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STUDY DESIGN: Retrospective. INTRODUCTION: Boutonniere deformity (BD) is a troublesome injury occurring from rupture of tissue connecting the extrinsic to intrinsic tendon systems. This causes loss of interphalangeal joint balance, and immobilization often results in adherence and difficulty restoring balance. PURPOSES: Review of relative motion flexion (RMF) orthotic use for safe healing during functional activity in 23 patients, and explanation of the rationale. METHODS: Anatomic rationale and clinical experience is reviewed in 8 acute BD patients utilizing RMF orthoses for 6 weeks, and for chronic BD patients, 3 months after serial casting. RESULTS: All patients met the Strickland and Steichen criteria for "excellent" results following treatment, with an average of 35° increase in ROM. DISCUSSION: The anatomic rationale for relative motion recognizes that altering relative positioning between adjacent metacarpophalangeal (MCP) joints produces a protective favorable impact on interphalangeal forces during hand function using 15°-20° greater MCP joint flexion. This provides dorsal and volar protective benefits because the extensor digitorum communis (EDC), a single-muscle-four-tendon system, attaches to the intrinsic lateral band (LB) tendons. With greater MCP flexion, dorsal EDC force is increased, pulling lateral bands medially, while on the volar surface the downward pull of the lumbrical on LB is relaxed due to origin from the flexor digitorum profundus tendon of the injured digit, also a single-muscle-four-tendon system. The RMF orthosis permits protected active motion during functional activity with acute BD. In patients with chronic BD and adequate passive extension, an RMF orthosis for 3 months also produced encouraging results. CONCLUSION: Management of acute BD with RMF orthoses provided earlier recovery of motion and hand function. Similar results occurred for chronic BD using serial casting for adequate extension followed by 3 months of RMF orthotic use and should be attempted prior to surgical intervention, with surgery remaining an alternative.

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The relative motion concept is simply recognition of the normal functional anatomic relationships that allow powerful extrinsic muscles, the extensor digitorum communis (EDC) and flexor digitorum profundus (FDP), to vary forces on individual finger joints and function in response to the relative position of adjacent metacarpophalangeal joints (MCPJs) in the hand, one to another. First identified as a cause of complications after surgery, a better understanding now allows us to harness these forces by way of differential metacarpophalangeal joint (MCPJ) positioning using an orthosis. This can reduce undesirable tension and allow immediate controlled active motion while permitting functional use of the hand. Tissue gliding with active motion prevents restrictive scarring, maintains joint mobility and avoids unnecessary limitations and stiffness on normal neighboring structures. The historical development of this concept is shared with explanation of the anatomic and biologic rationale for this approach. Acute and chronic hand conditions that may benefit from better understanding of relative motion are numerous and growing.

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BACKGROUND: As surveys reveal the prevalence of musculoskeletal pain among surgeons, it is important to have an appreciation and understanding of surgical ergonomics to protect against long-term injuries and mitigate the symptoms of existing conditions. Surgeons diagnosed with thumb carpometacarpal (CMC) joint osteoarthritis, a progressive and debilitating condition, can be especially vulnerable to the pain caused by the repetitive manual tasks of operating. METHODS: In this article, the authors describe a case of occupational thumb CMC arthritis in a right-hand dominant plastic surgeon and provide an ergonomic analysis of the different needle holders. RESULTS: Following diagnosis, the simple switch from the traditional Hegar needle holder to the Mathieu needle driver with its palm grip and rotating ratchet lock mechanism stalled the progression of the disease, allowing the surgeon to continue operating pain free. CONCLUSIONS: This is the first report of utilization of an alternative needle holder leading to the resolution of thumb pain. In sharing this case, the authors hope to bring awareness to the importance of hand ergonomics in the operating room and offer a practical tip to surgeons with CMC arthritis.

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LEARNING OBJECTIVES: After reviewing this article, the participant should be able to: Start early protected movement at 3 to 5 days after surgery with relative motion extension splinting for zone 5 extensor tendon lacerations over the hand. Allow patients to resume regular activities much sooner than the conventional 3 to 4 weeks of splinting after extensor tendon repair. Improve the rehabilitation of boutonniere deformities with relative motion splinting. SUMMARY: This article focuses on surgery and rehabilitation of extensor tendon injuries from the proximal interphalangeal joint (boutonniere) to the wrist. Relative motion flexion and extension splinting and wide awake, local anesthesia, no tourniquet surgery have revolutionized the management of these lesions, with early protected movement, sooner return to regular activities, and improved rehabilitation. This article explains and illustrates these new advances in extensor tendon management.

