//

PIPJ release little finger – Partial anterior teno-arthrolysis (PATA)

    Overview

    Learn the PIPJ release little finger – Partial anterior teno-arthrolysis (PATA) surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the PIPJ release little finger – Partial anterior teno-arthrolysis (PATA) surgical procedure.
    This is a step by step operative instruction for the volar release of the proximal inter-phalangeal joint (PIPJ) using the partial anterior teno-arthrolysis (PATA) method.
    The total anterior teno-artholysis (TATA) for combined distal inter-phalangeal joint (DIPJ) and PIPJ contracture releases was first described by Mr P. Saffar, a French surgeon from the Institue de la main in Paris in 1978. The PATA is a similar procedure used for release of the PIPJ alone.
    The procedure can be used in a number of pathologies including PIPJ trauma, volar plate injury, Dupuytren’s contracture, spasticity and post-operative contracture or post chronic regional pain syndrome contracture. As long as the articular surface of the joint is thought to be sound then this method may be applicable.
    As with all surgeries of the PIPJ the release is likely to get the joint fully straight intra-operatively however, due to a combination of post-operative scarring and a poorly functioning extensor mechanism after prolonged stretching and dysfunction, the release often results in around a 50% improvement of deformity once the patient has fully recovered.
    Following surgery the patient is placed in a volar plaster for a week and then a night extension splint and hand therapy following that. The splint maintains the extension while the finger is healing but also allows the extensor to tighten up to improve function. Final results are likely to present at 3-6months.
    Compared to a joint arthrodesis, this technique and other joint release procedures, aims to maintain flexion at the PIPJ. A well positioned arthrodesis will allow the flexed finger out of the palm, which can itself be quite debilitating. The resulting lack of active flexion however, particularly in the case of the gripping fingers, little and ring, results in their main function of a tight grip being lost.

    P Saffar, J P Rengeval. Total Anterior Tenoarthrolysis. Treatment of the Bent Fingers. Ann. Chir. Nov 1978;32(9):579-82.


    Indications

    Indications
    This procedure is best indicated to treat a painless fixed PIPJ contracture of a soft tissue nature with normal PIPJ bone and cartilage and active flexion and extension within the limited range. This can be following a soft tissue injury such as a PIPJ volar plate avulsion or after skin contracture for burns, Dupuytren’s or after neurological insults (CVA).
    Symptoms
    Limited function due to fixed flexion deformity of a finger at the PIPJ. This method may also be used for a soft tissue distal inter-phalangeal joint (DIPJ) contracture or combined contractures (a total anterior ten-arthrolysis – TATA).
    The flexed or contracted position of the finger can be very inconvenient. Patients complain of fingers remaining caught around door handles, poking themselves in the eye when washing their face, making hand shaking and glove wearing difficult and interfering with work to a lesser or greater extent depending on occupation.
    Examination
    The examination should measure the angle of deformity with a goniometer both active and passive, flexion and extension.
    The active ability of the flexors and extensors should be assessed as they need to be competent for a successful outcome. If the tendons are not functional then the result will be poor, particularly in the case of extensor tendons which can be stretched if the contracture is long standing and the tendon attenuated. If the flexors are poor then a PIPJ fusion may be advised as the main advantage of the release over fusion is maintained joint flexion.
    The neuro-vascular status of the finger needs to be assessed and an Allen’s test of the finger is useful where previous surgery has been performed. A digital Allen’s test is performed by gripping the finger over its length, effectively exsanguinating it with one hand, and using the other to press over the radial and ulnar digital arteries. The gripping hand is removed and then one finger over the radial digital artery is removed and the finger observed for pinking up. The test is repeated releasing the ulnar digital artery this time. If both arteries are intact then the finger will pink when each single vessel is released while the other is still occlude. If not it shows the released vessel is non-functional.
    Patients with slender, normally supply fingers and those who will be compliant with splinting and exercises with achieve better outcomes.
    Soft tissue causes for joint contracture are best treated with this release however if Dupuytren’s or skin scar is an issue then they must also be address at the same time as the release to remove the deforming force.
    Investigations
    Radiographs of the PIPJ in PA and lateral are performed to assess the joint. The PA may be of little use due to the flexed position of the contracted finger. CT and MRI are not routinely used however old radiographs of the digit following initial injury (if that was the underlying cause of the contracture) may be useful.
    In cases of previous surgery, especially on the flexor tendons, and USS may be useful also to assess tendon glide. If there is no tendon glide then the operation with not be successful and an arthrodesis of the PIPJ may be advised.
    Non-operative Management
    Serial casting or splinting may improve fixed flexion deformity in the PIPJ although the more chronic deformities may have a poorer response.
    Alternative operative Management.
    Alternative surgical procedures for PIPJ contracture include volar plate and check reign ligament and accessory collateral direct release or dynamic external fixation.
    The sequential release of the volar plate and check reign ligament and accessory collateral is a more limited version of a joint release which will cause less scarring post-operatively and may be adequate in moderate contractures but in more severe contractures is often not sufficient to achieve the desired correction.
    An external fixation device can also be used however this is often as an adjunct to a limited joint release to overcome the initial marked contracture and therefore requires two operations – one to site the fixator which is gradually distracted by the patient and then one to remove the fixator and release the soft tissues.
    Alternative surgeries which would not resolve the deformity but may improve function if the severity of contracture is getting in the way are PIPJ arthrodesis or amputation.
    PIPJ arthrodesis is vey functional in the index and middle finger which are more used for pinch and more restrictive in the little and ring used for gripping. This will also be affected by a patients occupation and hobbies.
    Similarly an amputation of the index and little can be accommodated very well whereas it can be very inconvenient in a central digit as it leave a gap in the hand.
    The choice of surgery therefore does depend on the cause of the contracture, the digit affected and the patient demands.
    Contraindications.
    Absolute
    PIPJ arthritis or joint deformity.
    Relative
    PIPJ pain – a neurectomy of the PIPJ can be performed in conjunction with this surgery if required.
    Flexor tendon adhesions – a flexor tenolysis can be performed in conjunction with this surgery if required.
    Reduced nerve function of the digit either of sensation which may mean post operative function is still limited or motor function which may create an element of clawing which will clearly not be resolved by the surgery however if the aim is only to change the arc of movement then this operation can still be useful in tetraplegia or spasticity patients relying on tenodesis effects.

