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Jo S, Calfee RP. General Principles of Flexor Tendon Repair. Hand Clin 2023; 39:131-139. [PMID: 37080645 DOI: 10.1016/j.hcl.2022.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
Flexor tendon repair techniques and rehabilitation have advanced tremendously in the past 50 years. However, the attributes of the ideal tendon repair articulated by Dr Strickland in 1995 hold true today. The ideal repair requires sutures easily placed in the tendon, secure suture knots, a smooth juncture of the tendon ends, minimal gapping, least interference with tendon vascularity, and sufficient strength throughout healing. When accomplished, the modern flexor tendon repair is a stout repair, sufficient for early mobilization and intrinsic tendon healing.
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Affiliation(s)
- Sally Jo
- Department of Orthopedic Surgery, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8233, St. Louis, MO 631, USA
| | - Ryan P Calfee
- Department of Orthopedic Surgery, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8233, St. Louis, MO 631, USA.
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Osanami Y, Aoki M, Shirato R, Saito Y, Hidaka E, Miyamoto H, Uchiyama E. Tensile load on the flexor digitorum profundus tendon during palmar and lateral blocking exercises: Influence on blocking force and distal interphalangeal joint flexion angle. J Hand Ther 2021; 34:555-560. [PMID: 32893102 DOI: 10.1016/j.jht.2020.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 05/19/2020] [Accepted: 07/22/2020] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN This is a basic science research. INTRODUCTION Isolating excursion of the flexor digitorum profundus (FDP) in zones I and II is common practice in the current management after flexor tendon repair. During this procedure, the proximal interphalangeal joint is sometimes fully extended with unmeasured external forces at the middle phalanx when the distal interphalangeal joint is actively flexed. PURPOSE OF THE STUDY The purpose of the study was to investigate the incremental effect of external force with palmar blocking versus lateral blocking and increased angles of flexion on internal tendon forces at the repair site for a safer application of force by the treating therapist. METHODS Eight human cadaveric fingers were studied. To simulate palmar or lateral finger blocking, a compression force of blocking was applied from 5N (510 grams) to 25N (2,550 grams) on the skin surface of the palmar or the lateral aspect of each of these middle phalanges in 5N increments. The tensile load on the FDP tendon during distal interphalangeal joint flexion from 0° to 60° was measured in 10° increments. RESULTS During palmar blocking, the tensile load was significantly increased with increases in palmar blocking force. However, no significant increase in the tensile load on the FDP tendon was observed at any lateral blocking. DISCUSSION Lateral blocking exercise can be performed with less tensile force on the FDP tendon when performing blocking exercise after flexor tendon injury repair. CONCLUSIONS This study supports the concept that lateral blocking with incremental joint angles allows a safer application of force for the healing tendon.
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Affiliation(s)
- Yukihiro Osanami
- Graduate School of Health Sciences, Sapporo Medical University, Sapporo, Japan.
| | - Mitsuhiro Aoki
- Department of Physical Therapy, School of Rehabilitation Sciences, Health Science University of Hokkaido, Ishikari, Japan
| | - Rikiya Shirato
- Department of Occupational Therapy, Faculty of Human Science, Hokkaido Bunkyo University, Eniwa, Japan
| | - Yuki Saito
- Graduate School of Health Sciences, Sapporo Medical University, Sapporo, Japan
| | - Egi Hidaka
- Graduate School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Hiroki Miyamoto
- Graduate School of Health Sciences, Sapporo Medical University, Sapporo, Japan
| | - Eiichi Uchiyama
- Graduate School of Health Sciences, Sapporo Medical University, Sapporo, Japan
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Thoreson AR, Rappaport PO, Yang TH, Reisdorf RL, Zhao C, An KN, Amadio PC. Calculation of flexor pollicis longus moment arm for wrist motion in a cadaver model validates the tenodesis effect for therapy. J Hand Ther 2021; 33:470-476. [PMID: 30792111 DOI: 10.1016/j.jht.2019.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 10/26/2018] [Accepted: 01/20/2019] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Synergies of fingers and wrist motion have been incorporated into therapies for finger flexor tendon injuries to improve repair outcomes. Similar synergistic therapy strategies have not been well documented for the thumb. PURPOSE OF THE STUDY The purpose of this study was to investigate the extent to which wrist motion enables a synergistic effect at the thumb in a cadaveric model by measuring flexor pollicis longus excursion and calculating the moment arm of this tendon at the wrist joint. STUDY DESIGN This is a basic science research. METHODS Eight fresh-frozen cadaveric arms were obtained from our anatomical bequest program. The proximal arm was fixed in neutral pronation/supination position, and motion of the wrist was guided through either flexion/extension or radial/ulnar deviation. Fingers were fixed in extension, thumb interphalangeal and metacarpophalangeal joints were fixed in neutral extension, and the carpometacarpal joint was fixed at 30° palmar abduction. The flexor pollicis longus tendon was exposed proximal to the wrist crease and connected to a rotary potentiometer to measure tendon excursion. Optical markers were attached to the hand to capture kinematics. Wrists were moved from a neutral position over the range of flexion and extension and then from the neutral position through the range of radial to ulnar deviation. Moment arms were calculated. RESULTS Moment arm calculation indicated that the flexor pollicis longus acts as a wrist flexor over the entire motion range and as a weak radial deviator at ulnarly-deviated positions. CONCLUSIONS This study provides a mechanistic rationale for passive interphalangeal joint motion in varying wrist positions when treating thumb flexor tendon injuries, with benefits seen primarily for wrist extension.
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Affiliation(s)
- Andrew R Thoreson
- Tendon and Soft Tissue Biology Laboratory, Mayo Clinic, Rochester, MN, USA
| | | | - Tai-Hua Yang
- Tendon and Soft Tissue Biology Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Ramona L Reisdorf
- Tendon and Soft Tissue Biology Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Chunfeng Zhao
- Tendon and Soft Tissue Biology Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Kai-Nan An
- Tendon and Soft Tissue Biology Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Peter C Amadio
- Tendon and Soft Tissue Biology Laboratory, Mayo Clinic, Rochester, MN, USA.
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Shin SH, Kang KH, Lee YS, Lee JW, Chung YG. Reconstruction and repair of atraumatic extensor tendon ruptures in rheumatoid wrists: Less extension lag after direct repair than interposition tendon grafting. HAND SURGERY & REHABILITATION 2020; 39:302-309. [PMID: 32275961 DOI: 10.1016/j.hansur.2020.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 03/18/2020] [Accepted: 03/20/2020] [Indexed: 10/24/2022]
Abstract
The purpose of this study was to investigate the outcomes of extensor tendon repair involving the original stump in atraumatic extensor tendon rupture of rheumatoid wrists. For this study, 16 cases were reviewed involving 14 patients with rheumatoid arthritis. A total of 52 ruptured tendons impacted 36 fingers; 51 tendons were repaired in 35 fingers. The ruptured tendon stumps were repaired either directly by end-to-end suture or by free interposition tendon graft. The 8- to 10-strand core suture method was used for direct repair with a looped 4-0 nylon suture. In all patients, the extensor retinaculum was released and repaired under the tendons. Postoperatively, a volar splint with the wrist and fingers extended was applied for 3 to 4 weeks, followed by a removable splint and gentle active flexion until 6 weeks. The mean follow-up period was 32 months. All fingers recovered active metacarpophalangeal (MCP) joint extension, including independent and active extension of the little finger. Overall, the mean extension lag at the MCP joint was 1.7°. The mean fingertip-to-palm distance with the MCP joint flexed was 0.24mm. The mean extension lag at the MCP joint was significantly greater after interposition tendon grafting (3.2°) than after direct repair (0°). There was no significant difference in the mean fingertip-to-palm distance between direct repair (0.38mm) and interposition tendon grafting (0.13mm). No re-rupture or additional extensor tendon rupture was observed. Repair of the original extensor tendon stump yields satisfactory outcomes and appears to be a viable alternative to tendon transfers in patients with rheumatoid wrists with atraumatic extensor tendon ruptures. Direct repair reduces postoperative extension lag without a significant difference in flexion deficit when compared with interposition tendon grafting.
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Affiliation(s)
- Seung-Han Shin
- Department of Orthopedic Surgery, Seoul St. Mary's hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero Seocho-gu, 06591 Seoul, Republic of Korea
| | - Ki Ho Kang
- Department of Orthopedic Surgery, Seoul St. Mary's hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero Seocho-gu, 06591 Seoul, Republic of Korea
| | - Yong-Suk Lee
- Department of Orthopedic Surgery, Incheon St. Mary's hospital, College of Medicine, The Catholic University of Korea, 56, Dongsu-ro, Bupyeong-dong, Bupyeong-gu, Incheon, Republic of Korea
| | - Ji-Won Lee
- Department of Orthopedic Surgery, Seoul St. Mary's hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero Seocho-gu, 06591 Seoul, Republic of Korea
| | - Yang-Guk Chung
- Department of Orthopedic Surgery, Seoul St. Mary's hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero Seocho-gu, 06591 Seoul, Republic of Korea.