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BACKGROUND: We have utilized relative motion splinting for early motion following acute repair of boutonniere injuries, and we have developed nonoperative orthosis-based therapy for the treatment of chronic injuries. We offer our early clinical experience using relative motion flexion splinting for boutonniere deformities and explain the anatomic rationale that permits immediate active motion and hand use following acute injury or repair. For chronic boutonniere deformity, we offer a nonsurgical management method with low morbidity as a safe alternative to surgery. METHODS: Our understanding of the extrinsic-intrinsic anatomic interrelationship in boutonniere deformity offers rationale for relative motion flexion splinting, which is confirmed by cadaver study. Our early clinical results in 5 closed and 3 open acute and 15 chronic cases have encouraged recommending this management technique. For repaired open and closed acutely injured digits, we utilize relative motion flexion orthoses that place the injured digits in 15° to 20° greater metacarpophalangeal flexion than its neighboring digits and otherwise permit full active range of motion and functional hand use maintaining the 15° to 20° greater metacarpophalangeal flexion for 6 weeks. In fixed chronic boutonniere cases, serial casting is utilized to obtain as much proximal interphalangeal extension as possible (at least -20°), and then relative motion flexion splinting and hand use is instituted for 12 weeks. RESULTS: Our acute cases obtained as good as, or better range of motion than, conventional management techniques, with early full flexion and maintenance of extension without any recurrences. The most significant difference is morbidity, with ability to preserve hand function during healing and the absence of further therapy after 6 weeks of splinting. Patients with chronic boutonniere deformity presented from 8 weeks to 3 years following injury (averaging 31 weeks) and were 15 to 99 years of age (averaging 42 years). All were serially casted to less than -20° (averaging -4°) and maintained that level of extension after 3 months of relative motion flexion splinting. All achieved flexion to their palm, and all met the Steichen-Strickland chronic boutonniere classification of "excellent." There were no recurrent progressive boutonniere deformities in either acute or chronic cases and no instances of reflex sympathetic dystrophy/chronic regional pain syndrome (RSD/CRPS). CONCLUSIONS: Relative motion flexion splinting affords early active motion and hand use with excellent range of motion achieved following acute open boutonniere repair or closed boutonniere rupture with less morbidity than conventional management. Chronic boutonniere deformity will respond to relative motion flexion splinting if serial casting can place the proximal interphalangeal joint in less than -20° extension, and the patient actively uses the hand in a relative motion flexion orthosis for 3 months, recovering flexion. No further therapy was needed in our cases. We believe this management technique should be attempted for chronic boutonniere deformity as a preferable alternative to surgery, which remains an option if needed.

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BACKGROUND: Periarterial sympathectomy is a proposed surgical treatment for patients with refractory Raynaud syndrome; however, there is debate regarding the indications and extent of dissection. Due to the segmental arterial sympathetic innervation, we favor an extended sympathectomy in concert with vein graft reconstruction of occluded vessels when necessary. The purpose of this study is to examine outcomes of extended periarterial sympathectomy in our patients. METHODS: A retrospective chart review was performed on 46 patients who underwent 58 periarterial sympathectomies (12 bilateral) since 1981. The data collected include demographics, comorbidities, previous therapy, operative details, and surgical outcomes. In addition, we contacted available patients for a phone survey. RESULTS: Of 58 cases, 68.9% were female, 29.3% were current smokers, and 58.6% had known connective tissue disease. Thirty-three vein graft reconstructions were performed with a long-term patency of 77.4%. Sustained improvement of ischemic pain was reported in 94.8% of cases, and 78% of patients with ulcers completely healed. For the most symptomatic fingertip, mean Semmes-Weinstein monofilament measurements improved from 4.15 preoperatively to 3.29 postoperatively ( P ≤ .05). Mean follow-up was 3.97 years. Of 10 patients contacted by telephone, all reported a decrease in frequency and severity of Raynaud attacks, while 9 reported a long-term decrease in pain an average of 11.6 years after surgery. CONCLUSIONS: Extended periarterial sympathectomy is an effective and safe procedure for patients with refractory Raynaud syndrome. Our data demonstrate long-term improvement in ischemic pain and sensibility, along with a high rate of ulcer healing and patient satisfaction.

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There is no consensus regarding etiology or best surgical technique for severe Raynaud syndrome in patients with connective tissue disease. Observations after 30 years' experience in more than 100 cases led to the conclusion that an extended periarterial sympathectomy (with or without vein-graft reconstruction) and adjunctive use of Botox topically will offer benefits that exceed palliation and reduce recurrent ulcerations. In this article the rationale for this approach is reviewed, techniques and results are outlined, and a hypothesis for the mechanism of Raynaud attacks is offered.

