sutures. Tension should be rm on these, but not cause radial
deviation of the digit. It is easiest to free the intrinsic tendon after the metacarpal
head has been resected and the bone prepared for the prosthesis and transfer the in-
strinsic tendon after placement of the silicone prosthesis. After soft tissue release,
insertion of the prosthesis, and cross-intrinsic tendon transfer, the extensor tendons
should be centralized and shortened by imbricating the extensor hood and radial
sagittal band.The joint should be checked for alignment and range of motion.The
skin is closed with 4-0 Prolene sutures and a wrist splint is applied, with the wrist
in neutral or slight extension and the MP joints in approximately 35 to 40 degrees
of exion and the IP joints fully extended.
Revision Arthroplasty
The approach for revision MP arthroplasty is the same as
that used for the primary procedure, except that the prosthesis usually must be re-
placed because of fracture. If the metacarpal head has eroded and there is more
bone missing on the ulnar side, the bone should be shortened slightly to provide a
cut perpendicular to the metacarpal shaft and again the proximal phalanx must be
capable of being stacked onto the dorsum of its metacarpal to provide adequate
exibility for the prosthesis.
If no intrinsic transfer was done in the primary procedure, recurrent ulnar drift at
the time of revision MP arthroplasty can be improved with a cross-intrinsic trans-
fer effort, although the muscle will not likely be as functional following previous ul-
From index
to middle

nar intrinsic release. On the ulnar side of the little nger, the abductor digiti quinti
tendon is released from its insertion on the base of the proximal phalanx, and can
be reinserted more palmarward to give more power to MP exion of the little n-
ger. The ulnar-sided intrinsic muscles on the index through the ring ngers are
released from their insertions on the extensor hood and transferred to the radial side
of the adjacent intrinsics to provide the cross-intrinsic transfers.
Titanium grommets added to the Swanson silicone rubber prostheses are believed
to stabilize and protect the bone-prosthesis interface, and thus diminish bone re-
sorption. These prostheses are press t devices, and have a corresponding presized
reamer used to prepare the canal. Since progressive bone resorption is a major prob-
lem with revision arthroplasty, it is probably advisable to use these grommets for re-
vision arthroplasty.
Postoperative Care
The bulky dressing is removed and a light dressing applied
in a few days following MP arthroplasty, and a dorsal splint fabricated with the
wrist in 0 to 20 degrees of dorsi exion.
1887
Chapter 46
Reoperative Hand Surgery
Coban wrap may be applied to the ngers to control edema. A dynamic outrigger
attachment is made with elastic loops around the proximal phalanges to pull the
MP joints into extension and slight radial deviation as in the illustration above.
This splint is worn at all times.The tension should be set to allow at least 60 to 70
degrees of active exion. If pronation of the index or long nger is needed, a fourth
couple can be added for those digits.The patient should actively ex the MP joints
10 times each hour during the day. If the patient substitutes PIP exion for MP
exion, then static PIP extension gutter splints need to be applied during exercise
periods. The patient should be seen by the therapist once or twice weekly. If at
least 45 degrees of active exion has not been achieved within 3 weeks after sur-
gery, then dynamic exion is begun and alternated with dynamic extension during
the daytime. At night, the patient must continue sleeping in the dynamic outrigger
or a gutter splint for extension.The amount of dynamic and static splinting needed
will vary greatly among patients, but prolonged use of night splinting helps prevent
recurrence of ulnar deviation and exion contractures at the MP joint. Some pa-
tients quickly recover active exion and their extension must be protected, while

1888
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
others must have attention devoted to the recovery of exion, as with dynamic
exion splinting.
Complications
The most common complication following MP arthroplasty is
recurrent ulnar drift, which can be minimized in the following ways:
Use cross intrinsic tendon transfers when physical examination indicates there
has been exor tendon ulnar translocation at the MP level.
Fully release the contracted synovial capsule, especially on the volar surface.
Make the bone cuts perpendicular to the shaft so that the prosthesis will t
ush with the cortical rim of bone. To ensure the metacarpal osteotomies
are perpendicular to the shaft, it is best to err by taking off more bone on the
radial side rather than the ulnar.52
Imbricate the radial sagittal band and extensor hood to be sure the central
tendon becomes centralized following soft tissue releases and insertion of the
prosthesis. This can also be slightly shortened to account for the length lost
by bone shortening.
If the wrist remains in radial deviation after axial alignment of the ngers, sta-
bilize it with either synovectomy and transfer of the extensor carpi radialis
longus to the extensor ulnaris, wrist joint replacement or arthrodesis; other-
wise, forces will encourage return to ulnar deviation.
Another complication involves insuf cient release of soft tissue contractures around
the base of the proximal phalanx. If the proximal phalanx cannot be stacked onto
the dorsum of its respective metacarpal before placement of the prosthesis, then
the patient will not be able to fully extend the MP joint because the volar attach-
ment is too short. Fracture of the prosthesis used to be a major complication in
MP arthroplasty, but the introduction of the high-performance silicone elastomer
has signi cantly reduced this problem.53,54
Proximal Interphalangeal Joint Arthroplasty
Arthrodesis is often the procedure of choice for treating severe arthritis involving
the PIP joint, since it provides more stability for pinch, especially in the index digit,
and facilitates motion in the MP joints following replacement arthroplasty. When
multiple joints of a nger have arthritic change, arthrodesis of the PIP joint may be
more advantageous than arthroplasty. However, when motion is needed, as in the
more ulnar digits for gripping, then arthroplasty may be recommended.The Swan-
son silicone elastomer arthroplasty is the most commonly used procedure to treat
the painful degenerative or posttraumatic DIP joint, and occasionally the rheuma-
toid hand.
Surgical Technique
A straight longitudinal incision is made over the dorsum
of the PIP joint and the subcutaneous tissues are re ected to reveal the underlying
extensor mechanism, which is split longitudinally, preserving the central slip at-
tachment to the base of the middle phalanx. If it is disrupted or needs to be de-
tached, the central slip attachment can be reinserted later through drill-holes in the

base of the middle phalanx. After the neck of the proximal phalanx is transected
with a microsagittal saw or bone cutting forceps, the head of the phalanx is re-
moved.The collateral ligaments can be preserved and reinserted through drill-holes
in the bone after the prosthesis has been inserted.The middle phalanx base is at-
tened and any spurs are removed.The intramedullary canal of the proximal phalanx
is reamed with a small Riordan rasp using oscillating power, and the appropriate-
sized silicone rubber implant is chosen and a similar square hole is rasped in the base
of the middle phalanx into the intramedullary canal to t the trial silicone rubber
implant.The wound is irrigated and excess bone debris removed. Smooth forceps
are used to insert the silicone rubber prosthesis to avoid tearing or puncturing it.
The collateral ligaments can then be repaired if desired, and the extensor hood is
repaired with a running 4-0 permanent suture, using clear suture in thin-skinned
patient.
Postoperatively, the PIP joints should be maintained in extension when at rest. If
boutonnière deformity exists concurrently as a result of lateral band palmar dis-
placement and central slip attenuation, the transverse retinacular ligaments should
be released on the palmar side of the lateral bands and the lateral bands mobilized
dorsally, and either the hood imbricated or the bands sutured in this more dorsal lo-
cation.The central slip is reattached more distally to the base of the middle phalanx.
Swan Neck Deformity
In RA patients with swan neck deformity, the rst pri-
ority is to establish the causative mechanism, which can be intrinsic muscle contrac-
ture, rupture of the exor sublimis, mallet deformity from ruptured lateral bands
over the DIP joint, attenuation of the PIP joint volar plate, or exor contracture at
the MP level. In an RA patient, remodeling into a swan neck posture will occur
more easily in response to any of these unbalanced forces, and successful correction
should address the cause. The second priority is the degree of lost motion in the
PIP and DIP joints and actual joint changes resulting from loss of cartilage.
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Treatment can be as simple as nonsurgical silver ring gure-of-eight splinting for
early changes or intrinsic tightness, or early surgical intrinsic release to surgical PIP
joint fusion when there is signi cant joint change and stiffness.

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Fusion of the DIP joint, checkrein sublimis slip restriction of PIP hyperextension
and dorsal relocation of the lateral bands are all intermediate surgical considerations
in selected cases.When swan neck deformity is present at the time of MP replace-
ment arthroplasty, the deformity is often corrected by creating laxity of the intrin-
sic tendons from the metacarpal resection, and use of small dorsal blocking splints
over the PIP joints postoperatively.When the swan neck arises from a mallet rup-
ture at the DIP joint level and a trial of DIP extension splinting corrects the defor-
mity, either a dermatotenodesis or fusion of the DIP joint will solve the problem,
although fusion is usually the best choice. When PIP replacement arthroplasty is
done in patients with xed swan neck deformity, the lateral bands are mobilized
from the central slip by releasing the triangular ligament over the dorsum of the
base of the proximal phalanx and incising between the lateral bands and central
slip on each side of the nger.The central slip is then lengthened with a Z incision
in the approach to the PIP joint. After the prosthesis has been inserted and the col-
lateral ligaments repaired, the central slip is snugly reattached with 4-0 permanent
suture, with the joint in approximately 20 degrees of exion. Following repair, the
joint should be able to be exed to 90 degrees without pulling out the tendon
sutures.
Postoperative Care
Bulky dressings and any splints are removed a few days af-
ter surgery, and lighter dressings are applied to the incisional area. Coban wraps are
applied to the ngers to control edema, as shown in the splint for MP arthroplasty
(p. 1887). Dorsal blocking figure-of-eight splints are used with the PIP joint in
slight flexion. The splints allow active flexion of the MP and DIP joints, unless
there has been a DIP fusion. The patient should perform 10 active exions per
hour during the day, and at night resting extension splints are left in place. Passive
exion is permitted after PIP arthroplasty that did not require takedown or repair
of the extensor mechanism. However, if the extensor tendon was lengthened or
shortened, if the lateral bands were mobilized dorsally, or if the tendon had to be
taken down for the approach and reattached later, passive exion is not allowed
until 6 weeks after surgery. If extensor tendon lengthening or reconstruction was
not performed, dynamic exion can be allowed 3 weeks after surgery if needed.
The extension block splints are worn continuously for 6 weeks after surgery, then
they can be removed during the day and light activities of daily living allowed. Sta-
tic resting splints are continued at night until 3 months after surgery.
Complications
Recurrence of PIP hyperextension is commonly seen in patients
with swan neck deformity,54,55 and to discourage recurrence chronic use of silver
ring gure-of-eight blocking splints can be encouraged as jewelry. PIP hyperexten-
sion can also occur as the result of laxity of the volar plate, intrinsic contracture
and adhesions of the exor tendons.These must be considered. After the prosthe-

