La plastie d'expansion en Oméga « Ω ». Une nouvelle technique d'expansion des poulies annulaires du tunnel digital fléchisseur

Secondary Procedures following Flexor Tendon Reconstruction

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the indications and management options for secondary flexor tendon reconstruction, including tenolysis, tendon grafting, and tendon transfers. 2. Understand the reconstructive options for pulley reconstruction. 3. Understand the options for management of isolated flexor digitorum profundus injuries.

SUMMARY

Despite current advances in flexor tendon repair, complications can still occur following surgery. This article presents the spectrum of treatment options for secondary flexor tendon reconstruction ranging from tenolysis to one- and two-stage tendon grafting, and tendon transfers. In addition, an overview of pulley reconstruction and the treatment of isolated flexor digitorum profundus injuries are discussed. A management algorithm for secondary flexor tendon reconstruction is provided.

Up to five-week delay in primary repair of Zone 2 flexor tendon injuries: outcomes and complications

We report the outcomes of delayed primary repair of flexor tendons in Zone 2 in 31 fingers and thumb (28 patients) averaging 15 days (range 4-37) after injury in 2020. The delay was longer than usual due to the COVID-19 pandemic. The tendons were repaired with a 6-strand core suture (M-Tang method) or a double Tsuge suture and a peripheral suture. This was followed by an early, partial-range, active flexion exercise programme. Adhesions in four digits required tenolysis. These patients were not with longest delay. Outcomes of two improved after tenolysis. The other two patients declined further surgery. One finger flexor tendon ruptured in early active motion. This was re-repaired, and final outcome was good. Overall excellent and good results using the Tang criteria were in 27 out of 31 fingers and thumbs (87%). The time elapsed between the injury and surgery is not an important risk factor for a good outcome, rather it depends on proper surgical methods, the surgeon's experience and early mobilization, properly applied. Adhesions may occur, but they can be managed with tenolysis.Level of evidence: IV.

Widening of Pulley by Interdigitating Cuts

While biomechanically important, pulleys present multiple challenges to a zone 2 flexor tendon repair and rehabilitation. Retrieval of tendon through an intact pulley is cumbersome. Following repair, venting is often needed to accommodate the bulk at repair site. On occasion, step lengthening, or even complete division of pulley and reconstruction with tendon graft are necessary. Finally, accessing the tendon under the pulley during tenolysis is difficult. The primary issue in all such cases is the lack of space under the pulley. We describe a technique of expanding the pulley by interdigitating cuts. This technique greatly increases the diameter of the pulley which could be demonstrated in cadaver model and noted in clinical setting. This technique is easy to perform and maintains the integrity of the pulley without complete division. It would allow easy tendon retrieval, provide space for the repair and gliding, and improve exposure during tenolysis.

US-guided percutaneous release of the first extensor tendon compartment using a 21-gauge needle in de Quervain's disease: a prospective study of 35 cases

PURPOSE

To evaluate the efficacy of ultrasonography-guided percutaneous treatment of de Quervain tenosynovitis with the combination of a corticosteroid injection and release of the retinaculum of the first extensor compartment tendons with a 21-gauge needle.

MATERIALS AND METHODS

The first part of our study consisted of ten procedures on cadaver wrists followed by dissection to analyse the effectiveness of the retinaculum release and detect any collateral damage. The second part was a prospective clinical study of 35 procedures. Outcomes were evaluated through a 6-month clinical follow-up and telephone interview at the end of the study. The following parameters were monitored over time: pain level on a visual analogue scale, the QuickDASH and the PRWE. Patient satisfaction questionnaires were also administered.

RESULTS

No complications were found during the cadaver study. However, the release was confirmed as 'partial' in all wrists. In the clinical portion of this study, significant improvement was observed in 91.4 % of cases (32/35) within 1 month and the results were stable until the end of the study; all of these patients avoided surgery. The release procedure failed in three patients who eventually required surgical treatment.

CONCLUSION

US-guided partial release and simultaneous corticosteroid injection for treatment of de Quervain's disease using a 21-gauge needle is feasible in current practice, with minimal complications.

KEY POINTS

• Ultrasound-guided treatment of de Quervain's disease is feasible with a 21G needle. • There was notable regression of clinical signs in 91.4 % of cases. • The procedure is very safe, no iatrogenic neurovascular or tendinous injuries occurred. • Our procedure requires only one session and 3 days away from work.