    Setup

    Pre-operative preparations and Equipment
    The procedure can be performed under local anaesthetic with or without adrenaline, regional anaesthetic or general anaesthetic. If adrenaline is not used then a forearm or arm tourniquet inflated to 250mmHg is used for the duration of the procedure. A finger tourniquet will restrict surgical access and therefore is not used.
    The operation takes around 25mins to do safely.
    Skin hooks, a 15 blade, a beaver blade, a Watson cheyne elevator and tenotomy scissors are used for sharp and blunt dissection.
    Loupes magnification is used.
    The hand may be held flat by a lead hand or similar supporting device during the procedure.

    Operation

    The hand is placed in lead hand for surgical positioning.
    With the patient under regional or general anaesthetic the arm is prepped and draped and placed in a lead hand on the arm board.
    In this case the little finger can bee seen to be flexed to 60 degree at the PIPJ.
    The patient has normal DIPJ movement and full flexion of the PIPJ beyond the 60 degrees.

    The skin is incised using a volar placed Brunners incision A Brunner incision is marked over the proximal and middle phalanx. The markings extend from the mid-lateral point of the finger at a palmar crease and travel at 45 degrees between the finger creases forming laterally based triangular full thickness flaps.
    The skin and fat are elevated off the Grayson’s ligaments of the finger.

    The Brunner flap is elevated off the fat and flexor sheath.The scissors are pointing to the Grayson’s ligaments overlying the radial neurovascular bundle (NVB). These ligaments help compartmentalise the NVB’s to locate them laterally and provide a palmar boundary against which to glide during finger flexion. They also stabilise the skin over the digit.
    These ligaments travel from the flexor sheath to the skin providing palmar protection to the NVB.
    The NVB’s are normally located unless they have been moved by soft tissue masses such as Dupuytren’s cords and nodules when they may then be located more centrally.
    On the ulnar side these have already been cut whilst elevating the skin flap. They are cut centrally between the flexor sheath and the skin directly over the NVB. This is performed whilst under tension when the skin is being retracted which elevated them off the NVB slightly.