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Woythal L, Hølmer P, Brorson S. Splints, with or without wrist immobilization, following surgical repair of flexor tendon lesions of the hand: A systematic review. HAND SURGERY & REHABILITATION 2019; 38:217-222. [PMID: 31132525 DOI: 10.1016/j.hansur.2019.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 04/02/2019] [Accepted: 05/08/2019] [Indexed: 10/26/2022]
Abstract
Splints with or without wrist immobilization can be used during the rehabilitation of flexor tendon lesions of the hand. The evidence base for these techniques has not previously been studied in a systematic review. We sought to thoroughly review patient-reported functional outcomes and pain to compare splinting with or without wrist immobilization. Five bibliographic databases were searched. Studies were considered for inclusion if they were randomized controlled trials or observational comparative studies reporting the difference in outcome among patients treated with or without wrist immobilization. No limits were set on publication date or language. Study selection was performed independently by two authors, and disagreements were resolved by consensus. The review protocol was preregistered in PROSPERO. There were no randomized controlled trials. No studies could be included based on our inclusion criteria. We decided to qualitatively summarize the most relevant studies although they did not meet our inclusion criteria. This resulted in a narrative review of the studies we found relevant. Based on the current literature, it is impossible to provide evidence-based recommendations for or against wrist immobilization during the rehabilitation period following flexor tendon repair. The lack of high-quality evidence points to a need for randomized clinical trials to guide rehabilitation decisions.
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Affiliation(s)
- L Woythal
- Department of Orthopedic Surgery, North Zealand Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark.
| | - P Hølmer
- Department of Orthopedic Surgery, North Zealand Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark.
| | - S Brorson
- Department of Orthopedic Surgery, Zealand University Hospital, Lykkebækvej 1, 4600 Køge, Denmark.
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6
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Abstract
The principles of hand therapy for proximal interphalangeal joint disorders include protecting injured structures, minimizing patient discomfort, and optimizing patient recovery. Comprehension of hand anatomy, the nature of the injury being treated, and the phases of healing are critical when designing a safe and effective hand therapy program. Hand therapists use a combination of orthoses, guided exercises, and modalities to improve edema, sensitivity, range of motion, and function.
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Affiliation(s)
- Nathan P Douglass
- Department of Orthopedic Surgery, Robert A. Chase Hand & Upper Limb Center, Stanford University, 450 Broadway Street, Pavilion C, Redwood City, CA 94063, USA
| | - Amy L Ladd
- Department of Orthopedic Surgery, Robert A. Chase Hand & Upper Limb Center, Stanford University, 450 Broadway Street, Pavilion C, Redwood City, CA 94063, USA.
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Chinchalkar SJ, Larocerie-Salgado J, Suh N. Pathomechanics and Management of Secondary Complications Associated with Tendon Adhesions Following Flexor Tendon Repair in Zone II. J Hand Microsurg 2016; 8:70-9. [PMID: 27625534 PMCID: PMC5018978 DOI: 10.1055/s-0036-1586173] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 05/12/2016] [Indexed: 10/21/2022] Open
Abstract
Despite the number of rehabilitation strategies and guidelines developed to maximize the gliding amplitude of repaired tendons, secondary complications, such as decreased range of motion and stiffness associated with tendon adhesions, commonly arise. If left untreated, these early complications may lead to secondary pathomechanical changes resulting in fixed deformities and decreased function. Therefore, an appropriate treatment regimen must not only include strategies to maintain the integrity of the repaired tendon, but must also avoid secondary complications due to reduced gliding amplitude. This review presents a biomechanical analysis of the dynamics of tendon gliding following repair in zone II and rehabilitation strategies to minimize secondary complications related with tendon adhesions.
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Affiliation(s)
- Shrikant J. Chinchalkar
- Department of Hand Therapy, Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Hospital, London, Ontario, Canada
- Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Hospital, London, Ontario, Canada
| | - Juliana Larocerie-Salgado
- Department of Hand Therapy, Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Hospital, London, Ontario, Canada
- Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Hospital, London, Ontario, Canada
| | - Nina Suh
- Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Hospital, London, Ontario, Canada
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Kociolek AM, Keir PJ. Relative motion between the flexor digitorum superficialis tendon and paratenon in zone V increases with wrist flexion angle. J Orthop Res 2016; 34:1248-55. [PMID: 26686976 DOI: 10.1002/jor.23133] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 12/08/2015] [Indexed: 02/04/2023]
Abstract
Carpal tunnel syndrome is characterized by non-inflammatory fibrosis of the subsynovial connective tissue (SSCT), a paratenon-like structure inside the carpal tunnel. This pathology suggests repetitive and/or excessive shear forces are involved in injury development. We assessed relative motion between the flexor digitorum superficialis (FDS) tendon and adjacent paratenon in Zone V using colour Doppler imaging as 16 healthy participants completed three long finger movements (metacarpophalangeal joint flexion, proximal and distal interphalangeal joint flexion, full finger flexion) in three wrist postures (30° extension, 0°, 30° flexion). While the type of finger movement did not affect tendon-paratenon relative motion, we found a significant main effect of wrist posture (p < 0.001). Relative displacement between the FDS tendon and paratenon (as a percentage of tendon displacement) increased from 27.2% (95%CI = 24.8-29.5%) in 30° wrist extension to 39.9% (95%CI = 37.3-42.4%) in 30° wrist flexion. Optical motion capture confirmed that wrist posture did not affect metacarpophalangeal joint range of motion (p = 0.265) or proximal interphalangeal joint range of motion (p = 0.582). These results indicate that relative motion increased due to paratenon strain when the wrist was flexed. While our findings agree with previous cadaveric research in wrist flexion, we found that relative displacement decreased in 30° wrist extension (compared to 0°). These results differ from cadaveric research, possibly due to challenges maintaining anatomic fidelity of the viscoelastic paratenon tissue in vitro. Overall, our study suggests a greater susceptibility to shear injury during repetitive finger movements, particularly when the wrist is flexed. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1248-1255, 2016.
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Affiliation(s)
- Aaron M Kociolek
- Occupational Biomechanics Laboratory, Department of Kinesiology, McMaster University, Hamilton, Ontario, L8S 4K1, Canada
| | - Peter J Keir
- Occupational Biomechanics Laboratory, Department of Kinesiology, McMaster University, Hamilton, Ontario, L8S 4K1, Canada
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9
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Park J, Han DW, Shim JK. Effect of Resistance Training of the Wrist Joint Muscles on Multi-Digit Coordination. Percept Mot Skills 2015; 120:816-40. [DOI: 10.2466/25.26.pms.120v16x9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study investigated the effects of a specific regimen of resistance training on coordinated actions of human hand digits during grasping. Participants were instructed to hold a rectangular object with all five digits and to maintain the orientation of the object against transient perturbation. Indices of co-varied actions (i.e., synergies) among multi-digit grasping and rotational actions were quantified. The index of anticipatory changes of co-varied actions among digit forces (i.e., anticipatory synergy adjustment) was also quantified, which represents the controller's ability to predict an upcoming perturbation. The synergies of both grasping force and moment stabilization increased with the training. No change in the index of anticipatory synergy adjustment with training was observed. The current results suggest that the resistance training on the wrist could be an effective way to enhance both voluntary muscle force/torque production capability and ability to stabilize task performances during multi-digit prehensile tasks.
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Affiliation(s)
- Jaebum Park
- Department of Health and Human Development, Montana State University
| | - Dong-Wook Han
- Department of Sport Science, Chonbuk National University
| | - Jae Kun Shim
- Department of Mechanical Engineering, Kyung Hee University and Department of Kinesiology, University of Maryland
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10
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Abstract
Innovations in operative techniques, biomaterials, and rehabilitation protocols have improved outcomes after treatment of flexor tendon injuries. However, despite these advances, treatment of flexor tendon injuries remains challenging. The purpose of this review is to highlight the complications of flexor tendon injuries and review the management of these complications.
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Affiliation(s)
- Nicholas Pulos
- Department of Orthopedic Surgery, University of Pennsylvania, 3737 Market Street, 6th Floor, Philadelphia, PA 19104, USA
| | - David J Bozentka
- Hand Surgery, Department of Orthopedic Surgery, University of Pennsylvania, 3737 Market Street, 6th Floor, Philadelphia, PA 19104, USA.