sis has been inserted, an intrinsic tightness test must be performed before incisions
are closed in the operating room and if the intrinsic muscles are tight, an intrinsic
release procedure should be performed with the arthroplasty to avoid recurrence.
If troublesome recurrent hyperextension interferes with function from laxity, a sub-
limis tenodesis checkrein procedure can be performed.
Pellegrini and Burton56 reported that 35% of silicone rubber PIP arthroplasties had
periarticular erosions within 2 years of surgery. Within 4 years of replacement
arthroplasty, extensive endosteal resorption was seen in 20% of cases.
Distal Interphalangeal (DIP) Joint Arthroplasty
Silicone rubber arthroplasty has been used occasionally in the DIP joint for pa-
tients who wish to maintain motion but results have been better in patients with
osteoarthritis than in patients with rheumatoid arthritis. In these patients, the ex-
tensor lag normally measures about 13 degrees with 33 degrees of active motion,
and the arc of motion is therefore from 13 degrees to 46 degrees of exion.57,58
Osteoarthritis patients with motion within this range usually have a stable result and
more motion should not be expected in the rheumatoid patient. However,
arthrodesis is usually the procedure of choice for DIP joint repair in patients with
rheumatoid arthritis, who commonly have incompetent collateral ligaments.
RECURRENT ISCHEMIC ULCERATION
IN SCLERODERMA PATIENTS
As in patients with rheumatoid arthritis, patients with scleroderma and mixed con-
nective tissue disease have a progressive, chronic disorder. However, unlike most
rheumatoid arthritis patients, the precipitating factor leading to hand surgery is
usually a painful ischemic crisis causing unremitting ischemic pain and sometimes
digital ischemic necrosis and gangrene. In the past, amputation of ngertips in these
patients led to reoperation more proximally because of ischemic change develop-
ing in the amputation stump. Often, other adjacent digits would soon undergo sim-
ilar change, leading to further reoperative amputations. After Flatt’s 1980 contribu-
tion59 describing distal digital artery periarterial sympathectomy for Raynaud
syndrome in eight patients (most of whom had frostbite), including two with con-
nective tissue disease, the value of this operation for connective tissue disease pa-
tients has remained controversial.There is lack of agreement regarding surgical in-
dications (palliative or beneficial), preoperative assessment (preoperative blocks,
MRA or arteriography), and surgical technique (extent of dissection), or even if
the procedures are of any value. Most articles on Raynaud syndrome are pessimistic
about any long-term bene t from surgery, other than debridement of necrotic tis-
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sue and proximal amputation.60-63 One author (W.H.M.) has dealt with a large
number (over 100) of these dif cult patients over the past 26 years in which reop-
eration seemed inevitable in early experience and led to changes in surgical indi-
cation, preoperative evaluation and surgical management in hopes of reducing the
need for reoperation in patients with severe Raynaud syndrome, predominantly as-
sociated with mixed connective tissue disease (55% of series), scleroderma (38%)
and lupus (2%).
PATHOPHYSIOLOGY OF R AYNAUD SYNDROME
In 1862 Maurice Raynaud described vasospasm causing the triad of ngertip color
change, classically described as Raynaud syndrome:
White (pallor)
Blue (cyanosis)
Red (hyperemia)
This triad is often followed by pain and numbness and sometimes digital gangrene.
We still cannot explain, 144 years later, the biologic mechanisms for these dramatic
changes, nor any consistently successful methods of management.
The wide spectrum of precipitating or associated factors is confounding, with more
than 40 described. It is puzzling that these are so widely varied, with anatomic fac-
tors including thoracic outlet syndrome, obstructive arteriosclerotic disease and
dialysis shunting; injuries such as vibratory (white nger syndrome) and frostbite;
toxic drugs such as nicotine, lead, vinyl chloride and beta-adrenergic stimulants;
diseases such as scleroderma (in 95% of patients), rheumatoid arthritis (11%), can-
cer and hypothyroidism; and rheologic causes such as cryoglobulinemia and poly-
cythemia vera.The largest group of patients described as having Raynaud disease or
primary Raynaud syndrome, however, has no known explanation at all. That such
a variety of different disorders is united by similar manifestations attracts search for
a common systemic or local factor, but to date no such factor can be held account-
able.The two most widely debated theories of pathophysiology are whether these
are (1) central changes causing hyperactivity of the sympathetic nervous system as
believed by Raynaud in 1862,64,65 or (2) local vessel changes at the periphery as be-
lieved by Lewis in 1926.66 After 80 years of debate, these two possibilities should not
continue to remain mutually exclusive.
Raynaud observed that vasospastic attacks could be precipitated by emotional as
well as cold stress, which led him to reason that generalized increased sympathetic
activity must be the explanation. Indeed, emotional stress is currently reported in
one-third of the characteristic attacks.61,67 However, evidence that local factors are
more important than the central nervous system includes experiments using skin

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microelectrodes that do not measure any increased activity in the sympathetic out-
ow, only an altered response to cold stimuli,68 and measurement of circulating cat-
echolamines do not show an increase over normal levels in patients with Raynaud
syndrome.69 Although there are ndings suggesting some altered responsiveness of
alpha and beta adrenergic receptors to catecholamines, isolation of any speci c re-
sponsible endothelial factor has not yet been accomplished.
One provocative hypothesis holds that dysregulation of the central neuropeptide
system could provide the mechanism for Raynaud attacks.70 This concept is attrac-
tive because it can reconcile studies that show both central and peripheral mecha-
nisms to be present. A nonadrenergic and noncholinergic powerful neurologic in-
fluence on both vasodilatation and vasoconstriction has been demonstrated,
mediated by the release of neuropeptides present in the sympathetic nervous system
(neuropeptide Y [NPY] and norepinephrine), parasympathetic nervous system (va-
soactive intestinal peptides [VIP] and acetylcholine), and sensory nervous system
(substance P [SP] and calcitonin gene-related peptides [CGRP]). Some of these
are identi ed as vasoconstrictors (NPY) and some as vasodilators (CGRP, SP and
VIP).Their action may be endothelial-dependent (SP) or they may act directly on
the smooth muscle cell (CGRP, NPY, and VIP).These neuropeptides are known to
be synthesized in the midbrain and spinal cord where some mediate pain percep-
tion, but also may be secreted at peripheral nerve endings such as afferent pain end-
ings and sympathetic endings where they may cause a number of vasoactive and in-
ammatory responses.71 Although the control of this neuropeptide system is poorly
understood, it is known that temperature simulation may induce their secretion
and that sensory neuropeptides are found in abundance in human digital skin.72 In
support of this hypothesis, it has been shown that direct infusion of the neuropep-
tide CGRP (a potent vasodilator) reverses vasospasm in Raynaud attacks, and is re-
ported to promote healing of ischemic ulceration.73 The fact that Raynaud’s pa-
tients have frequent placebo response, temperature biofeedback and TENS unit
response, and vasospastic episodes in response to emotional stress certainly implies
the presence of central mediated mechanisms, whereas obvious distal anatomic vas-
cular change and failure of sympathetic blocks and proximal sympathectomy imply
a peripheral origin. Dysregulation of the neuropeptide system causing Raynaud at-
tacks with subsequent vascular alteration resulting from reperfusion injury could
explain the presence of both factors, as well as the peculiar tricolor sequence of
vascular responses known as the French triad,with different neuropeptides having
profound opposing vasoactive responses in sequence:white, blue, and red. Raynaud
syndrome certainly occurs at anatomic sites where there are the highest numbers of
arteriovenous anastomoses that control thermal regulation and capillary blood ow
and also dense concentration of afferent nociceptor sensory nerve endings, such as
ngertips, toes, tongue tip, pinna of the ears, and tip of the nose. Symptoms have
been reported in all of these sites.74 Although the mechanism remains obscure, the

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problem is compelling in these patients, and overcon dence is never appropriate in
the management of this disorder.
NONSURGICAL MANAGEMENT
There is no cure for Raynaud phenomenon associated with connective tissue dis-
ease,60,75 and the physical medical, pharmacologic, and surgical approaches should be
coordinated and individualized, with surgery postponed until other measures fail.
Patients should be taught preventive measures that can reduce attacks, such as avoid-
ing cold exposure, cigarette smoking, caffeinated beverages, vibratory exposure, and
vasoconstrictive drugs, such as most decongestants, amphetamines, and cocaine.
Biofeedback therapy,76“induced vasodilation,”77 and speci c exercise therapy78 have
proved successful hand therapy measures in some patients who do not have is-
chemic ulceration. Other measures, such as acupuncture,79 TENS,80 stellate gan-
glion block,81 and spinal cord stimulation82 are of less convincing value.
Pharmacologic management is the principal treatment for Raynaud’s but is reported
to bene t only 40% to 66% of patients, and rarely offers complete relief from Ray-
naud syndrome.83-85 There is controversy concerning which medications are effec-
tive, and the choices vary with the differing concepts of etiophysiologic mecha-
nism:
Medications designed to vasodilate;for example, intravenous calcitonin gene-
related peptide
Agents that prevent vasoconstriction, such as calcium channel blockers, alpha-
adrenergic blockers, angiotensin-converting enzyme inhibitors, and sero-
tonin-receptor antagonists
Drugs that alter prostaglandin metabolism, such as prostaglandin E1 (Prostin)
Medications that have a rheologic effect, such as aspirin and pentoxifylline
Because there is no single physiologic mechanism that explains the peculiar cold-
induced vasospasm of the syndrome, it follows that to date the FDA has approved
no single pharmacologic agent as safe and effective for Raynaud syndrome, although
several are classi ed as “possibly effective.”86 The most effective and widely accepted
medications appear to be the calcium channel blockers, especially nifedipine and
diltiazem, and aspirin. It is interesting that when patients with other connective
tissue disease symptoms respond to steroids or methotrexate, these drugs do not
seem to help Raynaud phenomenon.
Botox injection along the vasculature has proven a recent rewarding addition to
the armamentarium managing patients who are having vasospastic crisis. In one
author’s experience (W.H.M.), this has produced marked relief of the vasospastic
pain soon after injection, and reportedly has resulted in healed ulcerations.87,88
Neumeister et al89 reported a 300% increased laser Doppler perfusion immediately

