Collateral ligament reattachment

Suture anchors or bone tunneling

Two alternative techniques are available for collateral ligament reattachment: suture anchors or bone tunneling.

The advantage of suture anchors is the relative ease of the procedure. It is also a time-saving technique.

Tunneling is the more demanding procedure, but it is significantly less expensive.

This fracture type may be associated with metacarpophalangeal (MCP) joint dislocation. In this case, the dislocation must be manipulated, and any interposed soft-tissue structures removed.

Note: Axial traction may permit soft- tissue to be interposed. This obstructs relocation and should therefore be avoided.

$Suture anchor and bone tunneling techniques for collateral ligament reattachment of an avulsion fracture of the metacarpal head$

For this procedure, a dorsal approach to the MCP joint is normally used.

Dorsal approach to the 2nd metacarpophalangeal joint

All free fragments need to be removed to prevent obstruction of joint movement.

Fragments remaining attached to the ligament should be maintained.

$Small fragments removal – collateral ligament reattachment of an avulsion fracture of the metacarpal head$

Visualizing the joint

Laterally deviate the phalanx in the opposite direction to gain maximal visualization of the joint (“open the book”). Remove all loose bony fragments.

$Phalanx laterally deviated to visualize joint – collateral ligament reattachment of an avulsion fracture of the metacarpal head$

Drilling an anchor hole

Keep the phalanx laterally deviated to visualize maximally the area of the fracture at the metacarpal head.

Insert the anchor according to the manufacturer’s instructions as close as possible to the subchondral bone.

$AP and lateral view of drilling the anchor hole – collateral ligament reattachment of an avulsion fracture of the metacarpal head$

Insertion of the anchor

Insert the anchor.

Ensure that the whole anchor is completely buried in the bone.

$Anchor inserted in anchor hole – collateral ligament reattachment of an avulsion fracture of the metacarpal head$

Insertion of sutures

Transfix the ligament and associated bone fragments with the anchor sutures.

Pitfall: The sutures should be placed as far apart as possible to avoid cutting through the ligament.

Reapproximate the ligament to the phalanx and make a loop in each end of the thread as an anchoring pass. Tie a knot to secure the ligament to the phalanx.

Reattaching the ligament close to the subchondral bone will ensure a smooth surface for ideal mobility.

$Anchor inserted in anchor hole – collateral ligament reattachment of an avulsion fracture of the metacarpal head$

Pitfall

Nonanatomic ligament repair may result in:

Articular surface damage
Joint instability
Joint stiffness
Progressive arthritis

$Correct, anatomic versus incorrect, nonanatomic placement anchor sutures – collateral ligament reattachment of an avulsion fracture of the metacarpal head$

Drilling holes

A pair of parallel perforations, using a 1.0 mm drill or a K-wire, can be made as close as possible to the subchondral bone, angled from distal to proximal, penetrating the opposite cortex.

A drill sleeve for soft-tissue protection is mandatory.

$Drilling of parallel perforation holes – collateral ligament reattachment of an avulsion fracture of the metacarpal head$

Insertion of sutures

4.0 nonresorbable, braided sutures, with straight needles, are used.

Insert the sutures obliquely through the end of the ligament, make a loop in each end of the thread as an anchoring pass, and thread each needle through a drill hole.

$Suture insertion in perforation holes – collateral ligament reattachment of an avulsion fracture of the metacarpal head$

Make a small incision in the opposite side of the finger to retrieve the sutures. Cut off the needles, pull the sutures to approximate the ligament, and tie a knot over the cortical bone.

$Suture retrieval and knotting – collateral ligament reattachment of an avulsion fracture of the metacarpal head$