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The relative motion splint was initially developed to facilitate postoperative rehabilitation after repair of extensor tendon injuries at the dorsum of the hand and forearm. It has subsequently been used for rehabilitation of sagittal band injuries and after repair of closed attrition extensor tendon ruptures in rheumatoid arthritis. This is much less awkward than other braces and can readily be worn during normal past-time and work activities. This so-called immediate controlled active motion splinting protocol has also more recently been applied to both operative and nonsurgical rehabilitation for boutonniere deformity.

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Botulinum toxin-A (BTX) has become a widely used pharmacologic agent for esthetic surgeons and those who treat neuromuscular and gastrointestinal conditions. Until recently, there has been very little basic science research related to how this powerful agent may be useful when applied to vessels. The mechanism of action of this agent suggests that it may be useful in treating vasospastic conditions and ischemic tissues. We present data from experiments conducted to establish whether perivascular application of BTX decreases skin flap necrosis in an island pedicle skin flap in the rat. Using an ischemic ventral pedicled island cutaneous flap model, 30 adult Sprague-Dawley rats were divided into groups and treated with BTX, papaverine, or saline to the intact vascular pedicle to determine the percentage of tissue necrosis and ischemia. Flaps were elevated, and the pedicle treated with 1 of the 3 agents, and the flaps reinset. Analysis of the percentage of flap necrosis and areas of flap ischemia were evaluated on postoperative day 4. There were no differences in area of flap necrosis between BTX-, papaverine-, and saline-treated animal groups. There was a significant decrease in flap ischemia in the papaverine-treated group compared with both BTX and saline (P < 0.01). When necrotic and ischemic areas were combined, papaverine again showed a protective effect when compared with the BTX- and saline-treated groups (P < 0.04). In our ischemic pedicled island cutaneous flap model, papaverine showed the greatest protective effect against skin flap ischemia compared with BTX and saline. However, our data suggest that BTX may provide a protective effect after the first several days following flap elevation.

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The purpose of this study was to demonstrate that perivascularly applied botulinum toxin-A (BTX) increases the diameter of treated blood vessels in a rat femoral vessel exposure model. Six adult Sprague-Dawley rats were used and bilateral femoral artery and vein exposures were performed. Five units of BTX were applied to the experimental side and an equal volume of sterile saline was applied to the control side. Digital images of the vessels were obtained at the following time points: pretreatment, immediately posttreatment, and postoperative days (POD) 1, 14, and 28. Vessel diameters were equivalent at baseline and immediately following application of BTX and saline. The BTX artery was significantly larger than the control artery on POD 1 and 14. The BTX treated artery was significantly larger than all other vessels on POD 14 (p < 0.05) as well as all prior time points (p < 0.01). Direct perivascular application of BTX increases the diameter of rat femoral vessels as early as POD 1. The affect is most robust on POD 14 where the artery was significantly larger than all other vessels at all time points. It is likely that the increased diameter of blood vessels results in an increased blood flow across the area of dilation. Such an increase in flow may serve to improve end-organ perfusion in microvascular procedures.

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The challenge to understand reflex sympathetic dystrophy/complex regional pain syndrome may require a better understanding of the complex relationship between the central and peripheral nervous systems. There is no comprehensive hypothesis that clearly explains the etiology and no uniformly successful treatment method. This brief summary of the challenge reviews some of what is known, hypothesizes a possible etiologic mechanism, and proposes 10 common-sense principles for management that recognizes the handicap of limited knowledge.

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This article describes a splint management program for zone 4-7 extensor tendon repairs that allows for immediate controlled active motion (ICAM) of the repair and greater arcs of motion for adjacent digits. The splint is designed to relieve tension on the tenorrhaphy by positioning the involved digit in slight metacarpophalangeal joint hyperextension relative to the uninvolved digits with a simple yoke splint designed to control the metacarpophalangeal joints and a second splint to control wrist position. Cadaver and intraoperative trials support this technique, and 140 patient cases managed over 20 years. The majority of patients achieved a rating of excellent for both digital extension and flexion as judged by Miller's criteria. There were very few extension lags and no tendon ruptures. Patients returned to work in the ICAM splint on average in 18 days. The average time to complete the program was seven weeks after repair, and required an average of eight therapy visits. The results of this study demonstrate that the ICAM splinting technique is safe, simple to manage, decreases the morbidity associated with immobilization, is cost effective, and has high patient compliance when compared to other early motion programs.

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