Wei David H, Strauch Robert J
Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY.
Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY.
J Hand Surg Am. 2014 Jun;39(6):1082-7. doi: 10.1016/j.jhsa.2014.02.004. Epub 2014 Mar 25.
Adequate exposure of the articular surface of the head of the proximal phalanx is essential for reduction of intra-articular fractures of the proximal interphalangeal (PIP) joint. We compared the articular exposure obtained by a dorsal extensor-tendon splitting (Swanson), an extensor tendon-reflecting (Chamay), and an extensor mechanism-sparing approach.
The PIP joints of 24 digits from 6 fresh-frozen cadaveric specimens were randomly assigned to 1 of 3 dorsal surgical exposures: an extensor tendon-splitting, extensor tendon-reflecting, or extensor mechanism-sparing approach. The exposed surface was painted with methylene blue and the PIP joints were disarticulated to reveal the distal articular surface of the proximal phalanx. Using 3-dimensional digital mapping, we calculated the percentage of the exposed dyed surface area to the total surface area and compared the 3 approaches.
The mean percent exposed joint surface area for the extensor tendon-splitting, extensor tendon-reflecting, and extensor mechanism-sparing approaches were 41%, 52%, and 16%, respectively. Each approach provided a significantly different percentage of articular PIP joint surface area from the other 2.
The amount of articular surface visualized using 3 dorsal approaches to the PIP joint must be weighed against the amount of extensor mechanism violated. Exposure of the articular surface by the extensor mechanism-sparing approach to the PIP joint allowed nearly a third of the exposure gained by the extensor tendon-reflecting exposure. Although the extensor tendon-reflecting technique revealed the greatest amount of surface, nearly 50% of the proximal phalanx articular surface remained inaccessible as long as the collateral ligaments were intact.
Understanding the limitations inherent in dorsal exposure of the PIP joint may help guide the surgical approach for the individual patient.
近端指间（PIP）关节内骨折复位时，近端指骨头关节面的充分显露至关重要。我们比较了经背侧伸肌腱劈开（Swanson法）、伸肌腱翻转（Chamay法）和保留伸肌装置入路所获得的关节显露情况。
从6个新鲜冷冻尸体标本上取下24个手指的PIP关节，随机分配至3种背侧手术显露方法中的1种：伸肌腱劈开、伸肌腱翻转或保留伸肌装置入路。将显露的表面用亚甲蓝染色，然后将PIP关节离断，以显露近端指骨的远端关节面。使用三维数字测绘，我们计算了染色显露表面积占总表面积的百分比，并比较了这3种入路。
伸肌腱劈开、伸肌腱翻转和保留伸肌装置入路的平均关节面显露百分比分别为41%、52%和16%。每种入路所提供的PIP关节面面积百分比与其他两种入路均有显著差异。
采用3种背侧入路显露PIP关节时，必须在关节面显露量与伸肌装置受侵犯程度之间进行权衡。采用保留伸肌装置入路显露PIP关节的关节面，其显露量接近伸肌腱翻转入路的三分之一。尽管伸肌腱翻转技术显露的表面面积最大，但只要侧副韧带完整，近端指骨关节面仍有近50%无法显露。
了解PIP关节背侧显露的固有局限性可能有助于指导针对个体患者的手术入路选择。