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11
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Kociolek AM, Keir PJ. Development of a kinematic model to predict finger flexor tendon and subsynovial connective tissue displacement in the carpal tunnel. ERGONOMICS 2015; 58:1398-1409. [PMID: 25679821 DOI: 10.1080/00140139.2015.1013575] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
UNLABELLED Finger flexor tendinopathies and carpal tunnel syndrome are histologically characterised by non-inflammatory fibrosis of the subsynovial connective tissue (SSCT) in the carpal tunnel, which is indicative of excessive and repetitive shear forces between the finger flexor tendons and SSCT. We assessed flexor digitorum superficialis (FDS) tendon and adjacent SSCT displacements with colour Doppler ultrasound as 16 healthy participants completed long finger flexion/extension movements captured by a motion capture system. FDS tendon displacements fit a second-order regression model based on metacarpophalangeal and proximal interphalangeal joint flexion angles (R(2) = 0.92 ± 0.01). SSCT displacements were 33.6 ± 1.7% smaller than FDS tendon displacements and also fit a second-order regression model (R(2) = 0.89 ± 0.01). FDS tendon and SSCT displacement both correlated with finger joint thickness, enabling participant-specific anthropometric scaling. We propose the current regression models as an ergonomic method to determine relative displacements between the finger flexor tendons and SSCT. PRACTITIONER SUMMARY Relative displacements between the finger flexor tendons and SSCT provide insight into gliding and friction in the carpal tunnel. Our regression models represent a move towards mechanistic-based ergonomic risk assessment of the wrist/hand. This is a natural evolution of ergonomic methods based on tendon-joint interaction.
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Affiliation(s)
- Aaron M Kociolek
- a Department of Kinesiology , McMaster University , 1280 Main Street West, Hamilton, Ontario L8S 4K1 , Canada
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Sapienza A, Yoon HK, Karia R, Lee SK. Flexor tendon excursion and load during passive and active simulated motion: a cadaver study. J Hand Surg Eur Vol 2013; 38:964-71. [PMID: 23221181 DOI: 10.1177/1753193412469128] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The aim of this study was to quantify the amount of tendon excursion and load experienced during simulated active and passive rehabilitation exercises. Six cadaver specimens were utilized to examine tendon excursion and load. Lateral fluoroscopic images were used to measure the excursions of metal markers placed in the flexor digitorum superficialis and profundus tendons of the index, middle, and ring fingers. Measurements were performed during ten different passive and active simulated motions. Mean tendon forces were higher in all active versus passive movements. Blocking movements placed the highest loads on the flexor tendons. Active motion resulted in higher tendon excursion than did passive motion. Simulated hook position resulted in the highest total tendon excursion and the highest inter-tendinous excursion. This knowledge may help optimize the management of the post-operative exercise therapy regimen.
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Affiliation(s)
- A Sapienza
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, NY, USA
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13
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Abstract
This article summarizes select multinational early motion protocols. Included are flexor and extensor protocols for digital tendon repair in many forms. Custom orthosis design, exercise regimens, and advanced techniques are examples of what to expect. The goal of the article is to expose the reader to new ideas, educate regarding advanced techniques in tendon rehabilitation, and stimulate independent study to further the reader's skill set.
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14
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Evans RB. Managing the injured tendon: current concepts. J Hand Ther 2012; 25:173-89; quiz 190. [PMID: 22326362 DOI: 10.1016/j.jht.2011.10.004] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Accepted: 10/31/2011] [Indexed: 02/03/2023]
Abstract
Despite advances in understanding of the mechanical aspects of tendon management with improved suture technique and early stress application with postoperative therapy, clinical results remain inconsistent after repair, especially within the synovial regions. Complementary research to enhance the intrinsic pathway of healing, suppress the extrinsic pathway of healing, and manipulate frictional resistance to tendon gliding is now the focus of current basic science research on tendons. In the future, application of these new biologic therapies may increase the "safety zone" (or tolerance for load and excursion without dysfunctional gapping) as therapists apply stress to healing tendons and may alter future rehabilitation protocols by allowing greater angles of motion (and thus tendon excursion), increased external load, and decreased time in protective orthoses (splints). However, at this time, the stronger repair techniques and the application of controlled stress remain the best and most well-supported intervention after tendon injury and repair in the recovery of functional tendon excursion and joint range of motion. The hand therapist's role in this process remains a critical component contributing to satisfactory outcomes.
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Affiliation(s)
- Roslyn B Evans
- Indian River Hand and Upper Extremity Rehabilitation, Vero Beach, Florida 32960, USA.
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15
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Korstanje JWH, Schreuders TR, van der Sijde J, Hovius SER, Bosch JG, Selles RW. Ultrasonographic assessment of long finger tendon excursion in zone v during passive and active tendon gliding exercises. J Hand Surg Am 2010; 35:559-65. [PMID: 20223603 DOI: 10.1016/j.jhsa.2010.01.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Revised: 01/09/2010] [Accepted: 01/14/2010] [Indexed: 02/02/2023]
Abstract
PURPOSE Cadaver and in vivo studies report variable results for tendon excursion during active and passive hand movements. The purpose of this study was to measure long finger flexor digitorum profundus (FDP) tendon excursion during active and passive movement using high-resolution ultrasound images. METHODS The FDP tendon excursion was measured at the wrist level in 10 healthy subjects during full tip-to-palm active and passive flexion of the fingers. Passive movement was performed 2 ways: (1) straight to full fist: passive flexion starting at the metacarpophalangeal joint, followed by proximal interphalangeal and distal interphalangeal joint flexion; and (2) hook to full fist: passive flexion starting at the distal interphalangeal joint, followed by proximal interphalangeal and metacarpophalangeal joint flexion. Tendon excursion was measured using an in-house-developed, frame-to-frame analysis of high-resolution ultrasound images. RESULTS Median FDP excursion was 24.3 mm, 14.0 mm, and 13.6 mm for active fist, straight to full fist, and hook to full fist movements, respectively. Tendon excursions during active movements was significantly larger than excursions during passive movements (p = .005). The adjusted median tendon excursion was 12.7 mm/100 degrees , 7.5 mm/100 degrees , and 7.4 mm/100 degrees for active fist, straight to full fist, and hook to full fist movements, respectively. Adjusted tendon excursions during active movement were significantly larger than those achieved during passive straight to full fist movement). Adjusted tendon excursions during straight to full fist movements were significantly larger than those achieved during passive hook to full fist movement. CONCLUSIONS Active motion produced 74% and 79% increases in excursions compared to both passive motions in healthy controls. The study results can serve as a reference for evaluating excursions in patients with tendon pathology, including those who have had tendon repair and reconstruction.
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Affiliation(s)
- Jan-Wiebe H Korstanje
- Department of Rehabilitation Medicine, Erasmus Medical Center, Rotterdam, The Netherlands.
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16
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Dovan TT, Ditsios KT, Boyer MI. Eight-strand core suture technique for repair of intrasynovial flexor tendon lacerations. Tech Hand Up Extrem Surg 2009; 7:70-4. [PMID: 16518245 DOI: 10.1097/00130911-200306000-00005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The concept of intrinsic tendon healing, the idea that tendons can heal primarily without the ingrowth of fibrous adhesions from the surrounding fibrous flexor sheath, has been validated both experimentally and clinically. The goals of the surgical treatment of intrasynovial digital flexor tendon lacerations are twofold: 1) to achieve a primary tendon repair of sufficient strength so as to prevent repair site gap elongation and possible rupture, and 2) to prevent the formation of intrasynovial adhesions that cause loss of tendon excursion within the flexor tendon sheath. It is well accepted that repair site strength, both at time zero and within the first 6 postoperative weeks, is directly related to the number of core suture strands crossing the repair site. The factor that limits more widespread use of multistrand suture techniques remains the surgeon's ability to perform the repair while also minimizing trauma to the tendon stumps and the circumferential epitenon. We describe an 8-strand core suture technique used at our institution that has been tested ex-vivo, in-vivo in canines, and used in human subjects over the last 4 years with excellent results.
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Affiliation(s)
- Thomas T Dovan
- Department of Orthopaedic Surgery Washington University St. Louis, Missouri, USA.
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17
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Sun Y, Chen MY, Zhao C, An KN, Amadio PC. The effect of hyaluronidase, phospholipase, lipid solvent and trypsin on the lubrication of canine flexor digitorum profundus tendon. J Orthop Res 2008; 26:1225-9. [PMID: 18404658 PMCID: PMC3898936 DOI: 10.1002/jor.20624] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Although the flexor digitorum profundus (FDP) tendon's gliding resistance is low, the lubrication mechanism that enables this is unclear. The principal lubricants in joints, such as hyaluronic acid, phospholipids, and lubricin, a lubricating glycoprotein, are known to be present in the canine tendon. In this study, we assessed the effect of these lubricants in the tendon by measuring gliding resistance before and after their removal. Canine FDP tendons were treated with hyaluronidase, phospholipase, lipid solvent, and/or trypsin. The gliding resistance of FDP tendons significantly increased after all treatments (p < 0.05). The largest effect on gliding resistance was observed after trypsin digestion. Scanning electron microscopy and immunostaining for hyaluronic acid and lubricin were used to qualitatively assess the tendon surface after treatments. The trypsin digestion produced the most irregular surface, with many exposed collagen fibers. The results of this study suggest that phospholipids, hyaluronic acid, and protein components are all involved in maintaining the low gliding resistance of the FDP tendon.