after injection. Unfortunately, Medicare and many of the insurance health man-
agement organizations will not approve this simple measure, regarding it as “ex-
perimental,” although the alternatives are far more expensive and morbid. A par-
enteral infusion of prostaglandin E1 (Prostin) will relieve a crisis, but if used for
more than 3 days, the patient will develop generalized edema.90 Calcitonin gene-
related peptide similarly is reported to relieve a crisis situation, but is available only
experimentally at present. In our experience, most patients will redevelop symp-
toms approximately 3 to 6 months after Botox injection.
PATIENT EVALUATION
Precise objective criteria for diagnosis of Raynaud syndrome is not agreed on, with
many investigators who feel that a carefully documented history is the best crite-
ria and a simple questionnaire is the best tool.91 The phasic “French tricolor” vas-
cular change is not now thought to be essential for diagnosis, although it occurs in
two thirds of patients.
We prefer the use of cold recovery time as our primary diagnostic tool when the
diagnosis is in question, using digital exposure to a water bath at 20° Celsius for 1
minute, and if there is no recovery of baseline temperature measurements after 20
minutes or longer, Raynaud syndrome is diagnosed.This method was described by
Porter et al92 who found control subjects recovered within 5 to 20 minutes (aver-
aging 10 minutes), whereas Raynaud subjects recovered in an average of 35 minutes.
We do not use this technique, however, in patients whose diagnosis is clear, and es-
pecially not in those who have severe ischemic change, for fear we might worsen
their clinical situation.This cold recovery test lacks speci city in that smokers with
no characteristics of Raynaud syndrome frequently cannot past the test. Some in-
vestigators have used laser Doppler with cold exposure in what would appear a
more precise measurement of cold response.93
Sensory testing is of particular help in these patients. Delp and Newton94 clearly
demonstrated signi cantly greater loss of sensation in Raynaud patients compared
with controls following cold exposure.We have noted that patients with severe dif-
culty will have decreased Semmes Weinstein mono lament measurements, often
with a characteristic nding of better sensation in the palm and base of their dig-
its than distally. This has proved a useful measurement to verify improvement fol-
lowing periarterial sympathectomy in that the more severely affected digits often
regain enhanced sensibility after surgery. The Allen test should be done in all pa-
tients because of the fairly high incidence of ulnar artery occlusion in scleroderma
patients. Doppler ultrasound mapping of vessels is of enormous value in assessing all
Raynaud syndrome patients, especially those for surgical consideration.90 Particular
attention should be paid to the ulnar artery of the wrist, super cial vascular arch in
the palm and dorsal radial artery, and the common volar and proper digital vessels.
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Often the proper digital arteries will not be audible in the of ce setting, but easily
heard in the operating room after the vasodilation of general or block anesthesia.
After general or axillary block anesthesia, previously cyanotic dying ngers may
become hyperemic as in photo above (left).When the problem is predominantly va-
sospasm, good perfusion is expected in the amputation stump after sympathectomy
(right). Laser Doppler study has been useful in the immediate preoperative and post-
operative settings, with improvement generally measuring 50% to 300% difference,
but preoperatively we have noted a very wide spectrum of response, even within
minutes, and postoperatively there appears to be less variability.
Radiographic evaluation is valuable in Raynaud patients who are surgical candi-
dates and have evidence of proximal occlusion on clinical and Doppler evaluation.
Although arteriography is regarded as the gold standard for upper extremity vascu-
lar evaluation,95 it has not been as accurate as MR angiography in our experience.
Using arteriography, vasospasm has led to misinterpretation of ulnar artery and su-
per cial vascular arch as occluded, as well as digital vessels, which were found to be
patent at surgery. This was also observed by O’Brien et al96 and may be caused by
the fact that radiopaque contrast media has been shown experimentally to cause ar-
teriolar spasm, increased vascular permeability, impaired microvascular blood ow
due to formation of erythrocyte aggregates and reduced erythrocyte deformabil-
ity.97 Furthermore, most of our patients have mixed connective tissue disease, lupus
or scleroderma, and are at greater risk for renal problems, which can be a known
complication of allergy to radiographic dye.With improved MR imaging, we have
found this noninvasive technique of assessment to be a reliable alternative to con-
ventional angiography in the hand and wrist.98 This has the advantage of offering
oblique, cross-sectional and longitudinal views of the ngers and hands, has lower
morbidity and is less expensive than conventional angiography. It does require ra-
diologists with the appropriate equipment and degree of interest to obtain all of the
planes of measurement needed. It is inferior to angiography for non–connective tis-

sue disease Raynaud syndrome patients, such as ulnar artery hypothenar hammer
syndrome, occlusion with emboli, or thoracic outlet syndrome, because the arteri-
ographic dye assessment provides a better evaluation of the intravascular anatomy.
Unfortunately, Medicare and many of the HMOs refuse to reimburse for MR an-
giography in upper extremity vascular evaluation—even though it appears safer,
more accurate in connective tissue disease patients, and a less expensive evaluation
technique—because it is regarded as “experimental.”
Obtain a careful hand functional assessment on all Raynaud syndrome
patients who are candidates for surgery, such as sensation, manual dex-
terity, range of motion, strength, baseline temperature, and skin and
digit appearance, because many of these patients will have or develop
sclerodactyly changes that need to be monitored.
The other useful preoperative parameters include the Allen test, Doppler ultra-
sound vascular mapping, laser Doppler assessment, and MR angiography.
R ATIONALE FOR EXTENDED PERIARTERIAL SYMPATHECTOMY
The concept of direct sympathetic denervation of arterial smooth muscle to re-
duce vasoconstriction is by no means new, having been recommended by Lerich a
century ago, then advocated and performed in 1899 by Jabollet on axillary vessels
of Raynaud patients.99 It was not until 1980 that Flatt59 introduced the concept of
distal vessel periarterial sympathectomy. Based on Pick’s classic text on the auto-
nomic nervous system,100 Flatt reasoned that proximal cervicothoracic sympathec-
tomy failure could be caused by alternative pathways to the brachial plexus from the
sinovertebral nerve, the carotid plexus and the nerve of Kuntz. Contribution to the
sympathetic supply in the hand is directly from the median and ulnar nerve to the
adjacent vessels at the wrist, super cial vascular arch, and common and proper dig-
ital vessels from the corresponding nerve. Pick’s descriptions and our clinical obser-
vations show the sympathetic contributions to be particularly intense at sites of bi-
furcation, such as from the super cial arch into the common volar vessels, and their
bifurcation into the proper digital vessels. Mitchell101 observed that the sympathetic
bers arborized in the adventitia of these vessels, and Morgan et al102 con rmed that
these bers are con ned to the adventitia without deeper penetration into the me-
dia. Rabbit ear experiments demonstrated that there was no sympathetic reinner-
vation after a year following periarterial stripping of vessels.103 Studies on mon-
keys, however, did not show complete loss of adrenergic innervation in the
vasculature distal to the operative site after a 1 cm perivascular sympathectomy in
the common volar vessels. Only the operative site itself and a few millimeters dis-
tally had complete loss of catecholamine fluorescence.104 Quantitative measure-
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ment of catecholamines in rabbit ear vessels after perivascular sympathectomy
showed response to be signi cantly lower in the distal segment compared to the
control side, but still about nine times higher than at the sympathectomy site it-
self.105 It may be concluded that periarterial sympathectomy (adventectomy) re-
moves the sympathetic innervation at the site of surgery itself, and to a lesser extent
removes sympathetic activity distally. Therefore we reason that a more extensive
perivascular sympathectomy of vessels known to occlude frequently may offer pre-
ventive measures at these sites, such as the wrist, proximal palm, common volar,
and proper digital vessels. Flatt performed distal sympathectomy at the level of bi-
furcation of the common into the proper digital arteries, stripping only a 3 to 4 mm
segment of adventitia under 2
magni cation.We now believe a much more ex-
tensive dissection is needed in patients with connective tissue disease.
It is of interest that patients with scleroderma typically give a history of Raynaud
syndrome for an average of 11.5 years before diagnosis.106 Because Raynaud attacks
may be a symptom of occult illness by such a long interval, Blunt and Porter107
have suggested that the terms Raynaud disease and Raynaud phenomenon be aban-
doned, using the term Raynaud syndrome for all patients. Pathologic study of post-
mortem scleroderma patients shows digital artery intimal brosis and thickening,
with the lumen narrowed to less than one fourth of its diameter in 79%108 and ul-
nar artery thickening to an extent that may completely occlude this vessel in almost
50%, which is the principal blood supply to the hand.These changes do not explain
why severe and frequent Raynaud attacks occur for so many years before any other
manifestations of connective tissue disease or blood vessel change in these pa-
tients.109 Indeed, it is suggested that the intimal brosis and thickening actually may
be caused by frequent and severe Raynaud attacks resulting from reperfusion injury
to the vessel walls from the ischemia and reperfusion cycle.70 In other words, the
vascular anatomic change may be the result rather than the cause of Raynaud at-
tacks, but may cause the attacks to be increasingly severe. If so, early extensive mi-
crovascular perivascular sympathectomy conceivably could prevent some of these
changes. Although the rationale for periarterial sympathectomy seems sound, there
has been little agreement among surgeons regarding indications, which digits need
surgery, and the extent of dissection.
SURGICAL INDICATIONS
All too often, the hand surgeon’s rst encounter with a Raynaud’s patient is weeks
or months after gangrenous changes have been present and the patient has suffered
prolonged ischemic pain. In our earliest experience, simple amputation of nger-
tip gangrenous tissue was followed by failed healing and necrosis of the amputation
stump, leading to a depressing sequence of progressively more proximal amputa-
tions.This has led some to recommend proximal amputation initially.

