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PIP Joint in Duputren’s

- Discussion:
    - flexion contractures of PIP joint are more difficult to correct;
    - flexion deformities of PIP joint may be caused by contracture of a diseased central cord (which is an extension of palmar pre-tendinous cord);
    - PIP join contracture may be presaged by development of firm, fixed nodule at proximal phalanx level;
    - flexion deformities may remain or recurr due to:
          - pericapsular fibrosis;
          - shortening of palmar plate checkrein;
          - accessory collateral ligaments;
                 - divided at their attachment to palmar plate;
          - scarring of the FDS to the proximal phalanx or volar plate (requires tenolysis)
          - contracture of flexor tendon sheath;
                 - correction can sometimes be obtained by a transverse division of tendon sheath just distal to the A2 pulley (over C1 pulley);

- Surgical Considerations:
    - consider Agee Digit Widget;
    - its better to accept mild contracture (upto 20 deg) than to release palmar plate from neck of proximal phalanx;
           - remember that contracted PIP joint that is functional (participates in grip, ect) is more beneficial than an extended but stiff PIP joint;
           - excessive dissection around the PIP joint risks excessive post-op scarring and stiffness;
           - scarring is especially likely to occur when the joint is entered;
    - often, a mild flexion contracture of the PIP joint will improve w/ PT, after fascial excision;
    - hence, in most cases the dissection should be limited to the spiral cords, C3 tendon sheath pulley, and checkreins;
    - in the finger, Cleland's ligaments are dorsal to the neurovascular bundle and are less involved as compared to Greysonn's ligaments;


    - Checkreins:
          - normally the volar plate is not attached to the proximal phalanx, but in Dupuytren's contracture, fibrous checkreins develop between the proximal
                 corners of the volar plate and the fibro-osseous sheath;
          - should be released, sparing digital arterial branches to vincular system running immediately dorsal to them;
                 - they pass 3 mm proximal to the proximal edge of the volar plate;
          - care is also taken to avoid entering the PIP joint, since this may lead to more scarring;
          - ref: Checkrein resection for flexion contracture of the middle joint. HK Watson, TR Light, TR Johnson.   J. Hand Surg. Vol 4: 1979. p 67.
    - K wires:
          - w/ contracture more than 80 deg, consider insertion of K wires to hold the joint extended;
          - take care that forced extension, does not lead to excessive wound tension, or flap ischemia;
          - K wires are thought to increase the possibility of infection;
    - Wound Closure:
          - in some cases, it may be necessary to apply a FTSG to the skin defect;

- Salvage:
    - salvage options for severe PIP contractures include fusion, skeletal shortening, interpositional arthroplasty, and amputation;

- Post Op Dressing:
    - w/ chronic PIP contracture, too much extension may lead to digital vascular compromise;
    - if the PIP joint has been entered, then earlier and more aggressive hand therapy may be required

Severe contractures of the proximal interphalangeal joint in Dupuytren's disease: results of a prospective trial of operative correction and dynamic extension splinting.

Central slip attenuation in Dupuytren's contracture: a cause of persistent flexion of the proximal interphalangeal joint.

Severe contracture of the proximal interphalangeal joint in Dupuytren's disease: does capsuloligamentous release improve outcome?

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