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Affiliation(s)
- Yulong Sun
- Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA
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18
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Zhao C, Moran SL, Cha SS, Amadio PC. An analysis of factors associated with failure of tendon repair in the canine model. J Hand Surg Am 2007; 32:518-25. [PMID: 17398363 DOI: 10.1016/j.jhsa.2007.02.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2006] [Revised: 01/25/2007] [Accepted: 02/12/2007] [Indexed: 02/02/2023]
Abstract
PURPOSE The canine model is commonly used for flexor tendon repair research. The purpose of this study was to analyze the factors, including laceration mode (partial and complete), suture techniques, therapy methods, and weight-bearing status, associated with tendon repair rupture or gap formation in the canine model in vivo. METHODS We reviewed the factors associated with repair failure among 624 flexor tendon repairs in zone II from 242 dogs reported previously from our institution, including both partial and complete lacerations. RESULTS We found that weight-bearing due to failure of postoperative immobilization was the most important factor influencing tendon repair rupture or gap formation. CONCLUSIONS As has been noted clinically, in our canine model failure and gapping of a flexor tendon repair was primarily the result of uncontrolled loading. Rehabilitation strategies that reduce the risk of catastrophic loading of the repair are critical to reducing the experimental failure rate when using dogs for flexor tendon research. Similar strategies may also reduce such failures in humans.
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Affiliation(s)
- Chunfeng Zhao
- Biomechanics Laboratory, Division of Orthopedic Research, Department of Orthopedics, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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19
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An KN. Tendon excursion and gliding: Clinical impacts from humble concepts. J Biomech 2007; 40:713-8. [PMID: 17092508 DOI: 10.1016/j.jbiomech.2006.10.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2006] [Accepted: 10/13/2006] [Indexed: 10/23/2022]
Abstract
As integral components of the musculoskeletal system, the primary function is transmission of muscle forces to the skeletal system. Proper excursion and gliding of the tendon determine the efficiency of this function. Studies of the tendon excursion and gliding based on two simple mechanical concepts have resulted in several significant clinical implications.
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Affiliation(s)
- Kai-Nan An
- Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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20
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Kutsumi K, Amadio PC, Zhao C, Zobitz ME, An KN. Gliding Resistance of the Flexor Pollicis Longus Tendon after Repair: Does Partial Excision of the Oblique Pulley Affect Gliding Resistance? Plast Reconstr Surg 2006; 118:1423-1428. [PMID: 17051113 DOI: 10.1097/01.prs.0000239595.97189.54] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND After tendon repair, it is critical for the repair site to pass smoothly under the pulley edge to promote gliding and reduce the risk of adhesion or rupture. In this study, the authors assessed the effect of partial excision by "squaring off" the distal edge of the oblique pulley on the gliding resistance of the flexor pollicis longus tendon after repair in vitro. METHODS Gliding resistance of 10 human thumbs was measured directly with three different sequential conditions: intact flexor pollicis longus tendon with intact A1 and oblique pulleys (group A), intact pulleys after repair of the tendon (group B), and after repair and excision of the distal triangular part (squaring off) of the oblique pulley (group C). RESULTS Gliding resistance increased significantly after repair and squaring off the oblique pulley (group A, 0.22 +/- 0.08 N; group B, 1.29 +/- 0.68 N; and group C, 2.01 +/- 0.84 N). CONCLUSIONS Previous studies suggest that the trimming of an annular pulley in the finger would not result in any significant mechanical disadvantage if other parts of the pulley system were intact. However, the authors' results suggest that in the case of the thumb oblique pulley, gliding resistance is increased after trimming and tendon repair, and thus the oblique pulley should be left intact if possible.
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Affiliation(s)
- Keiji Kutsumi
- Rochester, Minn. From the Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic College of Medicine
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21
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Abstract
The goals of flexor tendon repair are to promote intrinsic tendon healing and minimize extrinsic scarring in order to optimize tendon gliding and range of motion. Despite advances in the materials and methods used in surgical repair and postoperative rehabilitation, complications following flexor tendon injuries continue to occur, even in patients treated by experienced surgeons and therapists. The most common complication is adhesion formation, which limits active range of motion. Other complications include joint contracture, tendon rupture, triggering, and pulley failure with tendon bowstringing. Less common problems include quadriga, swan-neck deformity, and lumbrical plus deformity. Meticulous surgical technique and early postoperative tendon mobilization in a well-supervised therapy program can minimize the frequency and severity of these complications. Prompt recognition of problems and treatment with hand therapy, splinting, and/or surgery may help minimize recovery time and improve function. In the future, the use of novel biologic modulators of healing may nearly eliminate complications associated with flexor tendon injuries.
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Affiliation(s)
- Soma I Lilly
- Department of Orthopaedics, University of North Carolina School of Medicine, Chapel Hill, NC, 27610, USA
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22
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Tanaka T, Amadio PC, Zhao C, Zobitz ME, An KN. Effect of wrist and ulna head position on gliding resistance of the extensor digitorum minimi and extensor digitorum communis III tendons: a cadaver study. J Orthop Res 2006; 24:757-62. [PMID: 16514653 DOI: 10.1002/jor.20109] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
While attrition from sharp bony surfaces is the most common cause of extensor digiti minimi (EDM) tendon rupture, the etiology of other cases of spontaneous EDM tendon rupture is still unknown. Friction within the compartment may play a role, especially with ulna dislocation. The purpose of this study was to compare gliding resistance of the EDM tendon with that of a tendon which rarely ruptures spontaneously, the extensor digitorum communis of the middle finger (EDC III) tendon, under various wrist and ulna head positions. Eight fresh frozen cadavers were used. Gliding resistance between the tendon and its sheath in each compartment was measured in five different wrist positions and three different ulna head positions. Gliding resistance of the EDM tendon (0.13 +/- 0.03 N) was significantly greater than the EDC III tendon (0.09 +/- 0.03 N) (p < 0.05). For the EDM tendon, the gliding resistance in ulnar deviation or pronation was higher than the gliding resistance in neutral, radial deviation, or supination (p < 0.05), and the gliding resistance with ulnar lengthening (over 6 mm) or dorsal ulnar dislocation (over 9 mm) was higher than in neutral ulnar head positioning. For the EDC III tendon, the gliding resistance in ulnar deviation was significantly higher than the gliding resistance in neutral, radial deviation, or supination, or dorsal dislocation with ulnar lengthening (p < 0.05). Wrist ulnar deviation, ulnar dorsal dislocation (over 9 mm), and ulnar lengthening (over 6 mm) increased the gliding resistance of the EDM tendon. In patients at risk for EDM rupture, such as those with rheumatoid arthritis or distal radioulnar joint osteoarthritis, avoiding such positions may be advantageous.
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Affiliation(s)
- Toshikazu Tanaka
- Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, Minnesota 55905, USA
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23
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Taguchi M, Zhao C, Zobitz ME, An KN, Amadio PC. Effect of finger ulnar deviation on gliding resistance of the flexor digitorum profundus tendon within the A1 and A2 pulley complex. J Hand Surg Am 2006; 31:113-7. [PMID: 16443115 DOI: 10.1016/j.jhsa.2005.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2005] [Revised: 09/13/2005] [Accepted: 09/13/2005] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the effect of ulnar deviation of the finger on gliding resistance of the flexor digitorum profundus tendon within the A1 and A2 pulley complex. METHODS Thirty-two human cadaveric fingers (index through small fingers) were used. The gliding resistance was measured at 5 different angles of ulnar deviation (0 degrees, 15 degrees, 30 degrees, 45 degrees, 60 degrees). RESULTS There was a significant increase in gliding resistance with increased ulnar deviation. The gliding resistances at 0 degrees, 15 degrees, 30 degrees, 45 degrees, and 60 degrees of ulnar deviation were 0.40+/-0.13 N, 0.44+/-0.13 N, 0.55+/-0.17 N, 0.74+/-0.21 N, and 1.02+/-0.30 N, respectively. The gliding resistance at 60 degrees was significantly greater than at all other angles; 45 degrees ulnar deviation had significantly higher gliding resistance than 0 degrees, 15 degrees, and 30 degrees; and 30 degrees ulnar deviation had significantly higher gliding resistance than 0 degrees. CONCLUSIONS A greater angle of ulnar deviation causes higher gliding resistance during motion of the flexor digitorum profundus tendon within the A1 and A2 pulley complex. The gliding resistance increases significantly at angles greater than 30 degrees of ulnar deviation. The increased tendon loading needed to overcome increased gliding resistance caused by ulnar deviation could result in a vicious cycle of progressive ulnar deviation. Although mild degrees of ulnar deviation may be well tolerated mechanically a reasonable therapeutic guideline might be to prevent deviation from exceeding 30 degrees.