Our experience has been reversed by adjunctive digital artery sympathectomy and
sometimes revascularization (when the ulnar or radial artery is occluded) at the
time of initial debridement and amputation, permitting removal of only devitalized
tissue with predictable healing of the amputation stump.The amputation stump of
this 18-year-old patient healed primarily after periarterial sympathectomy con-
ned to her palm. She had scleroderma and was a smoker; 20 years later her ulnar
artery became occluded and required regional reconstruction, because the initial
procedure did not include the ulnar artery proximal to the wrist (or the nerve of
Henle).
Because of doubts regarding the value of periarterial sympathectomy, our earlier in-
dications for surgery required impending ischemic necrosis or gangrenous change.
Over the years, observation of the profound and seemingly sustained bene t has led
us to change our criteria to include any patient who has unremitting ischemic pain
that is not manageable by pharmacologic or hand therapy measures.
Wilgis110 combined digital plethysmography with cold stress testing using bupiva-
caine blocks at the palmar area as a criterion for determining the potential bene t
of surgery (digital artery sympathectomy). We have seen patients with ischemic
necrosis who did not respond to the blocks, but who did bene t from digital sym-
pathectomy. Zachary et al111 reported surgical bene t in connective tissue disease
patients who did not respond to blocks, so we feel patients should not be excluded
from surgery by this test.
Botox injection may prove to be an excellent criterion for the response of sympa-
thectomy.We have seen rather dramatic relief from discomfort by this measure, and
it may prove a practical treatment for amputations when an extended periarterial
sympathectomy is not desired, allowing healing of the amputation stump.This will
not correct proximally occluded vessels, such as the ulnar artery, but may obviate the
need for surgery in some patients, as suggested by Van Beek.113 Unfortunately, it is
still dif cult to get insurance coverage for use of this practical measure.
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SURGICAL TECHNIQUE
Technical Differences: Digital Artery Sympathectomy:
How Much Do You Strip?
Author
Sympathectomy
Flatt (1980)
Proper digital artery, 3-5 mm
Wilgis (1981), Morgan (1991)
Proper digital artery plus common volar, 20 mm
Egloff (1983)
Proper digital artery plus common volar, 5-10 mm
Jones (1987)
Proper digital artery plus common volar, entire arch
El-Gammal (1991), Blair (1991)
Proper digital artery plus common volar, segments of
radial and ulnar vessels
O’Brien (1992)
Ulnar artery at wrist to entire arch, common volar and
proper digital vessels in the ngers
Zachary (1995)
Proper digital artery plus common volar, from arch
Merritt (1997)
Ulnar artery distal forearm, wrist and entire arch,
common volar and proper digital vessels into web,
dorsal radial artery, and sometimes proper digital arteries
to the PIP level
Koman (2005)
Ulnar and radial arteries at wrist (2 cm), proximal
super cial arch and proximal common volar vessels in
palm, sometimes dorsal radial artery (if there are thumb
symptoms)
Although there are relatively few reports on digital artery sympathectomy, these
describe longer-lasting bene t and less morbidity than reports on cervicothoracic
sympathectomy.59,60,90,113-117 However, there is little consensus on how the opera-
tion should be done, regarding which digits and the extent of dissection. Some sur-
geons con ne their surgical approach to only the painfully ischemic or gangrenous
digit,110,114,115,118 stripping the distal common volar vessels and proper digital vessels
to the PIP joint level in those digits. This seems a good approach in patients with
injury to speci c digits, such as frostbite or trauma, but affords no prophylactic ben-
e t to avoid reoperation in patients with progressive connective tissue disease, such
as scleroderma. Zachary et al119 and others have used a more extensive procedure
including the other digits, but still con ning their efforts to the common volar and
proper vessels. El-Gammal and Blair120 included adventectomy of a segment of the
radial and ulnar vessels as well as the common volar and proper digital arteries us-
ing multiple vertical incisions but omitting the super cial arch. O’Brien et al117 de-
scribed a more aggressive approach, stripping the ulnar artery at the wrist, super -
cial arch, common volar and proper digital vessels well into the ngers of all of the
digits. Some of their cases were done as staged procedures.

Most of our reoperations were performed in younger women with scleroderma
or mixed connective tissue disease, and the reoperations led to a more aggressive ap-
proach that we call extended periarterial sympathectomy. In our early experience deal-
ing with patients having connective tissue disease at the time of amputation, we
stripped vessels to all four ngers using a transverse palmar incision, and a longer
segment of vessels than was described at that time, including 2 to 3 cm involving
the common volar vessels to well beyond their bifurcation and into the ngers. At
that time our criteria required either painful ischemic ulceration or frank gangrene.
Good results were presented among our rst 15 patients in 1985,121 with no recur-
ring ulcerations in operated hands and primary healing of amputation stumps. Six
of these patients returned for surgery in their other hand because of ischemic ul-
ceration or gangrene that had developed in the unoperated side. However, four of
these patients redeveloped painful ischemic change in operated hands and were
found to have ulnar artery occlusion at the hypothenar region or wrist. Before
these patients could develop ulcerations, reverse vein graft reconstruction was per-
formed in an end-to-side fashion from the ulnar artery proximal to the occlusion
to the super cial vascular arch (see p. 1903). The dissection of the super cial arch
was quite tedious after the previous surgery, so thereafter in the initial operation the
ulnar artery was stripped of its adventitia in the distal third of the forearm as well
as the wrist, palm, and digital vessels, including areas supplied by the nerve of Henle.
Later, two patients developed late postoperative problems in their index and thumb
digits that responded to periarterial dorsal radial artery sympathectomy from the
level of the snuff box distally to where the vessel bifurcates and goes beneath the
rst dorsal interosseous muscle. We then began to include the radial artery. These
experiences led to our current philosophy in patients with connective tissue disease.
It is in keeping with the experiments in monkeys that show protection from vaso-
constriction at the level of surgery and to a limited extent distally, but no protec-
tion from proximal vasoconstriction. Given that postmortem studies in scleroderma
patients suggest almost half may develop occlusion of the ulnar artery,117,121,123 pri-
mary periarterial sympathectomy of this vessel may avoid a more dif cult and te-
dious procedure in the future.
In patients with signi cant connective tissue disease, we now strip the dorsal branch
of the radial artery from the snuff box to its passage toward the palm, the ulnar ar-
tery from a point 8 to 10 cm proximal to the wrist crease, to and including the
entire super cial vascular arch, the common volar vessels, and the border of their
communicating branches to the deep system at their bifurcation, and the proper
digital arteries to all ngers about 3 to 5 mm distal from the common volar bifur-
cation in the base of the digit. When ischemic necrosis or gangrene is present, we
often include the proper digital artery in the affected digit to the level of the PIP
joint.
1901
Chapter 46
Reoperative Hand Surgery

1902
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
This illustration shows the areas for adventitial stripping (darker red areas). We now
believe high-risk vessels may be protected from occlusion by early adventectomy,
and the results of this extended more aggressive approach have been rewarding.
Approximately one fourth of our patients present with their ulnar artery already
occluded and primary reverse vein-graft reconstruction is included with the peri-
arterial sympathectomy. All of these vein grafts have been harvested from the volar
forearm and have varied from 6 to 15 cm in length; most frequently the cephalic
vein has been used.
Area of
adventectomy
Dorsal radial artery
Ulnar artery
This patient had severe skin induration from sclerodactyly-type changes. She under-
went sympathectomy to the wrist level previously then developed symptoms from
ulnar artery thrombosis years later proximal to the wrist.The vena comitans of the
ulnar artery was used for successful 15 cm end-to-side reverse vein grafting. We
have never found it necessary to use the saphenous vein, which seems too large.

In most patients surgery is performed with a general anesthetic but some with an
axillary block.The potential value of the periarterial sympathectomy becomes ev-
ident as soon as the patient is induced for general anesthesia or has an axillary block,
because vessels that were previously cyanotic become pink in the operating room
(see p. 1889). Reassessment with Doppler is convenient at that time, because a more
accurate appraisal can be achieved. Two incisions are now usually used because of
early problems with an L-shaped ap that tended to develop necrosis at its tip (none
of which required secondary surgery). One is a distal transverse incision 1 to 1.5 cm
proximal to the nger exion creases, and a second vertical incision is made in the
central palm, placed with a bridge of skin of approximately 1 cm between the two
incisions (see p. 1896).This is angled vertically along the level of the ring and fth-
digit web space bordering the hypothenar eminence in line with the level used for
carpal tunnel release, then at the wrist crease it is angled ulnarly then vertically
along the ulnar artery, and this can be mapped with Doppler assessment.
1903
Chapter 46
Reoperative Hand Surgery
The initial incisions are made under tourniquet control and ap elevation is accom-
plished with isolation of the neurovascular bundles under 4
loupe magni cation.
Then the adventitia is stripped and vascular reconstruction is done without tourni-
quet under microscopic control, as seen here in one of our early cases with the late
S. Dawson Theogaraj. It is much easier to determine the amount of adventitia that
can be stripped safely from these diseased vessels during blood ow, because their

1904
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
surface is frequently thickened and distorted. Ophthalmic Vannas scissors are most
useful to strip, push, and pull the adventitia circumferentially away from the vessels.
The most neuro laments will be found at the bifurcations in the super cial vascu-
lar arch, at the termination of the common volar vessels, and at the wrist level. Ad-
ditional time spent at these sites is worthwhile.
The dorsal radial artery is exposed with incision on the dorsum of the thumb web
extending to the snuff box, and adventitia is stripped from the level of the snuff
box beneath the extensor pollicis longus as far distally as possible until the vessels
branch and become inaccessible beneath the rst dorsal interosseous muscle. The
patient above had periarterial sympathectomy of the dorsal radial artery 6 years af-
ter a previous ulnar artery reconstruction because of Raynaud symptoms in the in-
dex nger and thumb.
There were three patients with occluded radial arteries who had vein graft recon-
struction, and it was found that they reconstituted at the distal level, where careful
dissection allows distal arterial elevation at this site of branching to perform an
end-to-side anastomosis.
Because in scleroderma patients there is a high incidence of ulnar artery occlusion,
reconstruction of this vessel is a frequent consideration. Jones124 and Koman et al124a
described replacing the entire super cial vascular arch by vein graft (usually the
saphenous vein) to the proximal ulnar artery with common volar vessels microvas-
cularly reinserted into the vein graft distally. In this series of 14 patients the super-
cial vascular arch was occluded from various causes, and recurrent ulcerations oc-
curred in 20%, with occlusion of the graft in 35%.
In our patients with connective tissue disease and ulnar occlusion, collateral circu-
lation to the super cial vascular arch was still audible, although not always visual-
ized on radiographic study, and we have been able to use an end-to-side method for
vein graft reconstruction of occluded ulnar vessels, thereby preserving the collateral
circulation.

