Outcomes of Combined Tenolysis and Proximal Interphalangeal Joint Capsulotomy
Kevin Zuo, MD; University of Toronto, Toronto, ON, Canada; Paul A. Binhammer, MD, MSc, FRCSC; Division of Plastic Surgery Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada; Herb von Schroeder, MD, MSc, FRCSC; Hand and Upper Extremity Program, University of Toronto, Toronto, ON, Canada
Tendon adhesions and capsular contractures of the proximal interphalangeal joint (PIPJ) are frequent complications of hand trauma that restrict motion and significantly reduce hand function. Management traditionally consists of prioritizing restoration of passive range of motion (PROM) through intensive hand therapy and, if necessary, surgical joint release or capsulotomy. If functional deficits persist due to restricted active range of motion (AROM), tenolysis may be performed in a second operation. This staged approach utilizes extensive hospital resources and is burdensome for the patient, prolonging rehabilitation and resulting in lost economic productivity. Our objective was to evaluate functional outcomes of single stage combined tenolysis and capsulotomy in patients with PIPJ flexion contractures and restricted tendon gliding despite vigorous hand therapy.
Materials and Methods
A retrospective chart review was performed for patients who underwent combined tenolysis and PIPJ capsulotomy from 2010-2016. Replantation and tendon graft cases were excluded. All surgical procedures were performed by the senior author under sedation and peripheral nerve block. Data was collected on patient demographics, injury mechanism, initial surgical intervention, therapy regimen, and pre- and post-operative outcome measures including range of motion (ROM), tip to distal palmar crease (DPC), and grip strength.
Twelve patients (9M:3F) of mean age 40.4 years (range 28-60 years) presented with functionally disabling PIPJ flexion contractures and impaired tendon gliding following crush (9 patients), laceration (2 patients), or dog bite (1 patient) injuries. Ten patients initially required fracture fixation, 3 required extensor tendon repair, and 1 required flexor tendon repair. A total of 15 PIPJs underwent single stage PIPJ capsulotomy with pulley preserving flexor tenolysis only (5 digits) or both flexor and extensor tenolysis (10 digits) a mean 12.9 months post-injury. Hand therapy was initiated within 1 week of surgery. At mean follow up of 4.4 months (range 2.1-9.3 months), there was improvement in mean AROM from 17° to 63°, total active motion from 109° to 203°, tip to DPC from 5.9 cm to 2.5 cm, and grip strength of the affected hand from 38% to 61% of the unaffected hand. Modified Strickland score was good in 46% of digits and excellent in 38%. There were no tendon ruptures, surgical site infections, or devascularized digits.
PIPJ stiffness and flexion contractures are exceptionally challenging to treat following hand trauma. Although a complete return to premorbid ROM and function is rarely attained, good outcomes may be consistently achieved with concurrent PIPJ capsulotomy and tenolysis.
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