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Affiliation(s)
- Manabu Taguchi
- Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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24
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Abstract
This article describes an immediate active motion protocol for primary repair of zone I flexor tendons treated with tendon to tendon, or tendon to bone repair, and reviews clinical results. A rehabilitation protocol is proposed that will limit excursion of the zone I repair by blocking full distal interphalangeal (DIP) extension and by applying controlled active tension to both the unrepaired flexor digitorum superficialis (FDS) and the repaired flexor digitorum profundus (FDP). The rehabilitation technique utilized a dorsal protective splint with a relaxed position of immobilization with 30 degrees of wrist flexion, 40 degrees of metacarpophalangeal (MP) joint flexion, and a neutral position for the proximal interphalangeal (PIP) joints without dynamic traction. In addition, within the confines of the dorsal splint, the involved DIP joint was splinted at 40-45 degrees to prevent DIP joint extension during the early wound healing phases. Relaxed composite flexion was used to apply active tension to both the uninjured FDS, and the repaired FDP. This technique applies excursion of approximately 3 mm to the zone I tendon in a limited arc (45-75 degrees). The modified position of active flexion applies low loads of force (< 500 g), even with drag considered. This technique is supported by previous mathematical studies of excursion and internal tendon force, and clinical experience. Forty nine cases treated over a 10-year period were reviewed, and eight were excluded for incomplete follow-up. The use of this protocol for 41 zone I flexor digitorum profundus repairs by 12 different surgeons using varied surgical techniques was evaluated. None of the tendon to tendon repairs used more than two suture strands for the core repairs. Mean total active range of motion was 142 degrees (PIP 95 degrees plus DIP 47 degrees), or 81% of normal. Three tendons ruptured in non-protocol-related incidents and were excluded from the study. Results from this clinical study support the use of limited DIP extension combined with active tension with conventional repair in zone I.
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Affiliation(s)
- Roslyn B Evans
- Indian River Hand and Upper Extremity Rehabilitation, Vero Beach, Florida 32960, USA.
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25
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Abstract
The most important difference between the various approaches to postoperative digital flexor tendon rehabilitation is how the repaired tendon is treated during the first three to six weeks, in the earliest stages of healing. Early mobilization is the most commonly reported method of managing the healing flexor tendon. There are many different protocols and abundant research to support published approaches to tendon management. With so many choices, today's hand therapist must understand not only what those choices are, but also why and when to use them. There is no one correct way to manage a repaired flexor tendon; the specialist who does not understand how current techniques evolved is ill-equipped to design the appropriate treatment for a given patient. This article presents an overview of management options and how they have been developed over time, with special attention to changes in splint and exercise design in the crucial first few weeks after repair.
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Affiliation(s)
- Karen M Pettengill
- NovaCare Hand and Upper Extremity Rehabilitation, Springfield, Massachusetts, USA.
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26
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Hung LK, Pang KW, Yeung PLC, Cheung L, Wong JMW, Chan P. Active mobilisation after flexor tendon repair: comparison of results following injuries in zone 2 and other zones. J Orthop Surg (Hong Kong) 2005; 13:158-63. [PMID: 16131678 DOI: 10.1177/230949900501300209] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To prospectively study the role of active mobilisation after flexor tendon repair. METHODS The standard modified Kessler's technique was used to repair 46 digits in 32 patients with flexor tendon injuries. Early active mobilisation of the repaired digit was commenced on the third postoperative day. Range of movement was monitored and recovery from injury in zone 2 was compared with injury in other zones. RESULTS There were 24 and 22 injuries in zone 2 and other zones respectively. The total active motion score of the American Society for Surgery of the Hand was measured. Patients with zone-2 injuries achieved similar results to those with other-zone injuries apart from a 3-week delay in recovery. The final results were good to excellent in 71% and 77% of zone-2 and other-zone cases respectively (p < 0.05). There were 2 ruptures in zone-2 and one rupture in zone-3 repairs (6.5%). CONCLUSION Preliminary results of this study showed that active mobilisation following flexor tendon repair provides comparable clinical results and is as safe as conventional mobilisation programmes although recovery in patients with zone-2 injury was delayed.
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Affiliation(s)
- L K Hung
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong.
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27
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Abstract
Fracture healing and surgical decision making are not always predictable. The suggested protocols are intended to be flexible rather than rigid to be responsive to patient progress and the fracture site stability. A methodologic approach to the rehabilitation following a distal radius fracture, based on a knowledge of the biology of fracture healing and biomechanics of fixation, may preempt some of the pitfalls associated with distal radius fracture healing.
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28
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Su FC, Chou YL, Yang CS, Lin GT, An KN. Movement of finger joints induced by synergistic wrist motion. Clin Biomech (Bristol, Avon) 2005; 20:491-7. [PMID: 15836936 DOI: 10.1016/j.clinbiomech.2005.01.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2003] [Accepted: 01/10/2005] [Indexed: 02/07/2023]
Abstract
BACKGROUND An experiment has recently been conducted to evaluate and compare the differences in tendon excursions between the flexor digitorum profundus and superficialis using three mobilization techniques. No previous studies deal with the total joint excursions with constant tendon length. The purpose of this study was to investigate the coordinated motion between the finger and wrist joints resulting from passive tension of the muscles while performing synergistic wrist motion. METHODS The relative joint positions of the hand and wrist were measured using a three-dimensional motion analysis system with external retroreflective markers 2 mm in diameter placed on the dorsal surface of the hand. Fifty normal subjects, with a 1:1 gender ration, ranging in age from 20 to 40 years, and with no previous history of upper extremity injury, were recruited for the experiment. FINDINGS The relationships of synergistic motion between the wrist and finger joints due to passive tension in the muscles were approximately linear. The ranges of wrist motion averaged 60 degrees extension and 60 degrees flexion. Moving the wrist from flexion into extension induced synergistic finger joint motion as follows: the distal interphalangeal joint angles changed from an average of 12 degrees of flexion to 31 degrees; proximal-interphalangeal joint angles changed from 19 degrees to 70 degrees; and metacarpal phalangeal joints changed from 27 degrees to 63 degrees of flexion. INTERPRETATION The relationships of synergistic motion between the wrist and finger joints were systematically documented. Such a relationship could be considered in optimizing the design of dynamic splints used for rehabilitation in post-surgical tendon repair, as well as providing useful information about potential diagnoses of problems with the integrity of the flexor and extensor mechanisms.
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Affiliation(s)
- F-C Su
- Institute of Biomedical Engineering, National Cheng Kung University, Motion Analysis Laboratory, 1 University Road, Tainan 701, Taiwan.
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29
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Yang C, Zhao C, Amadio PC, Tanaka T, Zhao KD, An KN. Total and intrasynovial work of flexion of human cadaver flexor digitorum profundus tendons after modified Kessler and MGH repair techniques. J Hand Surg Am 2005; 30:466-70. [PMID: 15925153 DOI: 10.1016/j.jhsa.2004.10.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2004] [Revised: 10/22/2004] [Accepted: 10/25/2004] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to compare directly the total work of flexion (TWOF) and the intrasynovial work of flexion (IWOF) of human flexor digitorum profundus tendons and to analyze the ratio of the IWOF to the TWOF of human flexor digitorum profundus tendons. These factors may be important clinically in understanding the role of different methods of postoperative tendon rehabilitation for different types of tendon repairs, especially at the early stage after tendon repair. METHODS Two different tendon repairs, the modified Kessler and the Massachusetts General Hospital, were used in 18 digits from 6 freshly frozen human cadaver hands. The TWOF and the IWOF were tested by using a digit-resistance testing device. RESULTS After tendon repair the TWOF increased 11.2% and 26.9% for the modified Kessler and MGH groups, respectively. The differences in increase between the 2 groups were significant. The IWOF increased 126.8% and 308.8% for the modified Kessler and Massachusetts General Hospital groups, respectively. The IWOF accounted for 16.4% of the TWOF for the intact tendon; this percentage was 28.6% and 45.0% for the modified Kessler and Massachusetts General Hospital groups, respectively. CONCLUSIONS The IWOF accounts for 16% of the TWOF of normal human cadaver digits but it accounts for a much higher fraction after tendon repair. The ratio of the work of flexion within the synovial sheath to the TWOF varies depending on the type of repair chosen.