The gure above illustrates the preferred end-to-side vein graft for ulnar artery
occlusion combined with extended periarterial sympathectomy, as outlined in red.
We are not aware of any patient who has lost a digit in approximately 30 cases, but
in at least seven the vein graft occluded without adverse effect, and two patients had
to have reoperative surgery for occlusion. We now maintain vein-grafted patients
on clopidogrel (Plavix). At the time of vein graft, it is useful to distend it with
heparinized saline and dot the surface of the vessel with methylene blue before
harvesting it to avoid twisting the graft. Most frequently the cephalic vein is used,
and its branches are suture-ligated at the vessel level with interrupted 9-0 nylon
sutures, and vascular clips used on distal portion of the branches. We now also in-
clude a regimen of dripping Botox solution on the vein graft as well as the other
exposed vasculature. It has been our impression that the vein graft has less trau-
matic vasospasm as a result of this maneuver. The ulnar arteriotomy for vein graft
reconstructions is done with a small, pointed Beaver blade, and the end-to-side
anastomosis is performed with 10-0 nylon at the distal end of the reverse vein graft,
which is the rst anastomosis. Doppler assessment assists in determining the best site
for anastomosis along the super cial vascular arch. Many times the lumen in the
super cial arch is thickened and narrowed, and using a 1.25 mm Flo-Rester stent
tube (Bio-Vascular, St. Paul, MN) often helps with the initial critical sutures. The
proximal anastomosis is generally accomplished with interrupted 9-0 microvascu-
lar sutures.The segments to be sutured are isolated with vascular clamps, and both
anastomoses are completed before release of the clamps. It is preferable to place
1905
Chapter 46
Reoperative Hand Surgery
Area of
sympathectomy
Vein graft

1906
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
the vein graft on slight tension at the time of proximal anastomosis, because even
though it appears to be under tension, this lengthens once blood is owing through
it. Patency is con rmed with the Hayhurst test, although blood ow through the
vein graft is usually apparent.
Closure is done with 3-0 chromic catgut for the dermal layer in the forearm and
dorsum of the hand and interrupted 4-0 Prolene for all of the skin incisions. Bupiv-
acaine (Marcaine) is injected along the median and ulnar nerves at the wrist level
and the super cial radial nerve on the dorsum of the hand to reduce postoperative
discomfort. Drains are not usually necessary, but if there is undue oozing in the
palm, a small Penrose drain can be placed. Our only patient who required this had
remained on anticoagulation therapy because of atrial brillation.The hand is im-
mobilized in a soft dressing with a tongue blade splint, maintaining the wrist in
approximately 15 to 20 degrees of extension, the MP joints exed and the IP joints
extended. Patients are given ketorolac tromethamine (Toradol) before the end of
the procedure to reduce postoperative discomfort and to discourage platelet ag-
gregation. In the past, we used low-molecular-weight Dextran, but studies that sug-
gested ineffectiveness led us to abandon this, without adverse effect. Patients are
treated on an outpatient basis unless a vascular reconstruction is performed (ap-
proximately one fourth of patients), then they are observed overnight with laser
Doppler monitoring. No patients have developed hematomas or decreased circu-
lation that required reexploration.
Even though a large segment of occluded ulnar artery is bypassed by the vein graft,
we believe it is important to also do an adventectomy on the occluded portion of
the vessel along with the patent vessels undergoing periarterial sympathectomy.
This is based on the fact that, before microsurgery, surgery for hypothenar hammer
syndrome was done simply by excising the occluded segment of ulnar artery, which
somehow gave relief from the ischemia. Although this might have been because
emboli were prevented, it is also equally possible that the sympathetic stimulation
from the occluded vessel played a role, and the resection of the occluded segment
gave relief by means of sympathectomy.The value of this additional dissection is un-
certain, but it seems prudent in these patients with such dif cult problems. This
more extended technique for periarterial sympathectomy is reserved for patients
with scleroderma or other connective tissue disease; its greatest advantage may
prove to be its early use in patients with connective tissue disease to reduce or pre-
vent future predictable occlusions.
PERIVASCULAR SYMPATHECTOMY FOR R AYNAUD
SYNDROME OF THE FEET
In approximately 40% of Raynaud patients the toes and feet are involved,61 occa-
sionally so severely that amputation is necessary.125 Pick100 described signi cant sym-
pathetic contributions to the posterior tibial and dorsalis pedis vessels at the ankle
level, similar to the description of sympathetic contributions to vessels at the
wrists.110,120

We have performed periarterial sympathectomies of the dorsalis pedis (left) and
posterior tibial vessels (right) for an arbitrary distance of approximately 7 cm, with
resultant subjective improvement that has been maintained. Zachary111 described a
successful similar effort by means of con ning his incision to the proper digital ar-
teries of the toes.Thus far, we have used this procedure in only eight patients, two
of whom have died of their disease, but the follow-up is up to 10 years, and the re-
sults are encouraging, so we recommend either this simple procedure or injection
with Botox for toe vasospastic pain.
1907
Chapter 46
Reoperative Hand Surgery
This patient with connective tissue disease had painful ischemic ulceration of her
great toe for 2 years that healed 1 month after periarterial sympathectomy and per-
mitted return to walking.

1908
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
POSTOPERATIVE MANAGEMENT
Following surgery the patient is maintained at rest with the hand elevated until the
fourth or fth day postoperatively, when hand therapy is instituted. Initial postop-
erative stiffness is common and hand therapy is used in all patients. In some cases
this has been rewarded by improvement over preoperative total active motion, but
in general, recovery of preoperative motion has been the achieved goal.When sen-
sation was diminished, it generally became improved after surgery. The therapist
places the patient in a resting splint with wrist extension and MP exion and ini-
tiates active motion recovery allowing the patient to use the hand to the extent
that it is comfortable. Most patients recover their range of motion fairly quickly, but
those with sclerodactyly will tend to have greater stiffness and need a longer ther-
apy regimen. Patients who have a vein graft are not allowed out of their wrist splint
until after the tenth postoperative day to avoid the possibility of hyperextension
and damage at the anastomotic level. Often one or more digits may suffer neura-
praxia, and the patient is reassured and monitored until he or she obtains full sen-
sory recovery. Although patients are given postoperative pain medication, it has
been surprising how little they have required, because the ischemic pain so often
was much worse than their postoperative pain. The therapy program is continued
until the patient has recovered full amplitude of motion and full sensation. This
varies from 3 weeks to as much as 12 weeks, especially in those with sclerodactyly
and postoperative stiffness.
OUTCOMES
All patients experience some relief from severe ischemic pain, usually immediately
after surgery.There have been no intraoperative or perioperative deaths associated
with the surgery; however, almost 20% of these patients have died during the late
follow-up interval, which likely represents the seriousness of the disease process
and involvement of other critical vessels of the heart, brain, kidney, and lungs. Al-
though these patients reported subjective relief and usually had objective sensory
improvement and enhanced nail growth, most continued to remain cold sensitive
and still vulnerable to Raynaud attacks, reportedly less severe and less frequent. Sev-
eral had transient episodes of paronychia, sometimes stubborn, which responded
to conservative management.
Jonathan Isaacs125a surveyed a group of these patients while he was in orthopedic
surgery training (he is now a hand surgeon at Virginia Commonwealth University),
studying 21 patients after 31 of these procedures several years ago. The long-term
results proved surprising. Average follow-up was approximately 7 years, with fol-
low-up up to 14 years in this group of patients.The average age at surgery was 27
years, with a range of 18 to 87 years, with twice as many women as men in the se-
ries. A favorable follow-up was present in 28 of the 31 hands operated, with two of
the unfavorable results in the same patient, who was a heavy cigarette smoker, and
all three failures had suf cient severity that amputations were done at initial surgery.
When recurrent ulceration was studied, 77% of the patients had remained improved

or were asymptomatic, with 83% of those surveyed more than 5 years after the
original operation. In answer to the question of ischemic pain, 90% of the patients
stated they were improved or asymptomatic compared with their preoperative sta-
tus, and this was true in 86% who were surveyed more than 5 years after surgery.
Because the patients who had the most serious involvement with the disease may
have died, the long-term results may represent patients who generally had a more
favorable course, but these surprising long-term results have encouraged the con-
cept of protecting the patient with earlier periarterial sympathectomy to reduce
the pattern of vasospasm and reperfusion injury resulting from less severe and less
frequent Raynaud attacks.The ndings suggest a surprising degree of bene t longer
than 5 years after surgery. It is dif cult to prove that this extended digital artery
sympathectomy altered the outcome in these patients, but if one reviews the history
of Raynaud syndrome in patients with connective tissue disease under medical
management, the incidence of ischemic ulceration is reported as high as 20% to
30% per year126 and ulnar artery occlusion is common, as high as 50% in sclero-
derma.117,122,123 Given that this surgical series selected unfavorable patients with ad-
vanced disease who were medical failures, postoperative relief of ischemic pain and
decreased incidence of recurrent ulceration or gangrene enhanced our support and
belief in the procedure.
COMPLICATIONS
1909
Chapter 46
Reoperative Hand Surgery
No patients died during the intraoperative or perioperative period, but early in the
series there was a high incidence of partial ap necrosis when an L-shaped incision
was used for the palmar dissection (see p. 1903). Switching to two T-shaped inci-
sions with a bridge of skin separating them has made it more dif cult to do the dis-
section, but it is still feasible and has reduced the incidence of flap necrosis, al-
though there has still been some dif culty with wound healing of the borders of the
ap. Only one patient has required reoperation for wound problems, which re-
sulted from infection with methicillin-resistant Staphylococcus aureus (MRSA) in the
vertical palmar incision. This resulted in a scar contracture that responded to Z-
plasty correction. Several developed hypertrophic scarring in the forearm postop-

