3. • ABORDAJE ABIERTO IFP UTILIDAD EN:
- ARTROPLASTIA CON IMPLANTE PARA
ARTROPATIA IFP
- LUXOFRACTURAS IFP
- FIJACIÓN Fx CONDILAR FP
- OSTEOTOMIA DE CORRECCIÓN
INTRAARTICULAR x MALUNIÓN IFP
• + COMÚN --- ABORDAJE DORSAL---- > RIESGO
- LESIÓN APARATO EXTENSOR
- LESIÓN VENAS DORSALES > EDEMA POP
- POBRE RANGO DE MOVIMIENTO
4. PUNTOS RELEVANTES DEL ARTÍCULO
• REVISIÓN SERIES CLÍNICAS PUBLICADAS
• DESCRIPCIÓN TÉCNICAS
• COMPLICACIONES TEJIDOS BLANDOS
• DESTACAR PUNTOS RELEVANTES PARA CADA
ABORDAJE
• PROPONER EL MEJOR ABORDAJE QUIRÚRGICO IFP
5. ANATOMÍA QUIRÚRGICA IFP
• ARTICULACIÓN EN BISAGRA
• ESTABILIZADA POR:
1. PLACA VOLAR (PV)
2. LIG. COLATERAL RADIAL (LCR)
3. LIG. COLATERAL CUBITAL (LCC)
( LIG COLATERAL PROPIO + ACCESORIO)
• PV ---- PORCIÓN DISTAL --- GRUESA--- BASE FM
PORCIÓN PROXIMAL--- DELGADA --- CUELLO FP
DESINSERCIÓN PROX. O DISTAL PV
• LC –-- LAT. CONDILO FP -- BASE TUBERCULO LAT. FM
6. ANATOMÍA QUIRÚRGICA IFP
• POLEAS IFP C1, A3, C2
• FDS PLANO PROFUNDO A FDP
• FDS INSERCIÓN DOS BANDAS METAFISIS FM
(DISTAL INSERCIÓN PV)
• PARALELO FDP ---- PAQUETES COLATERALES
• APARATO EXTENSOR --- ENVUELVE DORSOLATERAL IFP
• BANDELETA CENTRAL --- INSERCIÓN BASE FM
• BANDELETA LATERAL (5MM) --- INSERCIÓN BASE FD
LT--- ESTABILIZA MEDIALMENTE BL
• LRT IFP --- O: VAINA FLEXOR---- I: BL
28. • PROTOCOLOS DE REHABILITACIÓN
MOVILIZACIÓN ACTIVA INTERMITENTE
INMEDIATA CON ORTESIS DE REPOSO
VS. INMOVILIZACIÓN TOTAL POR 4 SEMANAS
SEGUIDO 4- 6 SEMANAS A 3 MESES:
- ÓRTESIS DINÁMICA + MOVIMIENTO
PROTEGIDO (ÓRTESIS YUGO)
MOVILIZACION INMEDIATA IFD
MANEJO POP IFP
29. OBJETIVO PPAL ABORDAJE IFP
MÍNIMA LESIÓN TEJ. BLANDOS + ADECUADA EXPOSICIÓN
PUNTOS A TENER EN CUENTA
ABORDAJE VOLAR
- PRESERVAR
PAQUETE
NEUROVASCULAR
- PRECAUCIÓN
FLEXORES
- AMPLIACIÓN
ABORDAJE
- CORTE BANDA
LATERAL FDS
- CORTE
PROXIMAL FDS
30. OBJETIVO PPAL ABORDAJE IFP
MÍNIMA DISRUPCIÓN PERMANENTE BANDELETA + ADECUADA
EXPOSICIÓN
PUNTOS A TENER EN CUENTA
ABORDAJE DORSAL
- PRESERVAR
BANDELETA CENTRAL
- ABORDAJE SUFICIENTE
INCISIÓN MEDIAL
LONGITUDINAL
BANDELETA CENTRAL
-ABORDAJE CHAMAY
RESTAURAR TENSIÓN
ORIGINAL
31. OBJETIVO PPAL ABORDAJE IFP
MÍNIMA DISRUPCIÓN PERMANENTE BANDELETA + ADECUADA
EXPOSICIÓN
PUNTOS A TENER EN CUENTA
ABORDAJE LATERAL
- PRESERVAR PAQUETE
NEUROVASCULAR
- TENDÓN FLEXOR
32. COMPLICACIONES
• DISMINUCIÓN RANGO DE MOVIMIENTO 5 – 20º
EXTENSIÓN IFP (TODOS ABORDAJES)
• POBRE MOVILIDAD IFP (ARTROPLASTIAS – ARTROSIS)
• DISMINUCIÓN MOVIMIENTO ACTIVO IFD (LESIÓN BL)
• DESINSERCIÓN PV --- CUELLO DE CISNE
• DESINSERCIÓN BC --- BOTONERA
• DESINSERCIÓN LCP--- DESVIACIÓN E INESTABILIDAD
PLANO CORONAL
33.
