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Sagittal band reconstruction (Middle finger)

    Overview

    Learn the Sagittal band reconstruction (Middle finger) surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Sagittal band reconstruction (Middle finger) surgical procedure.
    This is a detailed step by step instruction through a Middle finger Sagittal band reconstruction using a central segment of the extensor apparatus to realign and hold the extensor tendon in place during metacarpo-phalangeal joint (MCPJ) flexion.
    It is performed through a dorsal midline approach.
    This method is a modification of that published by Charles Carroll in 1987 (see results section).
    This is a procedure performed when the sagittal band, usually the radial sided band, ruptures. This is most commonly as a result of inflammatory arthritis but may also be required in neglected traumatic ruptures where a primary repair is not possible.
    The procedure can be performed as a day case under regional or general anaesthetic and takes around 1 hour.
    Following a period of 1 week in plaster cast the patient then starts mobilisation with active flexion and extension and a volar based splint which limits MCPJ flexion to 30 degrees for 2 weeks, 60 degrees for 2 weeks then 90 degree for the final 2 weeks.
    The joint will always appear swollen however the majority of post operative swelling will resolve by 3 months.

    Indications

    Indications
    Rupture of the sagittal band which is not repairable primarily.
    This usually occurs in inflammatory arthritis where the sagittal band ruptures with a gradual attrition and is of poor quality but may also occur if a traumatic rupture is neglected and the ligament retracts and therefore is too short for a primary repair.

    Symptoms
    Patients may have pain if the underlying inflammatory arthritis is active however the main symptoms in most patients is a snapping tendon or inability to smoothly or fully extend their MCPJ.
    When the tendon snaps back into place it can be tender for the patient.
    It is not uncommon for patients with a missed diagnosis of a sagittal band rupture to have been diagnosed with a trigger finger due to the snapping feeling. They may have already received injections to ‘treat’ the triggering. A lack of tenderness over the A1 pulley will lead the surgeon to examine the dorsum of the the hand to rule out a sagittal band insufficiency.

    Examination
    A patient with a sagittal band rupture will have normal flexion but has an impaired or abnormal extension at the MCPJ in the affected finger. The PIPJ will be able to fully extend due to the action of the intrinsic muscles.
    In mild cases the extensor tendon over the MCPJ will be seen to slip down one side (usually ulnarward) of the metacarpal head when the joint is fully flexed. This then recentralises when the finger is extended and may click or be uncomfortable.
    In more more marked cases the tendon is seen to drop into the gutter between the metacarpal heads on MCPJ flexion and when extension is attempted it is not possible as the tendon stays ‘stuck’ between the metacarpal heads exerting a lateralising force instead of an extensor force across the joint. As the extensor tendon is intact, the finger can be passively extended and the patient can then usually hold the finger in extension as the tendon has usually recentrailsed and lies dorsal over the metacarpal head exerting its normal extensor force over the joint.

    Investigations
    A sagittal band rupture is a clinical diagnosis however, if more detail is required the best investigation would be an Ultrasound scan.
    If pain is a large part of the complaint a PA and lateral radiograph may also be useful to assess the state of the MCPJ for potential articular pathology.
    If the patient does not have an inflammatory arthritis diagnosed and denies any trauma it may be prudent to perform screening blood tests for inflammatory arthritis as this episode may be the patients primary presentation with an undiagnosed condition.

    Non-operative Management
    Non-operative treatments will not resolve a sagittal band rupture which requires reconstruction. Splinting may be used in an acute traumatic rupture.
    Analgesia or patient advice can be provided for those patients who do not want to undergo surgical reconstruction.

    Alternative operative Management
    Alternative procedures for sagittal band reconstruction:
    There are numerous variations using local autologus tissue to reconstruct the sagittal band or stabilse the extensor tendon. Some of these methods are describes and illustrated in Green’s Operative Hand Surgery.

    Contraindications
    Absolute contra-indications
    Infection or acutely inflamed joint (from inflammatory arthritis).
    Relative contra-indications
    Poor tendon quality which would preclude or complicate this method.

    Setup

    Pre-operative preparations and Equipment
    The operation can be performed under general or regional anaesthetic. The duration of surgery is around 1 hour. An upper arm tourniquet is applied and inflated to 250mmHg
    Equipment – Curved tendon weaver/passer or fine artery clip, plaster cast.
    A single dose of antibiotics are given pre-operatively.

    Operation

    The skin incision and line of the extensor tendons in MCPJ flexion are marked as a reference.
    Once prepped and draped and the anaesthetic is checked, the skin markings are drawn.
    The incision is a dorsal midline approach from the metacarpal neck to two thirds of the way along the proximal phalanx.
    On this image the line of the extensor tendons have also been drawn with the fingers in flexion to highlight the ulnar subluxation of the middle finger extensor tendon.

    Skin and fat are sharply incised.Once the skin is incised the tendon can clearly be seen in the subluxed position with a thin attenuated sagittal band more dorsally over the metacarpal head.

