The extensor tendons and soft-tissue envelope are frequently compromised for RA patients. For patients suffering wrist level extensor tendon rupture associated with rheumatoid arthritis (RA), primary tendon repair is generally not feasible. This relates to the diffuse nature of the tendon damage that typically occurs in such patients, combined with fibrosis, atrophy, and retraction of the muscle, events that usually preclude effective tendon repair.
Several different methods have been previously used to repair finger extensor-tendon ruptures at wrist level for the rheumatoid-arthritis patient [3–8]. Primary repair involves the end-to-end suture of the two ends of the damaged tendon, and, as best we are aware, is generally not feasible for rheumatoid patients, as a significant length of tendon is typically damaged by the mechanical attrition and inflammatory process that occurs following tendon rupture. When multiple tendons are ruptured, the results of such surgical repair by any of these techniques are often unsatisfactory. The diffuse nature of the tendon damage, combined with fibrosis, atrophy, and retraction of the muscle, usually precludes repair. When rupture is diagnosed early, tendon grafting may be successful . Some authors think that tendon grafting resulted in good correction of extension lag, but patients were dissatisfied with accompanying loss of digital flexion because of the long standing nature of the disease and decreased musculotendinous unit excursion, leading to loss of flexion following grafting . Good results have been reported for tendon grafts, provided that the time from tendon rupture to surgery is short and muscle contracture is not allowed to become severe [9, 11, 12].
Interpositional grafting is able to be used as a surgical-repair technique for ruptured extensor tendons in order to overcome the problem of defects in the extensor mechanism where a portion of the relevant tendon has irreparably damaged and effectively lost. The tendon graft can be placed directly in between the ruptured extensor-tendon ends, or alternatively, re-routed subcutaneously in order to avoid the diseased tendon bed . Interpositional tendon grafting using palmaris longus to repair extensor-tendon defects has previously been described as constituting a technique that can be effectively used for the repair of ruptured finger-extensor tendons . The palmaris longus is the tendon of choice because it fulfils the requirements of length, diameter, and availability without producing a deformity. This choice of technique for tendon grafting features the advantage of the source of donor tendon being readily accessible in the same forearm.
The presence of this tendon should be determined before any grafting procedure. The tendon is reported to be present in one arm in 85% of people and in both arms in 70%. If the PL tendon absence occurred in our patients who need autogenous tendon graft to reconstruction, long extensors of toes were our second choice. The extensor of the third toe is probably easiest to remove and use. The method is to make multiple short transverse incisions over the tendon and remove it by elevating the skin proximal to each incision and dissecting to a more proximal level; then make another incision at this point and repeat the procedure. Extract the divided end of the tendon through each successive incision and remove it through the proximal incision.
On the basis of the results of the study, good functional outcomes can be achieved with end-to-end tendon-grafting technique using autogenous palmaris longus tendon graft. The mean extension lag of the metacarpophalangeal joint following tendon grafting for our study participants was 16.4°, a figure which was somewhat better than the 30° figure reported in 1987 by Bora et al. . Further, we observed that metacarpophalangeal-joint flexion was improved for all patients subsequent to surgery.
Promoting tendon healing and avoiding joint adhesion are critical parts of the postoperative management of tendon reconstruction following tendon rupture. In our study, the Pulvertaft technique of weaving two tendons together was used, it provides a very-strong connection between the two grafted tendon ends, and a surgical repair technique that can then be loaded more quickly. The feature of this technique makes the "early active" type of rehabilitative protocol (we allowed the wrists active flexion within one month postoperatively in our series) feasible for patients having undergone such a surgical-repair technique.
Dynamic splinting following extensor tendon repair is becoming increasingly popular. The use of dynamic outrigger splints which allow active flexion and extension of the interphalangeal (IP) joints and active flexion but only passive extension of the MP joints. The dynamic splint combined with the tendon mobilization program provided the gliding necessary and was easy for the patient to comply with and understand . Some studies relating to "early active" motion post surgical repair of ruptured extensor tendons have shown that patients who undergo early controlled, dynamic motion experienced improved damaged-hand function more rapidly than was the case for those more-immobilized patients, this shortening the overall total rehabilitation time required post such injury, and making dynamic motion treatment highly cost effective .
Reconstruction for multiple tendon ruptures is a salvage procedure that is often associated with extensor lag and impairment of overall hand function. For our study, the mean age at surgery for study participants was 47.3 (range, 32–66) years, the functional requirements of the injured hands of the patients participating in our study being highly "in demand" prospectively as regards these individuals' working lives. The average range of MCP-joint flexion and the extension lag at the metacarpophalangeal joint for our study participants was shown to be improved significantly following reconstruction using autogenous palmaris longus tendon grafting.