34.
35.
36. RECOMENDACIONES
• ELEGIR EL TIPO ABORDAJE DEPENDE:
• EXPERIENCIA DEL CIRUJANO
• NECESIDAD DE PROCEDIMIENTOS ADICIONALES DE
TEJIDOS BLANDOS
• + BASE FM ---- ABORDAJE VOLAR (RAFI, OC, APV)
• + CABEZA FP --- ABORDAJE DORSAL
Notas del editor
FIGURE 1: Skin markings for the choice of volar skin incisions. From left to right: Bruner incision, Bruner midlateral hybrid incision, and zigzag incision with smaller flaps.
FIGURE 2: Exposed flexor sheath with neurovascular structures on either side after elevation of the skin flap. The pulleys are marked with black dashed lines and the ulnar digital neuro- vascular bundle is marked with a red dashed line (the radial bundle is protected by the Ragnell retractor).
FIGURE 3: The flexor tendons are exposed after a laterally based flap of the C1, A3, and C2 pulleys is A designed (dotted with black marker) and B raised (arrow indicates the raised flap and asterisks show the vented A2 and A4 pulleys).
FIGURE 4: Proximal interphalangeal joint VP (asterisk) is accessed after retracting the flexor tendons to one side.
FIGURE 5: Alternative route to the VP (asterisk) between the 2 slips of the FDS (arrows).
FIGURE 6: The ACLs are incised (dashed line shows release of ulnar ACL) to release the VP (asterisk) from the collateral ligaments.
FIGURE 7: The PIPJ (red asterisk) is uncovered after the VP (black asterisk) is detached distally.
FIGURE 8: The PIP joint is shotgunned after one collateral lig- ament is released proximally (blue asterisk) and the other is left intact (dashed line). The black asterisk indicates the VP.
FIGURE 9: The Simmen approach to the PIP joint, in which the flexor sheath and ACL attachment to the VP is incised simulta- neously (dashed lines).
FIGURE 10: The flexor sheath and underlying VP are mobilized en bloc as a tubular sleeve to uncover the joint surface (red asterisk).
FIGURE 11: Skin markings for the choice of dorsal skin in- cisions. From left to right, midline longitudinal incision, curvi- linear incision, and lazy S incision
FIGURE 12: Exposed extensor apparatus after elevation of skin flaps. Asterisk shows insertion of the central slip; dashed lines indicate the course of the lateral bands.
FIGURE 13: Central slipesplitting approach to expose the PIP joint. Black and red asterisks show the central slip insertion and P1 head, respectively. Dashed lines indicate the split extensor tendon.
FIGURE 14: Detachment of the central slip (asterisk) to afford greater exposure of the PIP joint.
FIGURE 15: An increase in exposure gained to the PIP joint by proximal release of one collateral ligament (blue asterisk). Black asterisk shows the central slip insertion; dashed line shows the intact collateral ligament.
