Littler Tenodesis for Correction of Swan Neck Deformity in Rheumatoid Arthritis

Purpose: The aim of this study was to assess the results of operative treatment for rheumatoid swan neck deformity using Littler's technique consisting in the reconstruction of the oblique retinacular ligament. Patients and Method: From 2004 to 2007 twenty rheumatoid patients with 30 PIP-joints affected by swan neck deformity underwent surgical correction. In all cases the tenodesis described by Littler was used. Modification of the operative procedure because of insufficiency of the Cleland ligament or the A2-pulley was in no case necessary. Twenty six PIP-joints in 17 patients could be examined after an average follow-up of 22 months. In two PIP-joints the deformity was contract and in 12 PIP-joints partially contract. In 10 joints a dorsal arthrolysis had to be performed and in one a lengthening of the central slip. All PIP-joints were transfixed in 30 degrees flexion. After 6 weeks the transfixing wire was removed and active PIP-joint mobilisation was allowed. Active extension was limited to 20 degrees of flexion until the end of the 12(th) postoperative week. During this time an extension blocking splint was used. After the 12(th) week free active and passive mobilisation of the PIP-joint was allowed. In a retrospective study pre- and postoperative range of motion, X-ray findings, pain and patient's content were examined. Results: Swan neck deformity was corrected in all cases. Preoperative hyperextension of 21 degrees on average was corrected to 24 degrees of flexion. Thereby the ROM of 48 degrees was shifted from the extension sector to a ROM of 51 degrees towards the flexion sector. Recurrence of the deformity or complications were not noted. Pain could be reduced except in one patient. Radiologic changes were classified Larsen grade 2.2 before and 2.3 after operation. Conclusion: With the oblique retinacular ligament repair described by Littler reliable results can be achieved in rheumatoid swan neck deformity. It is indicated in contract and non-contract rheumatoid swan neck deformity when th PIP-joints are radiologically in a stage of less than Larsen grade 3. It corrects the deformity at the level of the PIP-joint as well as the DIP-joint.