    The ulnar NVB is mobilised.The forceps are gently elevating the NVB in this picture whilst blunt dissection with forceps and scissors is performed down to the bone. This will reduce the possibility of damage to the NVB and transverse digital artery.
    The NVBs normally lie lateral to the flexor sheath and just anterior to the phalanx between Grayson’s (volar) and Cleland’s (dorsal) ligaments.

    The transverse digital artery is identified.The very small vessel travelling up South-East to North-West at the tip of the forceps is the transverse digital artery which is a branch of the digital artery which joins its counterpart from the other NVB to create the vinculae for flexor tendon supply.
    These branches are preserved.
    The radial NVB is shown at the top right of the wound.

    The junction of the periosteum and the flexor sheath is identified.Cleland’s ligaments span from the phalanx to the skin and are the dorsal protection and stabilising ligaments of the NVB.
    The scissors in the image are identifying the transverse digital artery, with the artery now lifted anteriorly. The vessel is very difficult to see and lies under the NVB in this picture.

    The elevation of the flexor sheath and periosteum begins on the neck of the proximal phalanx.The correct plane to elevate the soft tissues will leave the volar plate and flexor sheath anterior and the bone and true collateral ligament dorsal.
    This plane is located by palpating the neck of the proximal phalanx with the forceps 2mm dorsal to its anterior edge. The knife can then be used to cut down to bone and gradually work sub-periosteally until the volar aspect of the bone is found, elevating the periosteum and any ligaments volar-ward. It is a simple plane to find in this way. If started too dorsally then too much of the true collateral may be divided which is not intended.
    When the plane is found the periosteum and flexor sheath are elevated as one off the distal end of the proximal phalanx with a blade.
    A skin hook is place at the corner of the flexor sheath to aid elevation and create soft tissue tension.
    The forceps are in the elevated plane.

    A schematic demonstrating the plane of deep dissection. The periosteum and flexor sheath are elevated as one off the proximal phalanx and this plane is extended medio-laterally and distally.

    The volar plate and accessory collaterals are elevated.The sharp dissection is continued distally elevating the volar plate, dividing the accessory collateral and preserving the true collaterals of the joint. This dissection progresses to at least the midline of the phalanges and will expose the joint and cartilage therefore care has to be taken over the joint not to damage the cartilage.
    In this image the forceps are in the elevated plane at the level of the volar plate.
    VP – Volar plate
    MP- Middle phalanx
    PP- Proximal phalanx
    PIPJ- Proximal inter-phalangeal joint

    The dissection continues distally and will include the flexor digitorum superficialis insertion.In this case, with isolated PIPJ contracture, the dissection may stop midway along the middle phalanx.
    The forceps are within the dissection plane with the NVB and transverse digital artery volar to this.

    The dissection is progressed beyond the midline.A Beaver (double edged) blade is used to progress the dissection.
    Despite the joint being elevated over half its width the cartilage is not yet visible due to the flexed position of the joint.
    The blade is shown resting on the neck of the proximal phalanx.

    The ulnar side elevation is completed and the same process is repeated on from the radial side.

    A Watson Cheyne elevator is passed beneath the elevated tissue, and across the width of the digit, to check for a full release. It needs to be slid both proximally and distallyIn the tissue layer above the Watson-Cheyne elevator are both NVB’s, the flexor sheath (containing the flexor tendons ) and the PIPJ volar plate, which is continuous with the volar periosteum of the proximal and middle phalanges.
    RNVB – Radial neurovascular bundle
    FS- Flexor sheath

    The elevator slide distally which ensures that the release to the distal extent of the wound is complete. The FDS slips will have been elevated with the periosteum as part of the dissection and therefore should not stop the distal passage of the elevator.

    The elevator slid proximally and should pass easily. If one side of the release is incomplete then the elevator will not be able to move evenly along the bone. A further release will then be required on the side that the elevators passage is arrested.

    Correction of finger tested.Full correction achieved in this case.

    Wounds are closed with 4/0 vicryl rapide.The skin will usually stretch to accommodate the new extended finger however is there was a skin issue involved in the contracture such as burns, scar or Dupuytren’s then alternative skin incisions or techniques should be planned pre-operatively.
    Alternatives to consider are either a Z-plasty or full thickness skin grafting.

    Finger extension is assessed following skin closure.If this appears restricted now, the skin edges may need to be re-approximated under less tension.

