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American Association for Hand Surgery

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Reconstruction of the Radial Sagittal Band Using a Palmaris Longus Tendon Graft Reconstruction in the Rheumatoid Hand
Danielle Thornburg, MD1, Victoria Aime, MD1, Bryn Morris, MD2, Lyndsay A Kandi, BS1 and Anthony Smith, MD3, (1)Mayo Clinic, Phoenix, AZ, (2)Mayo Clinic Arizona, Phoenix, AZ, (3)Plastic and Reconstructive Surgery, Mayo Clinic Arizona, Phoenix, AZ

Introduction
Sagittal band injury can be caused by an acute traumatic event or can occur as a chronic process in patients with underlying inflammatory conditions, such as rheumatoid arthritis (RA). Although acute rupture in non-rheumatoid patients can be selectively treated with splinting, indolent attenuation and rupture requires surgical repair. Although medical management has become the mainstay of treatment for RA, radial sagittal band attenuation or rupture is an indication for surgical intervention in the rheumatoid patient as it leads to destabilization of the metacarpophalangeal joint (MCP) and ulnar drift. Previous techniques utilize part of the extensor tendon to repair the radial sagittal band, although can result in extensor lag. An alternative technique was sought to repair the radial sagittal band without increasing risk of extensor lag. The aim of this study was to describe the senior author's technique for reconstruction of the radial sagittal band in rheumatoid hand patients presenting with extensor tendon subluxation using a free tendon graft harvested to craft a sling.
Methods
A retrospective chart review was performed using the electronic health record system to identify patients of the senior author that had a diagnosis of RA and underwent surgical repair of their radial sagittal band. Identified patients and their outcomes following surgery were reviewed.
Results
RA patients presenting to the hand surgery clinic with ulnar deviation of their MCP joints and extensor lag were assessed clinically for radial sagittal band attenuation or rupture by their ability to hold their MCP in extension if passively extended. X-rays and confirmatory MRI were obtained. These patients were offered surgical repair. The technique included harvesting the palmaris longus (PL) tendon and fashioning a sling to re-establish MCP joint stabilization. The free tendon graft was woven through the remnant radial collateral ligament and secured. Employing a Pulvertaft-type weave, the free PL tendon was woven into the extensor mechanism to recreate the radial sagittal band, maintaining the extensor mechanism directly over the metacarpal head throughout a complete passive arc of motion. Seven patients met inclusion criteria and their clinical courses were reviewed in detail. Patients treated with this technique had successful repair of their affected radial sagittal bands and went on to heal without major complications.
Conclusions
Herein, we present an alternative surgical technique for repair of the attenuated or ruptured radial sagittal band in the rheumatoid hand patient utilizing a PL tendon graft as a sling to restabilize the MCP joint.


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