ANALYSIS OF THE SURGICAL TREATMENT OF STENOTIC LIGAMENTITIS OF FINGERS IN CHILDREN

Purpose of the study. Clinical analysis of the surgical treatment of stenotic ligamentitis of fi ngers in children. Materials and methods. A retrospective analysis of data examining 140 children and surgical treatment of 105 children with the diagnosis of "constrictive ligamentitis of fi ngers" was performed in the G. I. Turner Research Institute for Children’s Orthopedics in the period from 2011 to 2013. We considered gender and age of patients, the symptoms of the disease and patient complaints, and nature of the preferential aff ection of one or both hands and fi ngers as well as the family history. Results. Regarding gender, the patients were evenly distributed: 54 girls (51%) and 51 boys (49%). Th e largest number of children in need of surgical treatment (89) belonged to the age group of 1–4 years (85%). Th e prevalence of preemptive aff ection of fi ngers of one of the limbs has not been noted. Th e disease was mostly diagnosed on the fi rst fi nger (131 cases). Recurrence of deformity in the long term was not noted. Conclusion. Conservative treatment may contribute to the progression of deformity. Th e applied surgical treatments permitted the maximum functional and cosmetic result.


Introduction
Stenotic ligamentitis of fingers is a disorder caused by the diff erentiation of the tendomuscular system [1,2]. Th is disorder was fi rst documented by the French physician A. Notta in the journal Archives of General Medicine in 1850. Th is article described the treatment of four adult patients who had a node on a deep fi nger fl exor tendon preventing the normal movement of the fi nger [3].
Th e disorder is rather widespread in children, with 3.3% of 1000 newborns aff ected [4]. Th e fi rst fi nger is aff ected in most children (up to 89%), with the eff ect oft en being ambilateral. Th is disorder is also found in triphalangeal fi ngers [1,5].
Documented treatment modalities are conservative or surgical. Conservative treatment mostly involves physiotherapeutic procedures. Electrophoresis with lydazum and hydrocortisone is used in most cases. However, effi cacy is only documented at the initial presentation of the disorder [1]. Th ermal procedures and massage may exacerbate progression [1]. Corticosteroid injections have proven to be eff ective and have been recommended before surgical treatment by a number of authors [6]. However, a signifi cant number and variety of complications associated with this therapy bring its advisability into question. Th e most common complications include skin atrophy in the area of injection, subcutaneous fat necrosis, and skin hypopigmentation [6]. Occasionally, corticosteroid injections may cause tendon rupture [7].
A method of percutaneous dissection of the first annular ligament has been described and widely used as an alternative to surgical treatment. Th is method was fi rst documented by J. Lorthior in 1956 [8]. Other authors have developed special instruments for this operation. However, complications still occur in 30% of cases. D. Gulabi et al. described the clinical treatment of 60 patients. Th e most common complications are partial tendon injury, temporary sensory anesthesia, and incomplete reversal of deformity [9,10].
Open surgical treatment allows for the careful dissection or excision of the annular ligament and revision of the tendon and its sheath. Many diff erent discission designs are documented that provide surgical exposure of the fi rst ligament. Th ey are subdivided into three categories: longitudinal, transverse, and combined. Th e use of longitudinal discissions in the median line of the arm with transition to the area of the metacarpophalangeal joint causes aching surgical scars, and fi nger fl exion contracture develops in the long term [1].
Th e purpose of this research was to analyze the results of the surgical treatment of stenotic ligamentitis of fi ngers in children.

Material and methods
From 2011 through 2013, we analyzed the results of the examination of 140 children diagnosed with stenotic ligamentitis of fi ngers, who presented to the Consultation and Diagnostic Center at the Turner Scientifi c Research Institute of Children's Orthopedics. Of these children, 105 were admitted for surgical treatment. Th e collected data were retrospectively analyzed, including sex and age of the children, symptoms of the disorder and complaints of the children, nature of the predominant eff ect of one or both hands and fi ngers, and hereditary history.