[Primary flexor tendons repair in zone 2]

Primary flexor tendon repair is still challenging even in the most experienced hands. With atraumatic surgery, the goal is to suture the tendon in a way that it will be strong enough to allow for tendon gliding without the risk of rupture or adhesions during the 12 weeks needed for the tendon to heal. After reviewing the zone 2 anatomy, the authors describe the state of art for flexor tendon repair along with their personal preferences. Although suture methods and postoperative rehabilitation programs are not universal, most specialized teams now use multistrand suturing techniques with at least 4 stands along with protected and controlled early active mobilization. Although the published rates of failure of the repair or postoperative adhesions with stiffness have decreased, these complications are still a concern. They will continue to pose a challenge for scientists performing research into the mechanics and biology of flexor tendon repairs, especially in zone 2.

[Management of zone 1 flexor digitorum profundus tendon injuries]

Flexor tendons repair in zone 1 is classically considered providing good results with an overall satisfactory finger function. However, the objective functional results after surgical repair of flexor digitorum profundus are sometimes disappointing. The authors describe the different surgical repair techniques available to the operator from so-called "traditional" sutures to newer methods of internal fixation using miniaturized anchor sutures. The management of postoperative procedures, that of failures and old cases are reported.

Outcomes and evaluation of flexor tendon repair

This article reviews recent reports of outcomes of flexor tendon repair and discusses the problems associated with such surgeries. Reports of no repair rupture in individual case series have emerged recently. Their results move toward the clinical goal of primary repair without repair rupture. The Strickland method remains the most common to record the outcomes. Outcomes should be provided by subzones of the tendon injuries, and the level of expertise of the surgeons expertise should be reported to allow comparisons of the results.

The effect of epitendinous suture technique on gliding resistance during cyclic motion after flexor tendon repair: a cadaveric study

PURPOSE

To investigate the effects of motion following repair with a modified Kessler core suture and 5 different epitendinous suture designs on the gliding resistance, breaking strength, 2-mm gap force, and stiffness of flexor digitorum profundus tendons in a human in vitro model.

METHODS

The flexor digitorum profundus tendons of the index, middle, ring, and little fingers of 50 human cadavers were transected and repaired with a 2-strand modified Kessler suture and assigned to 5 groups based on type of epitendinous suture design. The 5 epitendinous designs tested were a simple, running epitendinous suture whose knot was outside the repair (simple running KO); a simple, running epitendinous suture whose knot was inside the repair (simple running KI); a cross-stitch epitendinous suture; an interlocking, horizontal mattress (IHM) epitendinous suture; and a running-locking epitendinous suture. The tendon repair strength and 2-mm gap force were measured after 1,000 cycles of tendon motion. The resistance to gap formation, a measure of repair stiffness, was obtained from the force versus gap data.

RESULTS

None of the repairs showed any gap formation after 1,000 cycles of tendon motion. The cross-stitch epitendinous suture, IHM epitendinous suture, and running-locking epitendinous suture all had significantly lower gliding resistance than the simple running KO epitendinous suture after 1 cycle. The simple running KI epitendinous suture had significantly lower gliding resistance than the simple running KO epitendinous suture after 100 cycles and 1,000 cycles. The differences for gap force at 2 mm and stiffness of the repaired tendon evaluation were not statistically significant. The cross-stitch epitendinous suture, IHM epitendinous suture, and running-locking epitendinous suture all had significantly higher maximal failure strength after 1,000 cycles than the simple running KI epitendinous suture.

CONCLUSIONS

The cross-stitch, IHM, and running-locking epitendinous sutures had the best combination of higher strength and lower gliding resistance in this study. Although these findings suggest a potential for these suture types to be preferred as epitendinous sutures, these repairs should first be investigated in vivo to address their effect on tendon healing and adhesion formation.

A2 pulley incision or one slip of the superficialis improves flexor tendon repairs

Outcomes of flexor tendon repairs in the area covered by major pulleys are often unpredictable. We performed an in vivo study to investigate biomechanical effects of pulley incision, Kapandji pulley plasty, excision of one slip of the flexor digitorum superficialis, or closure of the incised pulley on function of the profundus tendons. Both long toes (104 total) of 52 leghorn chickens were divided into four experimental groups and one control group. The pulley and flexor digitorum superficialis tendon were subjected to the above-mentioned treatments in four groups, with 22 toes per group, after tendon transection in the A2 pulley area. Eight weeks after surgery, incision of the pulley improved excursion of the flexor digitorum profundus tendon and decreased the work of digital flexion over pulley closure. Resection of the one slip of the flexor digitorum superficialis tendon had results similar to pulley incision. Kapandji pulley plasty did not increase tendon excursion and decrease the work compared with a simpler pulley incision. Adhesions were more severe with pulley plasty or closure than with pulley incision. In this avian model, incision of the pulley or partial flexor digitorum superficialis resection improved outcomes of tendon repairs compared with pulley closure. Kapandji pulley plasty did not improve the outcomes over a simple pulley incision.