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Affiliation(s)
- Chao Yang
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
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30
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Kutsumi K, Amadio PC, Zhao C, Zobitz ME, An KN. Gliding resistance of the extensor pollicis brevis tendon and abductor pollicis longus tendon within the first dorsal compartment in fixed wrist positions. J Orthop Res 2005; 23:243-8. [PMID: 15734232 DOI: 10.1016/j.orthres.2004.06.014] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2004] [Accepted: 06/18/2004] [Indexed: 02/04/2023]
Abstract
PURPOSE While the etiology of de Quervain's disease is unknown, repetitive motion coupled with awkward wrist position and septation within the first dorsal compartment are considered causative factors. We hypothesize that these conditions might produce high gliding resistance, which could then induce micro-damage of the tendons and retinaculum. The purpose of this study was to measure the gliding resistance of the extensor pollicis brevis and abductor pollicis longus tendons within the first dorsal compartment in a human cadaver model. METHODS Fifteen human cadaver wrists, which included eight septation and seven non-septation wrists in the first dorsal compartment, were used. Gliding resistance of the extensor pollicis brevis and abductor pollicis longus tendons was measured in seven wrist positions: 60 degrees extension, 30 degrees extension, 0 degrees, 30 degrees flexion, 60 degrees flexion in neutral deviation and 30 degrees ulnar deviation, 15 degrees radial deviation in neutral extension/flexion. RESULTS The overall gliding resistance was not different between septation and non-septation wrists (0.21 versus 0.19 N for abductor pollicis longus and 0.21 versus 0.15 N for extensor pollicis brevis, respectively), but there was a significant effect on gliding resistance due to wrist position (p<0.05) in both tendons. Interaction between wrist position and septation status was observed in the extensor pollicis brevis tendon (p<0.05). With septation, the gliding resistance of the extensor pollicis brevis was significantly higher in 60 degrees wrist flexion (0.51 N) compared to all other wrist positions tested (all less than 0.26 N) (p<0.05). In the non-septation group, gliding resistance was significantly higher in 60 degrees flexion (0.20 N) and 60 degrees extension (0.22 N) compared to the other five wrist positions (all less than 0.15 N) (p<0.05). Although no significant difference was observed, the extensor pollicis brevis tendon with septation tended to have higher gliding resistance than that without septation in wrist flexion. In 60 degrees of wrist flexion the abductor pollicis longus tendon had significantly higher gliding resistance (0.33 N) than the other wrist positions (all less than 0.26 N) (p<0.05). CONCLUSIONS A combination of septation and wrist position significantly affected extensor pollicis brevis tendon gliding resistance in this cadaver model. These factors may contribute to the development of de Quervain's disease.
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Affiliation(s)
- Keiji Kutsumi
- Orthopedic Biomechanics Laboratory, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA
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31
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Li Z, Smith BP, Smith TL, Koman LA. Friction of the gliding surface. Implications for tendon surgery and rehabilitation. J Hand Ther 2005; 18:270-6. [PMID: 15891984 PMCID: PMC1370263 DOI: 10.1197/j.jht.2005.02.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Finger flexor tendon rehabilitation has come a long way, but further advances are possible. Ideally, a healing tendon should move, but under the minimum load necessary to achieve motion. It is possible to design suture repairs that minimize the friction between tendon and sheath while simultaneously maintaining adequate strength to provide a wide margin of safety during therapy. A looped, four-strand modified Kessler repair is a good example of this type of high-strength, low-friction repair. At the same time, rehabilitation methods can also be optimized. A new modified synergistic motion protocol is described in which wrist flexion and finger extension is alternated with wrist and metacarpophalangeal joint extension and finger interphalangeal joint flexion. Based on evidence from basic science studies, the authors hypothesize that this new protocol will deliver more effective proximal tension on the tendon repair than either passive flexion/active extension or synergistic protocols, and may be useful in patients who are not ready for, or are not reliable with, active motion or place and hold protocols. The scientific basis for these new methods is reviewed, and the concept of the "safe zone" for tendon loading, in which tendon motion occurs without gapping of the repair site, is developed.
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Affiliation(s)
- Zhongyu Li
- Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157-1070, USA
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32
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Tanaka T, Amadio PC, Zhao C, Zobitz ME, An KN. Flexor digitorum profundus tendon tension during finger manipulation. J Hand Ther 2005; 18:330-8; quiz 338. [PMID: 16059854 PMCID: PMC1307525 DOI: 10.1197/j.jht.2005.04.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Abstract The purpose of this study was to measure the tension in the flexor digitorum profundus (FDP) tendon in zone II and the digit angle during joint manipulations that replicate rehabilitation protocols. Eight FDP tendons from eight human cadavers were used in this study. The dynamic tension in zone II of the tendon and metacarpophalangeal (MCP) joint angle were measured in various wrist and digit positions. Tension in the FDP tendon increased with MCP joint extension. There was no tension with the finger fully flexed and wrist extended (synergistic motion), but the tendon force reached 1.77 +/- 0.43 N with the MCP joint hyperextended 45 degrees with the distal interphalangeal and proximal interphalangeal joints flexed. The combination of wrist extension and MCP joint hyperextension with the distal interphalangeal and proximal interphalangeal joints fully flexed, what the authors term "modified synergistic motion," produced a modest tendon tension and may be a useful alternative configuration to normal synergistic motion in tendon rehabilitation.
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Affiliation(s)
| | - Peter C. Amadio
- Correspondence and reprint requests to Dr. Amadio, Division of Orthopedic Research, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905; e-mail: <>
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Zhao C, Amadio PC, Tanaka T, Yang C, Ettema AM, Zobitz ME, An KN. Short-term assessment of optimal timing for postoperative rehabilitation after flexor digitorum profundus tendon repair in a canine model. J Hand Ther 2005; 18:322-9; quiz 329. [PMID: 16059853 PMCID: PMC1351120 DOI: 10.1197/j.jht.2005.04.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Abstract The purpose of this study was to compare the short-term outcome following flexor tendon repair for postoperative rehabilitation commencing on day 1 (a common clinical choice) versus day 5 (the day on which, with postoperative immobilization, the initial gliding resistance is least in this model) in an in vivo canine model. Work of flexion (WOF) and tendon strength were evaluated following tendon laceration and repair in 24 dogs sacrificed 10 days postoperatively. Starting postoperative mobilization at day 5 resulted in no tendon ruptures compared with tendon ruptures in four of the dogs (33%) in the group subjected to mobilization starting at day 1. While there was no statistically significant difference in WOF between groups at day 10, there was a trend toward lower resistance favoring the day 5 start group, and the statistical power to detect a difference in WOF was diminished by the ruptures in the day 1 group. We conclude that starting rehabilitation on day 5, when initial gliding resistance is lower, may have an advantage over earlier starting times, when surgical edema and other factors increase the initial force requirements to initiate tendon gliding. We plan further studies to evaluate the longer-term benefits of this rehabilitation program.
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Affiliation(s)
| | - Peter C. Amadio
- Correspondence and reprint requests to Peter C. Amadio, MD, Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic College of Medicine, Rochester, MN 55905; e-mail: <>
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Abstract
Postoperative rehabilitation for patients who have sustained a laceration to their flexor tendon apparatus is an important factor in maximizing functional outcome. Quality rehabilitation is characterized by the development of a tailored exercise regimen. There is currently no model available to tailor an exercise regimen for a person with an atypical physiologic response pattern. If rehabilitation protocols were classified according to the criteria of forces applied across a tendon juncture and/or excursion, and a clinical method were available to assist in the identification of optimal tendon loading and/or excursion application, then those individuals with atypical response patterns could be treated more efficiently and effectively. The author conducted a literature review and case study. A model for systematic application of progressive loading exercises to the intrasynovial flexor tendon injury and repair is conceptually developed. The model consists of a pyramidal series of eight specific rehabilitation exercises in the following sequence: passive protected extension, place and hold, active composite fist, hook and straight fist, isolated joint motion, resistive composite fist, resistive hook and straight fist, and resistive isolated joint motion. Concepts are developed to implement a three-point clinical adhesion-grading system. Clinical application of the system is highlighted. An excellent outcome was considered 112% total active motion. A model for systematic application of progressive loading exercises has been conceptually developed in concert with a method for determination of optimal tendon loading. Further substantiation is necessary to validate the proposed theory.
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Affiliation(s)
- Gail N Groth
- Department of Industry and Manufacturing Engineering, College of Engineering and Applied Science, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA.