    The sagittal band and capsule are incised longitudinally as separate layers.The incision is along the radial border of the tendon (is this case of ulnar subluxation) and the joint is inspected for synovitis and joint wear.
    The thin sagittal band (held up by a skin hook) and thick joint capsule can be seen as separate layers in this patient.
    The joint articular surface is normal.
    Care must be taken not to damage the joint surfaces when opening the joint.

    A curved tendon weaver/passer is passed beneath the MCPJ radial collateral ligament. The tendon weaver/passer is passed from inside the joint capsule, volar to the collateral ligament and out through the capsule on the radial side of the joint (in this case of ulnar subluxation – this would be passed through the ulnar side of the joint in a case of radial tendon subluxation).
    The tendon weaver/passer is then opened to create a hole to pass the tendon graft through later in the procedure.
    The sagittal band is retracted and not punctured during this step.
    Care must be taken once again with the joint surfaces which can be scratched easily by the tendon weaver or dented if leant on too hard.

    The central third of the extensor tendon is harvested.The graft used for reconstruction is harvested from the central third of the central slip. It is proximally based and great care needs to be taken during the harvest as it is easy to drift to radial or ulnar when preparing the graft and transect the outer thirds of the tendon which should remain in continuity. (If a narrow tendon is seen, the graft can also be harvested from the extensor proximal to the MCPJ and this would then be used as a distally based graft).
    The graft extends from a few mm proximal to the MCPJ joint line to around two thirds of the way along the proximal phalanx. The dissection should not breech the PIPJ or damage the insertion of the central slip onto the middle phalanx.

    Leaving the proximal end attached, the distal end is cut and the graft can be seen to measure around 3cm which is long enough to perform the reconstruction and have 5mm at the tip which can be grapsed without worry when passing the tendon around the collateral liglament.

    The proximally based tendon slip is passed beneath the radial collateral ligament.The tendon weaver/passer is passed back through the hole previously made in the joint capsule, volar to the collateral ligament, from outside to inside the joint and the graft grasped by its free end.
    The sagittal band can be seen retracted by the forceps.

    The graft is then pulled through the capsule and is seen to centralise the extensor tendon.

    The central slip/ extensor hood defect is then repaired using a 4/0 PDS suture.

    The joint capsule is repaired.This can be repaired with same suture material deep to the extensor tendon.

    The mobilised tendon slip is sutured centrally to the extensor tendon.The graft is then sutured to the dorsum of the extensor at the level of its attached end.

    The reconstruction is tested in flexion to shown a stable extensor glide.The attachment of the graft is performed/tensioned with the MCPJ at 45 degrees of flexion to avoid stiffness of the MCPJ during rehabilitation.

    The stretched sagittal band is sutured over the reconstruction.If of a good enough substance, the stretched radial sagittal band can be sutured to the graft insertion site with 2 interrupted sutures.

    The MCPJ movement is tested to ensure full flexion is possible and the tendon remains centralised throughout the full range.

    The skin is closed with a continuous absorbable suture.

    An adherent dressing is applied.

    A volar slab is applied with the MCPJs in full extension.

    Post Operative

    The procedure is performed as a day case and the patients are discharged with a sling and return within a week for wound review and hand therapy.
    The wound is redressed and a resting splint which is worn 24/7 is applied. The sutures are trimmed and dressing removed at 2 weeks post operation.
    The splint is volar based and limits MCPJ flexion to 30 degrees for 2 weeks, 60 degrees for 2 weeks then 90 degree for the final 2 weeks. During this time extension of the fingers off the splint and full flexion of the DIPJ and PIPJs is encouraged.
    The joint will always appear slightly swollen however the majority of post operative swelling will resolve by 3 months.
    Range of movement should be full by 3 months. Strong gripping with a clenched fist is discouraged for 3 months.
    It will usually take patients 6-8 weeks to return to light work and 3-6 months to return to heavier work.

    Recommended Reading

    Complications include infection, stiffness, continued pain, recurrent subluxation and continued swelling.
    The vast majority of patients are very satisfied and significant complications are rare.
    For further details please read the below articles:
    In this original paper 3 patients and 5 tendons were treated. Post-operatively all patients achieved a full painless range of movement with no recurrences of subluxation.
    A Reconstructive Stabilization Technique for Nontraumatic or Chronic Traumatic Extensor Tendon Subluxation.
    Lee JH1, Baek JH2, Lee JS2.J Hand Surg Am. 2017 Jan;42(1):e61-e65. doi: 10.1016/j.jhsa.2016.10.008.
    This series describes a reefing of the injured sagittal band with 13 cases and a mean follow up of 14 months. The were no reported complications, no re-subluxations and all patients regained a full pain free range of movement.
    Complications include infection, stiffness, continued pain, recurrent subluxation and continued swelling.
    The vast majority of patients are very satisfied and significant complications are rare.
    For further details please read the below articles:

    Posttraumatic ulnar subluxation of the extensor tendons: a reconstructive technique.
    Carroll C 4th, Moore JR, Weiland AJ. J Hand Surg Am. 1987 Mar;12(2):227-31.

    Reference

    • orthoracle.com

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