1910
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
eratively, and one African-American has undergone revision surgery for a keloid
scar. As mentioned, there were several reoperations due to proximal vessel occlusion
and radial artery vasospasm early in this series. In patients with sclerodactyly, stiff-
ness has been a greater problem postoperatively than other patients, but eventually
they achieve their preoperative range of motion, and in some cases exceeded it.
Transient neurapraxia has been common, sometimes with troublesome paresthesias
that respond to Neurontin, but patients eventually recover their preoperative sen-
sation and most have improved sensation.We had hoped that increased blood sup-
ply might reduce the tendency toward sclerodactyly and calcinosis (in patients with
calcinosis, Raynaud syndrome, esophageal dysmotility, sclerodactyly, and telangiec-
tasia [CREST] syndrome) but this does not appear to be the case. Several patients
continued to develop calcinosis and changes of sclerodactyly, and it is doubtful this
procedure altered their course in any way.
SUMMARY
At present, most clinicians regard surgery for Raynaud syndrome as a salvage pro-
cedure to debride necrotic tissue or to amputate gangrenous digits in patients who
did not respond to pharmacologic or physical medicine management usually fol-
lowed by a sequence of similar depressing reoperations. Experience with these
newer microvascular surgical techniques on distal vessels, however, appears to offer
improved bene t and lower morbidity than previous proximal sympathectomy pro-
cedures. Our long-term follow-up also suggests that later vasospastic occlusion may
be reduced or prevented in connective tissue disease patients because of these pro-
cedures. However, the appropriate role, timing, indications, and technique for
perivascular distal sympathectomy are still evolving, and we must still agree with
Maurice Raynaud’s original 1862 observation:“I hope it will be readily understood
that for a disease, so many aspects of which are still obscure, I cannot formulate a
complete treatment.”
GIANT CELL TUMOR OF THE TENDON SHEATH
Benign giant cell tumor of the tendon sheath is the second most common tumor
arising in the hand (after ganglia) and has a signi cant reoperation rate, reportedly
5% to as high as 50%.127 It is a confusing disorder, because it does not always con-
tain giant cells, often is not associated with the tendon sheath, and carries other ti-
tles, such as pigmented villonodular synovitis, fibrous xanthoma, and localized
nodular synovitis. It must not be confused with giant cell tumor of bones, which is
regarded as a low-grade malignancy that may metastasize and kill, especially when
arising in the hand, and may lead to amputation when the tumor perforates the
bony cortex.
Giant cell tumor of the tendon sheath has never been reported undergoing malig-
nant transformation as reviewed by Glowacki and Weiss.128 Therefore aggressive
treatment, such as amputation, is not warranted. However, when the tumor arises
from within the DIP joint, the probable need for reoperation must be discussed

with the patient; otherwise, a formidable tumor may recur, which can be exceed-
ingly dif cult to excise. Other factors (than DIP joint origin) that increase risk for
recurrence include degenerative joint disease and the presence of radiographic pres-
sure degeneration.129
These tumors are usually firm, painless, multinodular, and grow slowly, causing
symptoms because the patient bumps them. They may occur anywhere synovial
cells exist, but are most commonly found in the nger, especially the DIP joint, and
most often in the radial three digits.The fact that they are not moveable and do not
transilluminate distinguishes them from a ganglion cyst.
Immunohistochemical studies show that the cell of origin is a multipotential cell
arising from synovial tissue130; thus, when tumor arises from within the DIP joint,
it becomes impossible to excise the cells of origin without too much morbidity for
the benign process. However, we know this tumor will always tend to recur when
incompletely excised. Therefore, in an older patient with extensive DIP joint in-
volvement or signi cant degenerative arthritis, arthrodesis might be considered.
The surgeon must explain to the patient that this is a benign process that is likely
to recur, especially if it originates from within the DIP joint, and at the rst sign of
new nodularity, early return and reoperation will greatly simplify management. Re-
currence is often within 2 to 3 years. One author (W.H.M.) prescribed postoper-
ative DIP radiotherapy after the eighth recurrence and reoperation in a nurse who
does not desire arthrodesis, and she has had a ninth and tenth reoperation subse-
quently with no apparent bene t from radiotherapy and with full-thickness skin
grafts used because of the involvement into the overlying skin and scar. Her digit
has had resections done circumferentially with episodes of recurrence on all sides
of her DIP joint, but only one at a time.
1911
Chapter 46
Reoperative Hand Surgery
She returned noting dorsal nodules from her tenth recurrence of giant cell tumor
of the tendon sheath in the middle DIP joint that did not respond to radiotherapy.
An adjacent split-thickness skin graft was used from the index nger, as marked in
the above photo.

1912
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
When return to the surgeon is delayed, extensive recurrence can be circumferen-
tial and impose a formidable challenge to achieve complete excision without leav-
ing tumor in the soft tissue, as seen in the above patient, who watched extensive re-
currence until 6 years after her original surgeon had removed a small dorsal giant
cell tumor. After the oblique original dorsal incision was opened, three longitudi-
nal incisions were used for excision, trying to preserve vascularity to the ngertip
but completely remove the lesion from the soft tissue. Unfortunately, the excision
caused too much devascularization of the tip and she lost the pulp and had a DIP
amputation to obviate any further recurrence.
SURGICAL TECHNIQUE
The goal of surgery is to completely remove the giant cell tumor of the tendon
sheath (that would otherwise recur) without more morbidity than warranted for a
benign process. When the tumor does indeed arise from synovial cells of the ten-
don sheath this can be accomplished, including the tendon sheath at the tumor’s
base; but when the tumor originates from within the joint, a small rongeur should
be used to remove all of the involvement found along the rim and outer border of
the joint. However, to divide the collateral ligaments to open the joint is not war-
ranted because it creates stiffness and still does not ensure that there will be no re-
currence, so possible recurrence and reoperation should be anticipated.
Most operations are done on an outpatient basis under local bupivacaine (Mar-
caine) anesthesia using a nger tourniquet. The incision is made directly over the
tumor, using previous scar when it is available, and under loupe magni cation the
tumor is separated from surrounding structures, with care to remove all multiple
lobes and its base, wherever it is attached. Sometimes digital nerves have to be care-
fully dissected off the tumor.

POSTOPERATIVE CARE
If the extensor lateral bands were not damaged, patients can usually remove their
bandage in a few days, use Band-Aids, and resume normal activity, with plans to
have sutures removed at 2 weeks. If there was invasion and partial excision of the
lateral extensor bands over the joint, prolonged extensor splinting is used for a pro-
portional time, according to the amount of damage, up to 6 weeks if they were
completely divided.
GANGLION EXCISION
Although primary excision of dorsal or volar wrist ganglions has a recurrence rate
of 5% to 10%, excision of recurrent ganglions has a recurrence rate of 30% to 40%,
suggesting the problem is intrinsic to the patient rather than technical. The most
common dorsal wrist ganglions are located at the scapholunate ligament. Although
a transverse incision is commonly used for esthetic reasons, a longitudinal incision
is easier to extend if needed and the cutaneous nerves are more easily dissected be-
cause they lie parallel to the incision rather than perpendicular.
SURGICAL TECHNIQUE
Dorsal Wrist Ganglion Cyst
The surgical incision (transverse or longitudinal) is carried down to the cyst, which
usually lies beneath the fourth dorsal compartment. Dissection is carried along the
cyst wall and the stalk of the cyst is traced to the level of the joint, which is nor-
mally the scapholunate joint for dorsal wrist ganglions, and a portion of the capsule
removed at the base with the stalk. In surgery for recurrent ganglions, the scar tis-
sue often makes it dif cult to be sure exactly where the stalk extends. If the stalk is
lost, it is best to take out a small section of dorsal capsule directly over the scapho-
lunate interval. Extensive dissection between the scaphoid and lunate bones should
be avoided, since this might disrupt the interosseous membrane and lead to poten-
tial wrist instability. In spite of the dissection over the scapholunate joint capsule,
scapholunate disassociation following ganglionectomy is quite rare.
Volar Wrist Ganglion Cyst
Volar ganglia usually lay between the exor carpi radialis and rst dorsal compart-
ment tendons. Again, a transverse incision provides a less conspicuous scar, and a
longitudinal incision facilitates dissection. After opening the volar antebrachial fas-
cia, the radial artery adhering to the cyst must be dissected free throughout the
length of the cyst and the artery preserved.The ganglion cyst is then traced to the
level of the joint capsule.The stalk for the volar ganglion normally extends either
to the radioscaphoid joint or scaphotrapezial joint. The most common location is
the radioscaphoid joint, and a small section of capsule over the radioscaphoid joint
should be removed with the stalk. Great care must be taken when removing palmar
capsule, because the most substantial wrist ligaments are on the palmar side;disrup-
tion can lead to wrist instability if too much capsule is excised.
1913
Chapter 46
Reoperative Hand Surgery

1914
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
POSTOPERATIVE CARE
The wrist is splinted for 3 weeks. Normally, the patient has full range of motion by
4 weeks postoperatively. If not, an Oppenheimer splint alternating wrist exion
and extension may be added along with a hand therapy program, and full range of
motion should be attained.
COMPLICATIONS
Recurrent ganglia may occur because of the dif culty in tracing the stalk to the ap-
propriate joint level; if the entire stalk and its joint capsule base are not excised, a
recurrence will likely develop. Pain may be a complication of dorsal ganglionec-
tomy as a result of neuroma in the posterior interosseous nerve, especially with
wrist motion. The terminal branch of the posterior interosseous nerve, which in-
nervates the dorsal wrist capsule, is in the area of capsular resection for dorsal gan-
glia, and may be injured. If the patient has point tenderness at the level of the ra-
dial carpal joint dorsally after ganglionectomy, whether or not a ganglion has
recurred, a posterior interosseous neuroma must be suspected of causing the pain.
Temporary relief from anesthetic injection of the nerve may encourage surgery.
The treatment for this is to simply resect the posterior interosseous nerve about
2.5 cm proximal to the level of the radiocarpal joint.This places the new neuroma
in an area where no traction is placed on it when the wrist is exed and extended.
CARPAL BOSS SYNDROME
Dorsal wrist ganglions may be confused by and associated with carpal bosses. A
carpal boss is a congenital rest or prominence that develops at the base of the sec-
ond and/or third carpometacarpal joints. It is a rm, bony, nonmobile mass that is
likely to be bilateral, and at a glance may appear to be a ganglion cyst, especially
when the wrist is exed. Furthermore, ganglion cysts arise from carpal boss in 30%
of cases.131 The carpal boss characteristically becomes symptomatic in the dominant
hand rst as a result of osteoarthritic change in the elevated spur, and causes more
discomfort than is characteristic of a ganglion cyst. Relief from symptoms requires

resection of the spur with a rongeur or osteotome until only normal cartilage sur-
faces are seen at the joint. This is usually well below the level of carpometacarpal
joint surfaces. Less resection will not provide pain relief.
1915
Chapter 46
Reoperative Hand Surgery
A characteristic beaklike appearance is present on oblique view of the CMC joint
with a pen on the mass; this is the structure to be excised.
Resection of the associated ganglion cyst only down to the carpal boss level will re-
sult in prompt ganglion recurrence and will not relieve the pain.Thus the surgeon
should perform a dorsal ganglionectomy that leads to the carpometacarpal joint
(rather than the wrist carpal joint) and excise the bony mass at the stalk until a
healthy cartilaginous joint surface level is achieved. Unfortunately, often the relief
lasts only a few years, with the prominence and symptoms recurring, requiring re-
peat similar surgery.
FLEXOR TENDON REPAIR AND STAGED
GRAFTING
Tendon adhesions occur whenever the surface of the tendon is violated, either from
traumatic injury or by surgical manipulation, such as puncture by a forceps or nee-
dle.132-135 Amadio136 noted that increased brosis and contracture following exor
tendon surgery can also result from sacri ce of vincula, which results in devascu-
larization of the tendon. Kleinert et al137 reported that staged exor tendon recon-
struction is needed when extensive adhesions develop, as in crush injury, nearby
fracture, skin loss or damage, previous operations, healed infections, joint contrac-
tures, and destruction of critical pulleys. Excision of the exor digitorum sublimis
tendons at the PIP joint can also lead to adhesions on the exor digitorum profun-
dus, which diminishes tendon healing and gliding because of loss of an important
gliding surface for the profundus tendon and loss of the vinculum longus to the
profundus tendon, decreasing the tendon’s vascularity and therefore increasing -
brosis.