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Kutsumi K, Amadio PC, Zhao C, Zobitz ME, An KN. Measurement of gliding resistance of the extensor pollicis longus and extensor digitorum communis II tendons within the extensor retinaculum. J Hand Surg Am 2004; 29:220-4. [PMID: 15043892 DOI: 10.1016/j.jhsa.2003.10.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2003] [Revised: 09/29/2003] [Accepted: 09/29/2003] [Indexed: 02/02/2023]
Abstract
PURPOSE The etiology of spontaneous extensor pollicis longus (EPL) tendon rupture is still largely unknown. It is possible that friction within the sheath may play a role. The purposes of this study were to compare gliding resistance of the EPL tendon with that of the extensor digitorum communis tendon of the index finger (EDC II) and to find the wrist position that gives the EPL tendon the lowest gliding resistance. METHODS Fifteen fresh-frozen cadavers were used. Gliding resistance was measured directly in 7 different wrist positions. RESULTS The mean gliding resistance of the EPL tendon was 0.16 +/- 0.08 N and that of the EDC II tendon was 0.11 +/- 0.06 N. This difference was significant. There was also a significant effect on gliding resistance due to wrist position. For the EPL tendon, the gliding resistance was significantly greater in 60 degrees wrist flexion compared with all other wrist positions tested. Additionally the gliding resistance of the EPL in 30 degrees flexion, 60 degrees extension, and 15 degrees radial deviation was significantly higher than wrist positions of 30 degrees extension, neutral, and 30 degrees ulnar deviation. CONCLUSIONS Positioning the wrist close to neutral flexion/extension and in some ulnar deviation minimizes the friction within the EPL sheath. Such positions may be advantageous for splinting patients at risk for EPL rupture.
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Affiliation(s)
- Keiji Kutsumi
- Orthopedic Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
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Zhao C, Amadio PC, Paillard P, Tanaka T, Zobitz ME, Larson DR, An KN. Digital resistance and tendon strength during the first week after flexor digitorum profundus tendon repair in a canine model in vivo. J Bone Joint Surg Am 2004; 86:320-7. [PMID: 14960677 DOI: 10.2106/00004623-200402000-00015] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND After flexor tendon repair, the strength of the repair and the resistance to digital motion are important considerations in deciding when to initiate postoperative rehabilitation. Our objective was to assess these factors in a short-term in vivo canine model of flexor tendon repair. METHODS Forty-eight dogs were randomly allocated to four groups based on the duration of postoperative follow-up (one, three, five, or seven days). In each group, two flexor digitorum profundus tendons of one forepaw were exposed. One tendon (the repair tendon) was sharply transected and repaired with a modified Kessler suture, and the other one (the sham tendon) was simply exposed without laceration. The involved paw was immobilized until the animal was killed on the designated day. Three tendons from each dog, including the repair tendon, the sham tendon, and a control tendon from a corresponding normal digit on the contralateral side, were tested. RESULTS The mean peak total digital resistance force in the repair group was lowest at five days (p < 0.01 compared with seven days; p > 0.05 compared with one and three days). The mean peak force needed to overcome the internal gliding resistance between the repaired tendon and sheath was significantly higher than that in both the sham and control groups at all time-points (p < 0.001); however, this value was also smallest at five days. There was no significant difference in suture strength at any time-point (p > 0.05). CONCLUSIONS When we evaluated tendon-gliding and suture strength after flexor tendon repair, the least favorable ratio of repair strength to force needed to overcome the resistance to digital motion was noted on Day 7, whereas the best combination of tendon strength and low peak resistance force was noted on Day 5.
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Affiliation(s)
- Chunfeng Zhao
- Orthopedic Biomechanics Laboratory, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA
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Abstract
This article describes an early active motion protocol for use after a four-strand flexor tendon repair. The protocol uses a simple dorsal blocking splint with the wrist in neutral and four fingers in rubber band traction for the first five weeks, then gradually advances the patient over the next seven weeks. The patient is able to perform the exercises without changing the splint at home during the first five weeks of the protocol. The results of the retrospective chart review are promising. Of 40 digits, 95% experienced excellent and good results in zone II, and 87.5% experienced excellent and good results in zones I, II, and III. One rupture (2.5%) occurred in a noncompliant patient. The DASH scale was used to determine functional outcome, with results of 7.82 on the physical function/symptoms category, 16.07 in sports/ performing arts, and 10.23 in the work category.
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Affiliation(s)
- Linda Klein
- Hand Surgery, Ltd., Milwaukee, Wisconsin 53226, USA.
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Chu MML. Splinting programmes for tendon injuries. HAND SURGERY : AN INTERNATIONAL JOURNAL DEVOTED TO HAND AND UPPER LIMB SURGERY AND RELATED RESEARCH : JOURNAL OF THE ASIA-PACIFIC FEDERATION OF SOCIETIES FOR SURGERY OF THE HAND 2002; 7:243-9. [PMID: 12596287 DOI: 10.1142/s0218810402001230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
It is beyond doubt that splinting programmes have often been an integral and important part of the rehabilitation process in tendon injuries. Over the past three decades, hand splints for tendon injuries of various designs and different mobilisation programmes have been developed in the hope of pursuing better clinical and functional outcome for patients. In this paper, the development of different splinting programmes in flexor and extensor tendon injuries and the current practice in some acute hospitals in Hong Kong were discussed.
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Affiliation(s)
- Mary M L Chu
- Department of Occupational Therapy, Queen Mary Hospital, Pokfulam, Hong Kong China.
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Abstract
The study of loading in the muscle is essential to better understanding the adaptation and plasticity of the muscle under pathologic or surgically-altered conditions. Muscle recruitment and muscle force are determined by the muscle's mechanical function as a joint mover and a joint stabilizer. The coordination of muscle contraction affects joint stability. However, the conditions of the joint passive constraints influence the muscle recruitment. Furthermore, muscle force is regulated based on muscle size, such as the physiologic cross-sectional area, and its physiology, namely, the length-tension and the tension-velocity relationship. Alterations of these physiologic relationships also will influence the overall mechanical function of the muscle.
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Affiliation(s)
- Kai-Nan An
- Division of Orthopedic Research, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA
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Fess EE. Splinting flexor tendon injuries. HAND SURGERY : AN INTERNATIONAL JOURNAL DEVOTED TO HAND AND UPPER LIMB SURGERY AND RELATED RESEARCH : JOURNAL OF THE ASIA-PACIFIC FEDERATION OF SOCIETIES FOR SURGERY OF THE HAND 2002; 7:101-8. [PMID: 12365053 DOI: 10.1142/s0218810402000820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Frequently used zone 2 flexor tendon repair splints are reviewed and classified according to the American Society of Hand Therapists' Splint Classification System. These splints both restrict and mobilise digital motion and fall into two main groups: (1) splints that incorporate the wrist and digital joints as primary joints to allow predetermined increments of early passive or active motion at both the wrist and digital joints; and (2) splints that include the wrist as a secondary joint and the digital joints as primary joints, allowing early passive or active motion at digital joints but not at the wrist.
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Zhao C, Amadio PC, Zobitz ME, Momose T, Couvreur P, An KN. Effect of synergistic motion on flexor digitorum profundus tendon excursion. Clin Orthop Relat Res 2002:223-30. [PMID: 11859247 DOI: 10.1097/00003086-200203000-00033] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Clinical and experimental studies have shown that postoperative rehabilitation is an important factor that improves digital function after flexor tendon repair. In the current study, the effect of synergistic wrist and finger motion therapy and fixed flexed wrist motion therapy on the in vivo gliding excursion was evaluated after repair of partial laceration of the canine flexor digitorum profundus tendon. The gliding excursion of the repaired tendons treated with synergistic wrist and finger motion therapy was significantly greater than that of tendons rehabilitated with the wrist fixation therapy, suggesting that wrist extension generates force that can pull the repair site through the pulley, thereby increasing passive excursion of the tendon. As a result of increased tendon excursion, synergistic therapy may improve the clinical outcome after repair of partial tendon lacerations.
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Affiliation(s)
- Chunfeng Zhao
- Orthopedic Biomechanics Laboratory, Mayo Clinic/Mayo Foundation, Rochester, MN 55905, USA
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Momose T, Amadio PC, Zhao C, Zobitz ME, Couvreur PJ, An KN. Suture techniques with high breaking strength and low gliding resistance: experiments in the dog flexor digitorum profundus tendon. ACTA ORTHOPAEDICA SCANDINAVICA 2001; 72:635-41. [PMID: 11817881 DOI: 10.1080/000164701317269085] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
We studied the breaking strength and gliding resistance between the pulley and flexor tendon for various suture techniques. Canine flexor digitorum profundus tendons were transected and sutured using one of eight repair techniques: modified Kessler (MK); Tsuge (Tsuge); two variations of a double modified Kessler (DK1, DK2); combined modified Kessler-modified Tsuge (MKT); augmented Becker (Becker); Cruciate (Cruciate); and modified double Tsuge (DT). The force to produce a 1.5 mm gap, ultimate failure load, resistance to gap formation, and gliding resistance were measured. The force to produce a 1.5 mm gap and the ultimate breaking force were higher with the DK1, DK2, MKT, Becker, Cruciate, and DT repairs than they were with the MK and Tsuge repair, while the gliding resistance of the Becker was higher than that of the MK, DK1, DK2, MKT. Cruciate, and UT repairs. In addition to confirming that repair strength increases as the number of strands crossing the repair increases, we also found that these stronger repairs need not produce higher gliding resistance than less robust repairs.