Results
Of the 140 children referred for consultation, 132 were newly admitted. Eight children required medical attention due to the relapse of the deformity: seven aft er prior percutaneous ligamentotomy and one aft er surgical treatment. Relapse occurred at 2 to 5 months (average 2.7 ± 1.2 months). Th e treatment was performed according to the place of residence. A total of 105 children (75%) with 137 fi nger disorders were admitted to the Hand Surgery and Reconstructive Microsurgery Clinic for surgical treatment. Of 35 children not admitted for surgical treatment, 11 presented to other hospitals, while 24 (17%) experienced recession of stenotic ligamentitis. In terms of sex, the children were evenly distributed: 54 girls (51%) and 51 boys (49%). Th e age of the ch ildren ranged from 1 to 17 years (average 3.1 ± 2.4 years; Fig. 1). Th ere were no newborns in the group.
Most children who required surgical treatment (89, or 85%) were 1 to 4 years old, while 22 (21%) were 1 year old. Surgical treatment was performed in 16 children who were more than 5 years old. No predominant eff ect of the fi ngers of one hand was observed. Stenotic ligamentitis occurred in the left hand in 39 children (37%), right hand in 34 (32%), and bilaterally in 32 (31%). In most children (131), the disorder was diagnosed on the fi rst fi nger. One child had ambilateral stenotic ligamentitis of the fi ft h fi nger, while four had stenotic ligamentitis of the third and fourth fi ngers. In no child was the second fi nger aff ected.
Th e analysis of disorder development history showed that the parents of most children (64, or 61%) noticed on their own that the aff ected fi nger's movement was limited. Some parents associated the deformity with trauma (8, or 8%). Th e deformity was also diagnosed by a surgeon or an orthopedic traumatologist during preventive examination (33, or 31%). Th is disorder had never previously occurred in any of the families.
During clinical examination, joint hypermobility was diagnosed according to Carter's criterion. By the end of the examination, 47 children (45%) were diagnosed with signifi cant joint hypermobility. One of the diagnostic characteristics was determining the blanching rash at pressure, which occurred in all children with the fi rst fi nger aff ected.
During treatment, special attention was paid to the intraoperative examination of fl exor tendons and the presence of nodes on them. A node on the tendon of the long fi rst fi nger fl exor was found in 81 children (77%). In two children, changes in the tendon of the fl exor of the third or fi ft h fi nger caused limited movement aft er the excision of the fi rst annular ligament. Spindle resection of the central portion of the tendon node reduced its size, allowing complete restoration of the fi ngers' range of movement. In one child, an edge defect of the long fi rst fi nger fl exor tendon was observed aft er percutaneous ligamentotomy.
Th ree months postoperatively, the children were invited for a control examination to evaluate the results of the treatment. All children completely recovered full range of movement of the metacarpophalangeal and interphalangeal joints. No child experienced pain syndrome or a click when moving the fi nger, which would indicate disorder relapse. Th e surgical scar was barely noticeable and did not cause any functional disorders.
Th e clinical examples given below illustrate the features of diagnosis and stages of surgical treatment of children diagnosed with stenotic ligamentitis of the fi rst and fi ft h fi ngers. Diff erent topographic/ anatomic locations of the fi rst annular ligaments of the fi rst and long fi ngers determined diff erent approaches and tactics for surgical treatment.
Th e parents of two 4-year-old children presented their children to the Consultation and Diagnostic Center with complaints of limited movement of the fi rst fi nger of the right hand and fi ft h fi nger of both hands. While taking the history, a gradual development of the disorder was determined. Six months before presentation to the hospital, the parents noticed rigidity of the fi ngers, particularly in the morning. Th e fi rst fi nger unbent with a click without pain, which would resolve by evening. After a massage course, the fi rst fi nger became less mobile. It became impossible to fully unbend the fi rst fi nger, and trying to do so was painful. Th e child diagnosed with stenotic ligamentitis received no conservative treatment. First fi nger stenotic ligamentitis diagnosis was confi rmed: a round mass that was 5 mm in diameter was visible in the annular ligament. It was mobile and not glomerate with the surrounding tissues and with positive blanching rash at pressure. Th e fl exion contracture in the interphalangeal joint could not be passively removed (Fig. 2). Th e diff erential diagnostics was camptodactyly in the child diagnosed with a deformity of the fi ft h fi nger. An X-ray image of the fi ft h fi nger in the lateral projection revealed no sign of changes in the bone-joint structure. No soft tissue defi ciency on the palmar surface was determined during physical examination.
Th e chosen discission design was a transverse incision in the projection of the fi rst annular ligaments made in skin folds. The access provided good visualization of the deformed ligament and neurovascular bundles and allowed for tendon revision. Th e child diagnosed with stenotic ligamentitis of the fi rst fi nger had a node on the tendon (Fig. 4) that required spindle excision of the central portion of the tendon (Fig. 5). No obvious changes in the fi ft h fi nger's deep fl exor tendon were seen. The result of the treatment was intraoperatively determined and involved the complete recovery of movement (Fig. 6, 7). There was no relapse 3 months postoperatively.

Discussion
Stenotic ligamentitis in children is a disorder with several stages of development [1]. It is most common in 1-4-year-old children, which was noted by other authors as well [1,5,11]. We did not observe children under 6 months old, probably due to the rather narrow selection criteria of children.
Th is research showed that the exclusion of mechanical stimuli, such as massage and movement workouts, may lead to the regression of stenotic ligamentitis, as confi rmed by other authors [1,5]. If movements persist in the involved fi nger, observation is recommended. Flexion contracture requires surgical treatment.
A high deformity relapse rate aft er percutaneous ligamentotomy signifies a low efficacy of the method. Th is also was noted by several authors who performed a comprehensive examination of patients who received treatment via this method. Special attention should be paid to changes in tendon diameter because of its gradual growth and node formation, thus requiring surgical correction in 99% of cases. Th is gives us reason to consider percutaneous ligamentotomy to be even less eff ective as it makes tendon revision and correction impossible.
Although some authors suggest using longitudinal incisions to avoid damage to neurovascular bundles [5], transverse incisions provide good visualization of anatomical structures and are more physiological and cosmetic.
Th e execution of all components of surgical treatment, excision of the fi rst annular ligament, tendon revision, and correction, allows for the avoidance of deformity relapse. If, during surgical treatment, only the excision of the first annular ligament is performed, including a revision and, if needed, correction of the ligament, then deformity persistence and early relapse occur in only 4% of cases [4].

Conclusions
Stenotic ligamentitis in children mostly aff ects the fi rst fi nger and is oft en ambilateral. Treatment tactics should depend on the disorder state. Observation, excluding thermal procedures, massage, or workouts, is recommended for newly-admitted patients and those without fl exion contracture. Finger fl exion contracture requires surgical treatment. Discissions providing access to the fi rst annular ligament must be transverse, going along skin folds. In any case, tendon revision and correction are required. Th e execution of all components of surgery allows for the recovery of the complete range of movement and reduces the risk of relapse.