1916
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
In addition to the conditions just discussed, primary flexor tendon grafting or
staged grafting may be necessary following tendon rupture. A repaired tendon is
also more likely to rupture when only one of the two exor tendons is repaired.136
If a ruptured exor tendon repair is identi ed and treated within the rst 2 weeks,
it can often be repaired again without grafting. However, with time, shortening of
the proximal tendon and muscle unit occurs, and the tendons cannot be advanced
enough for delayed primary repair. If the profundus tendon ruptures off the inser-
tion on the base of the distal phalanx, it is sometimes possible to advance the exor
tendon to make a primary repair even as late as 6 weeks after rupture. The index
exor digitorum profundus is more independent than the other profundus ten-
dons and may often be advanced as much as 1.5 cm, while the remaining profundi
usually tolerate only 1 cm advance without causing a exion contracture.
PATIENT EVALUATION
Supple joints and skin are prerequisites for exor tendon grafting. The maximum
range of motion must be attained preoperatively by splinting and passive exercises.
If motion cannot be obtained by splinting, then capsular releases may be indicated
as a preliminary surgery to exor tendon reconstruction. Capsulectomies can be
performed simultaneously with the insertion of the first-stage tendon rod. The
scars from previous surgery and injury must be supple and mature before grafting
so that passive motion is maintained in the rst stage of the tendon grafting.
A contraindication to exor tendon reconstruction is either damage to both digi-
tal arteries or both digital nerves in the same nger. Patients with insensate ngers
make very limited gains in motion postoperatively, and the results are usually dis-
mal.138-140 Nerve repair and sensory recovery should precede the exor tendon re-
construction.Wilson139 stated that the greatest prognostic indicator for exor tendon
grafting is the patient’s age. The best results are obtained in patients between the
ages of 10 and 30 years. Staged tendon grafting in children usually should not be
done until the child is at least 7 years old, and can cooperate with rehabilitation.141-144
Other factors that portend a poorer prognosis after exor tendon grafting include
crush injury to the local soft tissues, adjacent fracture or joint injury, skin loss, in-
fection, nonunited fracture, previous surgeries and a joint contracture.138-140
Single nerve involvement in a digit and simultaneous pulley reconstruction seem to
have no effect on the results of exor tendon reconstruction.139 Most surgeons be-
lieve that the poorest results occur in zones I and II, whereas those outside the
broosseous tunnel do better.138-141 Amadio et al141 found that the best results have
been obtained in zones III and IV when all postoperative therapy is under the di-
rect supervision of the treating surgeon.

If a patient does not have good prognostic indicators preoperatively, alternatives to
exor tendon grafting must be sought. Patients who have not regained passive mo-
tion, fracture stability, and sensibility preoperatively, as well as those patients who
cannot cooperate with a strict therapy regimen and those who do not have supple
skin coverage, should not undergo exor tendon grafting. In these patients, either
arthrodesis or amputation may be a better alternative.138
STAGE I R EPAIR
Surgical Technique for Staged Tendon Grafting
The Bruner zigzag incision is particularly useful when exor pulleys need to be re-
constructed, but a mid lateral incision has the advantage of less scar adherence to the
tendons, although less visibility if pulleys are needed. The incision extends from
the pulp of the nger to the mid palmar level, leaving the carpal tunnel region in-
tact. A separate incision is made over the palmar aspect of the distal forearm, begin-
ning at the wrist exion crease and proceeding proximally approximately 4 to 5 cm.
The pulley system is identi ed and any remaining intact pulleys are preserved, par-
ticularly the A1, A2, and A4 pulleys.
Any remnants of the exor profundus tendon are removed from the broosseous
tunnel and a 0. 75 cm stump of profundus tendon is preserved at its insertion site.
In an adult, a size 3 Hunter rod is usually needed for the little nger, and size 4 rods
are used for the other digits, but this varies with hand size. Kleinert et al137 found
that a rod that is too large will stretch the pulleys and contribute to bow-stringing.
Also, a large rod or pulley that is too tight will cause the rod to buckle because it
cannot glide beneath the pulley system with passive exion of the nger.145 Beyond
the remaining stump of profundus tendon, the Silastic rod is xed distally with a
wire suture or nonabsorbable mono lament suture to periosteum on either side of
the base of the distal phalanx, and the stump of profundus tendon is sutured over
the rod. The rod is passed through the remaining pulley system and then through
the carpal tunnel, which can easily be done using a pediatric catheter. The pass
through the carpal tunnel is normally made deep to the profundus tendons. With
the nger in full extension and the rod attached distally, the excess length of the
Silastic rod is cut about 3 to 5 cm proximal to the wrist. Finger dissection is then
used to enlarge a space in the forearm deep to the profundus tendons to make a
tunnel in which the rod can glide when the digit is exed.The operative nger is
then taken through a passive range of motion to ensure no buckling of the rod.
Buckling would indicate that the proximal tunnel is not large enough in the distal
forearm, or a pulley is too tight and not allowing the rod to glide, or the pulley sys-
tem is insuf cient. If any of these factors are present, they must be corrected. A
large suture (No. 2 Mersilene or Tevdek) is attached to the disrupted profundus
tendon that can serve as a marker to reduce the dissection that will need to be
done at stage II surgery.The skin is closed and the patient is placed in a bulky hand
wrap. Because of the risk of infection, perioperative antibiotics are given for 48
hours.
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PART VI
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Pulley Reconstruction
When pulley reconstruction is done at the time of one-stage tendon grafting, ad-
hesions usually develop during the immobilization interval and can cause dismal re-
sults.Therefore, when pulley reconstruction is necessary, it is preferred to proceed
with staged tendon grafting and reconstruct the pulley system over a Silastic rod.
The intraoperative view shown above demonstrates a tendon pulley graft encir-
cled around the phalanx.
At least two pulleys (A2 and A4) must be retained or reconstructed146-150; Schnei-
der and Hunter138 recommend a minimum of three pulleys. Others suggest that
even a four- or ve-pulley system provides increased ef ciency.141,149,151,152 When
reconstructing pulleys for the thumb, a minimum of two pulleys is required. If fewer
than two or three pulleys are present, bowstringing will usually develop in the
exor tendon, displacing it more palmarward, thus increasing the exor force at
the joint level and leading to a diminished range of motion, and ultimately a xed
exion contracture.137-139,153 Basically, any area of destroyed pulley system greater
than 1.5 cm in length should be reconstructed from the DIP joint to the level of
the distal palmar crease.
There are numerous methods of pulley reconstruction.138 Many surgeons use a
piece of exor tendon or palmaris longus. A sublimis tendon graft is quite broad but
may be split in half or into thirds for a more appropriate working size. A favorite
choice (W.H.M.) when only one or two pulleys are needed is from the extensor
retinaculum, which provides an excellent gliding surface on the side that was adja-
cent to the extensor tendon; however, care must be taken to preserve a narrow in-
tact donor portion to avoid extensor tendon wrist bowstringing.

This view shows the tendon interwoven in a running shoelace fashion through
remnants of the broosseous tunnel.
Postoperative Care
The bulky dressing is usually removed in the recovery room and a light dressing is
applied to the involved digits and hand.The wrist is supported with a splint and a
continuous passive motion unit is applied.The patient is usually more comfortable
if a long-acting regional block has been given either before the surgery or before
the initiation of passive motion. The patient should wear the continuous passive
motion unit at night during sleep for 1 week, or the patient can be committed to
a vigorous early hand therapy program without need for the continuous passive
motion device. During the day, the involved joints and ngers are periodically taken
through a passive range of motion and the patient should spend 5 minutes per hour
doing the exercises. If adjacent ngers have normal exor tendons and motion, the
involved nger can often be buddy-taped to an adjacent digit and thereby get a
more continuous passive motion pull. If the pulley system has been reconstructed,
the area is protected with either a Coban wrap or thermoplastic ring. Scar massage
and softening techniques are instituted after the sutures are removed, along with
more intense passive range of motion exercises. At this time, dynamic splints are ap-
plied if needed for any joint contractures.
Complications
Synovitis is the most common complication of Silastic rod placement, occurring in
15% to 20% of patients.153-155 The patient will present with warmth over the in-
volved digits, crepitus with passive motion, increased swelling, and often uid in the
pseudosheath.There is still some debate over whether synovitis in uences the end
results of tendon grafting, but most practitioners feel that it will lead to a poorer re-
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PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
sult following stage II surgery.138,152,153,156 Schneider and Hunter138 found that a
thickened and less pliable sheath occurred after the stage II procedure if synovitis
was present after the stage I operation.
The implant should not be handled with gloves during insertion and should be
kept in saline solution to prevent the accumulation of talc, lint and dust, which
could lead to synovitis.137,154 Other possible causes of synovitis include breakdown
of the distal juncturae with detachment of the rod and buckling of the implant
secondary to inadequate or tight pulleys.138 When synovitis occurs after stage I
exor tendon grafting, the nger needs to be placed in a resting splint and the pas-
sive motion exercise program reduced. If the synovitis does not subside, then stage
II procedures should be performed at an earlier date than planned.
Wehbe et al155 found that infection occurs in 5% to 6% of implants. Initially, antibi-
otic therapy should be instituted and the nger drained, irrigated, and immobi-
lized. If no improvement is seen within several days, the rod must be removed
(which is usually the case). The rod can be replaced with a new implant a few
months after the infection has cleared, preserving passive motion in the interval.
Skin erosion usually occurs over the distal juncture of a rod when it does not glide
smoothly, either because of inadequate or too tight pulleys, and the rod buckles.
Also, erosion over the rod can result when the skin is damaged and does not pro-
vide adequate coverage. Hunter and Salisbury151 and Bora157 have found skin ero-
sion over the rod to be quite common in the insensate nger. If the distal juncture
of the rod is placed deep to the stump of the profundus tendon, the problem of skin
erosion is reduced. If erosion does occur, motion exercises of the nger should be
delayed and the patient placed on antibiotics until skin healing occurs or the rod is
removed.
One further complication during stage I is migration of the rod. This usually oc-
curs when an inadequate distal xation ruptures, forming an inadequate pseudo-
sheath.This problem can be corrected by reattaching the distal juncture of the rod.
A lateral radiograph of the distal forearm with the nger rst in full extension and
then full exion will usually show the tip of the rod. If the rod is gliding with the
nger, then it is still attached distally.
STAGE II R EPAIR
Surgical Technique
Stage II surgery should not be performed any sooner than 6 to 8 weeks after stage
I surgery. If the patient has not attained passive range of motion equal to that pres-
ent before the stage I surgery, or if the scar from the stage I surgery is still thickened
and indurated, stage II surgery should be delayed until passive motion and mature
scar have been achieved.