FIGURE 16: Distally based triangular extensor tendon flap designed (dashed line). Asterisk shows the central slip attachment.
FIGURE 17: The triangular tendon flap is then raised to expose the distal P1, collateral ligaments (blue asterisks), and articular surface while preserving the central slip attachment (black asterisk).
FIGURE 18: Interval between the central slip and lateral bands can be used as access to the PIP joint. The black asterisk shows the central slip attachment, the red asterisk indicates the P1 head, and the dashed line shows the tendon split.
FIGURE 19: Midlateral skin incision used for the lateral approach to the PIP joint.
FIGURE 20: The TRL (black dashed line) exposed after the skin flaps were raised. The extensor tendon and flexor sheath are marked with thin and thick green dashed lines, respectively.
FIGURE 21: Lateral aspect of the collateral ligament (thick and thin blue lines represent the outline of the PCL and ACL, respectively) uncovered after incision of the TRL. Black dashed line represents the VP; asterisk shows the P1 head.
FIGURE 22: Release of the ACL from its attachment to the lateral edge of the VP (dashed line). Asterisk shows the flexor tendons.
FIGURE 20: The TRL (black dashed line) exposed after the skin flaps were raised. The extensor tendon and flexor sheath are marked with thin and thick green dashed lines, respectively.
FIGURE 21: Lateral aspect of the collateral ligament (thick and thin blue lines represent the outline of the PCL and ACL, respectively) uncovered after incision of the TRL. Black dashed line represents the VP; asterisk shows the P1 head.
complete detachment of the central slip (Fig. 18). No repair of the extensor tendon is required when using this approach.
The lateral approach
This approach has been described for implant arthroplasty of the PIP joint but may also be used
FIGURE 22: Release of the ACL from its attachment to the lateral edge of the VP (dashed line). Asterisk shows the flexor tendons.
FIGURE 23: Proximal release of the PCL (blue asterisk) to ac- cess the PIP joint. The black asterisk indicates the VP and the red asterisk shows the P1 head.
FIGURE 24: Partial lateral release of the VP (dashed line) to increase exposure of the joint. Blue, red, and green asterisks show the cut PCL, P1 head, and flexor tendons, respectively.
FIGURE 27: Increased exposure of the VP by releasing one FDS slip. A Exposure of the VP (asterisk) before FDS slip release. B Complete release of one FDS slip (asterisk). C Increased expo- sure of the VP (black asterisk) shown after FDS release (both cut ends are marked with green asterisks).
FIGURE 28: Increased exposure of the VP by proximal split of the FDS. A Exposure before the FDS (asterisk) is split. B Split- ting of the FDS (shown by dashed lines) proximal to VP (asterisk). C Increased exposure of VP (asterisk) shown after the FDS split. Dashed lines show the course of the FDS tendons.
FIGURE 29: Exposure that can be gained with recession but not detachment of the central slip. The asterisk shows the portion of the central slip attachment that has been recessed; the arrow points to the remaining central slip attachment.
FIGURE 30: A window is made in the lateral surface of the flexor sheath to identify and protect the flexor tendons before the VP (black asterisk) is incised. The FDP is marked with a green asterisk.
Extensor lag and PIP and distal interphalangeal joint active range of motion are reported as degrees. HHA, hemi-hamate arthroplasty; SIA, silicone implant arthroplasty; SRA, surface replacement arthroplasty; NR, not reported.
Extensor lag and PIP and distal interphalangeal joint active range of motion are reported as degrees. HHA, hemi-hamate arthroplasty; SIA, silicone implant arthroplasty; SRA, surface replacement arthroplasty; NR, not reported.
Extensor lag and PIP and distal interphalangeal joint active range of motion are reported as degrees. HHA, hemi-hamate arthroplasty; SIA, silicone implant arthroplasty; SRA, surface replacement arthroplasty; NR, not reported.