    A non-adherent dressing and gauze is applied with a volar plaster slab in extension.The patient in this case improved their fixed flexion deformity at 3 months from 60 to 35 degrees with full flexion maintained.

    Post Operative

    The procedure is performed as a day case and the patients are discharged with a simple triangular sling to use for 24 hours.
    We provide paracetamol, codeine and ibuprofen on discharge.
    They return within a week for wound review and require splintage and regular hand therapy for the first 4 weeks.
    The wound is redressed with an adherent dressing and remains covered until 10 days when the patient can start to wash their hand as normal and the dissolvable sutures will fall out over the following few days.
    Patients are advised to mobilise their fingers once out of cast, massage the scar after 2 weeks and avoid tight gripping and lifting for 4-6 weeks.
    The a review at 6 months is booked to assess the final result and help resolve and continuing scar issues if present.
    It is normal to have a enlarged PIPJ as a final result following this surgery as is often seen with traumatic ligament injuries or dislocations which a reduced and regain function.

    Recommended Reading

    Complications of a PIPJ PATA procedure are neurovascular injury, infection, stiffness, tendon injury, skin necrosis, contracture recurrence or failure of improvement and new joint pain.
    Leti Acciaro A, Gabrieli R, Landi A. The total anterior tenoarthrolysis in the treatment of the stiffness in flexion of the fingers. Chir Organi Mov. 2009 Dec;93(3):163-9. doi: 10.1007/s12306-009-0036-0.
    The authors present results of 49 fingers in 16 patients with contractures for a mixture of pathologies from flexor tendon surgery, Dupuytren’s contracture and trauma to the digit or spinal cord trauma causing dysfunction. A mixture of TATA and PATA surgeries were performed and in severe cases a k-wire was inserted across the PIPJ for around 2 weeks. Over both joints the total extension deficit reduced on average by 90 degrees and the total active movement increase by 20 degrees. 80% of patients were satisfied with their outcome, 1 patient had a PIPJ fusion due to recurrence and one had dorsal skin necrosis requiring debridement surgery.
    Lorea P, Medina Henriquez J, Navarro R, Legaillard P, Foucher G. Anterior tenoarthrolysis for severe flexion contracture of the fingers (the “TATA” operation): a review of 50 cases.J Hand Surg Eur Vol. 2007 Apr;32(2):224-9.
    The authors present the results of total anterior teno-arthrolysis in 50 fingers with combined DIPJ and PIPJ contracutres. Three quarters of the patients had undergone previous surgeries on the finger and these were most commonly related to the flexor tendon surgery. The mean PIPJ flexion deformity was around 80 degrees and the DIPJ 50 degrees. The mean follow up was >7 years.
    At follow up 90% were improved and none were worse in the range of movement. The mean gain in extension was around 50 degrees in the PIPJ and 35 degrees in the DIPJ. There was a 2 % septic arthritis rate.

    The authors present results of 49 fingers in 16 patients with contractures for a mixture of pathologies from flexor tendon surgery, Dupuytren’s contracture and trauma to the digit or spinal cord trauma causing dysfunction. A mixture of TATA and PATA surgeries were performed and in severe cases a k-wire was inserted across the PIPJ for around 2 weeks. Over both joints the total extension deficit reduced on average by 90 degrees and the total active movement increase by 20 degrees. 80% of patients were satisfied with their outcome, 1 patient had a PIPJ fusion due to recurrence and one had dorsal skin necrosis requiring debridement surgery.
    Lorea P, Medina Henriquez J, Navarro R, Legaillard P, Foucher G. Anterior tenoarthrolysis for severe flexion contracture of the fingers (the “TATA” operation): a review of 50 cases.J Hand Surg Eur Vol. 2007 Apr;32(2):224-9.
    The authors present the results of total anterior teno-arthrolysis in 50 fingers with combined DIPJ and PIPJ contracutres. Three quarters of the patients had undergone previous surgeries on the finger and these were most commonly related to the flexor tendon surgery. The mean PIPJ flexion deformity was around 80 degrees and the DIPJ 50 degrees. The mean follow up was >7 years.
    At follow up 90% were improved and none were worse in the range of movement. The mean gain in extension was around 50 degrees in the PIPJ and 35 degrees in the DIPJ. There was a 2 % septic arthritis rate.

    Reference

    • orthoracle.com

    Tags:

    You might be interested in

    Dark mode powered by Night Eye