A tourniquet is again used, and the old incision opened distally over the DIP joint.
The stump of profundus tendon is identi ed and elevated off the rod.The rod is left
in place at this time, sutured to the periosteum. Passive exion of the involved n-
ger should enable the surgeon to feel the underlying Silastic rod in the distal fore-
arm as it glides.The pseudosheath around the rod is then opened and the tip of the
rod is identi ed.
At this point, a graft is harvested from the palmaris longus, plantaris, toe extensors,
or extensor indicis proprius tendons. Unless the tendon graft is being used for a
thumb, the palmaris longus is usually not long enough to reach from the distal pha-
lanx to the distal forearm, replacing a profundus tendon. Strickland158 reported no
difference among the different donor tendons as far as ultimate results. However, the
plantaris tendon may be absent and varies in size but is an excellent choice most of
the time; otherwise, a toe extensor tendon is preferred. The tendon graft may be
harvested by making multiple small incisions and dissecting subcutaneously be-
neath the incision to release the tendon, or the tendon can be removed with a ten-
don stripper. Controversy exists as to whether the peritenon should be left with the
graft, because it is unknown whether the peritenon will facilitate gliding or lead to
increased adhesions.159-166
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Chapter 46
Reoperative Hand Surgery
The tendon graft is sutured end-to-end to the proximal end of the Silastic rod in
a fashion similar to a tendon repair. The intraoperative view above shows the dis-
tal end of the Silastic rod being released from its attachment on the distal phalanx
and being pulled through the sheath, bringing the tendon graft with it. The distal
edge of the tendon graft is freshened and a pullout suture placed.163,167,168 A 4-0
permanent suture on a small needle works well, but wire suture or nylon may also
be used. Next, the periosteum over the base of the distal phalanx on the palmar sur-
face beneath the profundus stump insertion is roughened with a curette so good
tendon graft-to-bone contact can be obtained for favorable dense scar.The tendon
suture is either brought through drill-holes in the distal phalanx or may be brought
out through the pulp or dorsum of the nger by going around the distal phalanx.
One of the easiest choices is to pass this directly through the prepared segment of

1922
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
the distal phalanx and ngernail so that the button is sutured to the nail and a Keith
needle using a Bunnell hand drill can facilitate this maneuver. The tendon suture
is pulled snug over a pullout button, and under visualization the tendon graft is
pulled up into the roughened area of the bone. The suture is tied over the button
and the distal skin incision on the nger is closed. Attention is now turned back to
the wrist, where traction on the tendon graft is applied to ensure the suture has
holding power, and to con rm that the pulley system does not impinge on the
graft. The large Tevdek or Mersilene suture previously used for marking the mo-
tor exor tendon is identi ed at the level of the wrist, and that tendon freed from
surrounding tendons.The proximal edge of the tendon graft is woven through the
motor tendon in a Pulvertaft weave,167,168-170 and after the rst weave is performed
tension adjusted before suturing, placing the involved digit in slightly more exion
than the adjacent ones while securing the proximal weave. Dif culty in attaining
full active exion is more common than a exion contracture after staged exor
tendon grafting. Therefore, a finger with a slight flexion contracture is less of a
functional problem than a finger with inadequate flexion. The wrist wound is
closed and a sterile bulky dressing and plaster splint are applied.The wrist is exed
approximately 30 degrees in the dressing, with the MP joints in 70 to 80 degrees
of exion and the IP joints extended.
Amadio et al141 and Rowland171 have found no difference between grafts that extend
into the mid palmar region versus those that extend to the distal forearm region. In
the rare instance in which the palm is uninjured by trauma, a shorter graft may be
used and motored by the profundus tendon at the origin of the lumbrical muscle.
Amadio et al141 also report no difference in results between a exor digitorum sub-
limis versus a profundus motor at the distal forearm level. If a profundus graft rup-
tures and is too tight to readvance distally, the distal tendon may be inserted into the
middle phalanx rather than the distal phalanx, thus creating a sublimis nger.164,172,174
In the thumb, the stage II procedure can be done with a free tendon graft, but
Schneider and Wiltshire175 report that transferring a sublimis tendon through the
pseudosheath at the stage II surgery provides stronger, earlier healing because it is
not necessary to await revascularization of a tendon graft. Also, simple arthrodesis
of the thumb interphalangeal joint may be preferable to staged tendon grafting for
exor pollicis longus replacement in some patients.138
Postoperative Care
Two schools of thought exist regarding postoperative management of exor tendon
grafts. One belief holds that grafted tissue should be immobilized until it can estab-
lish a blood supply from surrounding tissues and synovial nutrition (approximately
4 to 6 weeks), and the other belief is that tendon grafts should be managed in a sim-
ilar fashion as primary tendon repair with early passive motion to prevent adhe-
sions. Both management methods have their advocates and reported successes.
Masear176 showed that early passive mobilization did not signi cantly in uence the
nal outcome. Those who prefer immediate motion (V.R.M.) have the patients

seen by the hand therapist on the rst or second postoperative day, and a hook
glued to the ngernail is attached to a rubber band, and the nger is pulled into
exion with Kleinert-type traction. Lister et al177 recommend blocking nger ex-
tension at the MP joint level at 60 to 70 degrees, and holding the wrist in 30 de-
grees of exion. Tension is adjusted to obtain maximum exion of the digits but
preserve active extension, which is encouraged and maintained.
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Chapter 46
Reoperative Hand Surgery
A Duran-Kleinert type splint is used to provide rubber band passive exion and ac-
tive extension and mobile joints.
To increase PIP joint exion, the patient can be tted with a sling with a rubber
band going beneath an arti cial pulley at the distal palmar area to give greater pas-
sive PIP and DIP joint exion, and improve total active motion.177,178 The patient
should perform active extension exercises within the splint (i.e., attempt to touch
the extension block) and passive exion exercises 10 times per hour. Splinting re-
mains unchanged until the fourth postoperative week when the wrist is brought
into a neutral position; the patient should then add 5 to 10 exercises for passive
exion with active hold to the hourly exercise regimen. Five weeks after surgery
the dorsal extension block splint is removed, but the dynamic traction is continued
for another week. Ten weeks after surgery dynamic extension splinting is used if
needed to correct any exion contractures and passive exercises for extension are
added. Resistive exercises are not usually begun until 16 weeks after surgery, when
passive stretching exercises with simultaneous wrist and nger extension are added.
Before that, all passive stretching exercises are done one joint at a time. By 18
weeks, heavy resistive exercises and grip strengthening can be added. However, the
therapy program should be modi ed according to each patient’s needs. For exam-
ple, if a patient recovers full active motion within 7 to 8 weeks after surgery, he is
at risk for rupture and needs to be protected from forceful exion. If motion is
limited passively, earlier dynamic splinting is needed because rupture is unlikely
until gliding and joint mobility can be restored. Those who prefer to immobilize
and protect tendon grafts for 4 to 6 weeks (W.H.M.) institute a similar hand ther-
apy program after the protected interval.

1924
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
Complications
Kleinert et al137 and Wehbe et al155 have found that adhesions leading to limited
passive extension and exor lag are the most common complication following stage
II exor tendon grafting. Hunter and Salisbury151 reported that most adhesions oc-
curred between the grafts and pseudosheath, rather than at the proximal tendon
juncture. A common problem is adhesions between the graft and exor digitorum
sublimis,137,179,182 resulting in exion contracture of the nger and exor lag. Arti-
cial membranes, such as cellophane, silicone rubber sheeting, polyethylene lm,
gelatin sponge, amniotic membrane, fascia, peritenon, and tunica vaginalis have
been used to prevent recurrence of adhesions,183-188 with dubious bene t.
Amadio et al141 and Strickland158 report that graft rupture occurs in 4% to 7% of
cases, usually within the rst 2 months after surgery. Kleinert et al137 have found that
low-grade infections and uneven protruding bone surfaces can also result in graft
rupture. When distal ruptures occur, they are usually about 1 cm proximal to the
point of bony attachment, implying inadequate revascularization as a cause. Early
reoperation can often salvage the distal rupture.
Flexion contractures are common after staged tendon grafting,138,139,153,155 especially
when the nger rests in a position with PIP exion such as in a dynamic splint
without an adequate extension program. Improper length of the tendon graft will
cause diminished motion. A graft that is too short will prevent full extension and
cause exion contracture. A graft that is too long will lead to exor lag; also, the
profundus tendon may retract into the palm, putting increased tension on the lum-
brical muscle and thereby lead to a lumbrical plus deformity.When this occurs and
exion is attempted, the profundus tendon will glide proximally, thus putting more
tension on the lumbrical muscle, leading to a paradoxical extension of the IP joint,
most commonly seen in the middle nger.192
If the tendon graft is placed with too much tension, a exion contracture or even
quadregia may develop.This complication is more likely in the middle through lit-
tle ngers because the index profundus is more independent. Quadregia develops
when any of the long through little finger profundus tendons are attached to a graft
that is too short; when the common profundus tendon pulls distally the proximal
excursion is limited with greatest tension on the grafted tendon, causing a exor lag
to occur in the uninvolved ngers (quadregia) when the common muscle con-
tracts.
Pulley breakdown can occur after staged tendon grafting if the pulleys are not prop-
erly protected with blocking or external rings for 2 months after reconstruction.
When bow-stringing occurs from pulley rupture or stretching, the pulleys must
await repeat reconstruction until digital range of motion has plateaued. The best
time to reconstruct the pulleys is when the Silastic rods are implanted.