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Affiliation(s)
- T Momose
- Division of Orthopedic Research, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA
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Zhao C, Amadio PC, Zobitz ME, An KN. Gliding characteristics of tendon repair in canine flexor digitorum profundus tendons. J Orthop Res 2001; 19:580-6. [PMID: 11518265 DOI: 10.1016/s0736-0266(00)00055-3] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The gliding resistance between the flexor digitorum profundus (FDP) tendon and the proximal pulley system was measured using the method of S. Uchiyama, J.H. Coert, L. Berglund, P.C. Amadio, K.N. An (J. Orthop. Res. 13 (1995) 83) in 108 adult dog digits in vitro. The FDP tendons were then lacerated to 80% of their transverse section. Each tendon was repaired with one of the following six suture techniques: Kessler, modified Kessler, Savage, Lee, Becker and simple running suture alone. Each repaired tendon was then tested again using the same method. The Student-Newman-Keuls test for multiple comparisons was performed for statistical analysis. The average gliding resistances of the Kessler, Savage, and Becker repairs were significantly greater than the resistances of the Lee, modified Kessler, and running suture alone repairs (P < 0.05). The Lee suture technique had a significantly greater resistance than the modified Kessler repair and the running suture (P < 0.05). The results of the peak gliding resistance followed the same trends, except that the modified Kessler repair was significantly higher than the running suture alone (P < 0.05). Suture techniques with a multi-strand core suture, with knots located outside the tendon surface, and with multiple-loops on the tendon surface may result in increased gliding resistance between the tendon and pulley system after tendon repair.
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Affiliation(s)
- C Zhao
- Orthopedic Biomechanical Laboratory, Mayo Clinic/Mayo Foundation, Rochester, Minnesota, USA
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45
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Silva MJ, Brodt MD, Boyer MI, Morris TS, Dinopoulos H, Amiel D, Gelberman RH. Effects of increased in vivo excursion on digital range of motion and tendon strength following flexor tendon repair. J Orthop Res 1999; 17:777-83. [PMID: 10569491 DOI: 10.1002/jor.1100170524] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Postoperative rehabilitation is an important factor in determining functional outcome following intrasynovial flexor tendon repair. We hypothesized that a rehabilitation protocol that produced increased in vivo excursion would lead to increased digital range of motion and tendon strength and decreased adhesion formation in a canine model. Ninety-six flexor digitorum profundus tendons from 48 dogs were cut transversely and repaired by a multistrand suture technique. Postoperative rehabilitation was performed daily with a low excursion-low force (1.7-mm average excursion; < 10 N force) or a high excursion-low force (3.6 mm excursion; < 10 N force) protocol. After death of the dogs at 10, 21, or 42 days, specimens were evaluated for digital range of motion, tensile mechanical properties, elongation of the repair site, and adhesion formation. Our data indicate that the range of motion of digits whose tendons were at low or high excursion was similar to that of controls. Increased in vivo tendon excursion due to synergistic wrist motion did not significantly affect ex vivo flexion of the distal and proximal interphalangeal joints or tendon displacement (p > 0.05). Similarly, tensile properties (ultimate load, repair site rigidity, and repair site strain at 20 N and at failure) and length of the gap at the repair site were not significantly affected by increased excursion (p > 0.05). Severity of adhesion formation was reduced slightly by increased excursion (p = 0.04). Our findings indicate that 1.7 mm of tendon excursion is sufficient to prevent adhesion formation following sharp transection of the canine flexor tendon and that additional excursion provides little added benefit.
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Affiliation(s)
- M J Silva
- Department of Orthopaedic Surgery, Barnes-Jewish Hospital at Washington University School of Medicine, St. Louis, Missouri 63110, USA.
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Nishida J, Amadio PC, Bettinger PC, An KN. Flexor tendon-pulley interaction after pulley reconstruction: a biomechanical study in a human model in vitro. J Hand Surg Am 1998; 23:665-72. [PMID: 9708381 DOI: 10.1016/s0363-5023(98)80053-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Ten cadaver digits were used to evaluate excursion resistance between a tendon and pulley after completing 4 methods of pulley reconstruction (Bunnell's, Kleinert's, Lister's, and Karev's techniques). Five tissues (palmaris longus tendon, extensor digitorum tendon, flexor digitorum superficialis tendon, extensor retinaculum, and volar plate) were used to reconstruct the A2 pulley. Intrasynovial tissue sources (extensor retinaculum, volar plate, and flexor digitorum superficialis tendon) produced less excursion resistance than extrasynovial tissue sources (extensor digitorum tendon and palmaris longus tendon). The models using the extensor retinaculum and volar plate as reconstructive materials produced less excursion resistance than the normal A2 pulley, whereas the models using the palmaris longus tendon produced the highest excursion resistance. Bunnell's technique of pulley reconstruction produced less excursion resistance than Kleinert's technique with all 3 tissues tested. The results of the in vitro study of excursion resistance between the tendon and reconstructed pulley demonstrated that Lister's technique of pulley reconstruction using the extensor retinaculum produced the least resistance to tendon gliding.
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Affiliation(s)
- J Nishida
- Department of Orthopedics, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA
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47
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Nishida J, Seiler JG, Amadio PC, An KN. Flexor tendon-pulley interaction after annular pulley reconstruction: a biomechanical study in a dog model in vivo. J Hand Surg Am 1998; 23:279-84. [PMID: 9556269 DOI: 10.1016/s0363-5023(98)80127-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The excursion resistance between the canine flexor digitorum profundus tendon and A2 pulley was compared after pulley reconstruction using tendon grafts of either intrasynovial or extrasynovial origin at 10 days, 3 weeks, and 6 weeks after surgery. The changes over time in the underlying flexor digitorum profundus tendon after pulley reconstruction were also evaluated. The excursion resistance for both types of pulley reconstruction was significantly greater than that of the control group at all time periods. The excursion resistance of the extrasynovial tendon graft reconstruction was greater than that of intrasynovial pulley reconstruction at all time periods. In conclusion, pulley reconstruction with intrasynovial tendon grafts may facilitate tendon gliding after surgery.
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Affiliation(s)
- J Nishida
- Department of Orthopedic Surgery, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA
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Bischoff RJ, Morifusa S, Gelberman RH, Winters SC, Woo SL, Seiller JG. The effects of proximal load on the excursion of autogenous flexor tendon grafts. J Hand Surg Am 1998; 23:285-9. [PMID: 9556270 DOI: 10.1016/s0363-5023(98)80128-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
To determine the relationship between the intrinsic properties of tendon and tendon excursion in 2 types of autogenous tendon grafts, hindpaw intrasynovial and extrasynovial tendons were transferred to the lateral and medial forepaws of adult mongrel dogs (16 experimental and 16 control tendons). After each digit was marked with radiopaque markers, it was placed in a specialized jig, and weights of 25 g, 100 g, or 200 g were applied to the flexor tendons. Specialized radiographs were obtained with the digit in flexion and extension. Tendon excursion and joint rotation were calculated. There were no statistically significant differences between experimental groups for tendon excursion or for joint angular rotation (p > .05). For intrasynovial tendon grafts, the angular rotation per millimeter tendon excursion was 10.9 degrees +/- 2.4 degrees/mm, 9.4 degrees +/- 1.2 degrees/mm, and 9.0 degrees +/- 1.4 degrees/mm with 25-g, 100-g, and 200-g loads, respectively. Comparisons between experimental groups revealed that a statistically significant difference could not be determined (p > .05). With varying proximal loads, both intrasynovial and extrasynovial grafts showed similar amounts of tendon excursion. Variations in proximal load did not significantly influence the amount of excursion within the range of loads tested. Based on these data, it appears that the difference in repair potential for these 2 types of tendon grafts is not related to a differential in the amount of tendon graft excursion following transfer to the synovial space.
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Affiliation(s)
- R J Bischoff
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
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Uchiyama S, Amadio PC, Coert JH, Berglund LJ, An KN. Gliding resistance of extrasynovial and intrasynovial tendons through the A2 pulley. J Bone Joint Surg Am 1997; 79:219-24. [PMID: 9052543 DOI: 10.2106/00004623-199702000-00009] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The gliding ability of the flexor digitorum profundus tendon and of the palmaris longus tendon through the A2 pulley was compared, in terms of gliding resistance, with use of a system that we developed. Fourteen digits and the ipsilateral palmaris longus tendons from fourteen cadavera were used. The average gliding resistance at the interface between the palmaris longus tendon and the A2 pulley was found to be greater than that between the flexor digitorum profundus tendon and the A2 pulley under similar loading conditions. We concluded that the gliding ability of the palmaris longus tendon was inferior to that of the flexor digitorum profundus tendon in vitro.
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Affiliation(s)
- S Uchiyama
- Orthopedic Biomechanics Laboratory, Mayo Clinic, Rochester, Minnesota 55905, USA.0
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50
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Affiliation(s)
- R B Evans
- Indian River Hand Rehabilitation, Inc., Vero Beach, Florida 32960, USA
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