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Kang A, McKnight RR, Fox PM. Current Concepts: Flexor Tendon Injuries. J Hand Surg Am 2024:S0363-5023(24)00240-5. [PMID: 39093238 DOI: 10.1016/j.jhsa.2024.05.013] [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: 09/09/2023] [Revised: 05/13/2024] [Accepted: 05/27/2024] [Indexed: 08/04/2024]
Abstract
Flexor tendon injuries are complex, and management of these injuries requires consideration of the surgical timing, injury location, approach, and soft tissue handling. Complications are common, including adhesions, tendon rupture, infection, and a high reoperation rate for zone 2 repairs. Special considerations are given to chronic ruptures, concomitant fractures, and pediatric cases. We discuss current concepts that may improve patient outcomes.
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Affiliation(s)
| | - Richard Randall McKnight
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, CA; Robert A. Chase Hand and Upper Limb Center, Stanford University Medical Center, Stanford, CA
| | - Paige M Fox
- Robert A. Chase Hand and Upper Limb Center, Stanford University Medical Center, Stanford, CA; Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA; Division of Plastic Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA.
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Pastor T, Zderic I, Dhillon M, Gueorguiev B, Richards RG, Pastor T, Vögelin E. New dynamic suture material for tendon transfer surgeries in the upper extremity - a biomechanical comparative analysis. Arch Orthop Trauma Surg 2024; 144:2905-2914. [PMID: 38693291 PMCID: PMC11211109 DOI: 10.1007/s00402-024-05322-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/07/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND Early mobilization after tendon surgery is crucial to avoid commonly observed postoperative soft tissue adhesions. Recently, a new suture was introduced (DYNACORD; DC) with a salt-infused silicone core designed to minimize laxity and preserve consistent tissue approximation in order to avoid gap formation and allow early mobilization. AIMS To compare the biomechanical competence of DC against a conventional high strength suture (FiberWire; FW) in a human cadaveric tendon transfer model with an early rehabilitation protocol. METHODS Sixteen tendon transfers (flexor digitorum superficialis (FDS) IV to flexor pollicis longus (FPL)) were performed in 8 pairs human cadaveric forearms using either DC or FW. Markings were set 0.8 cm proximally and 0.7 cm distally to the level of the interweaving zone of the transfer. All specimens underwent repetitive thumb flexion against resistance in 9 intermittent series of 300 cycles each, simulating an aggressive postoperative rehabilitation protocol. After each series, the distance of the proximal marker to the interweaving zone (proximal), the length of the interweaving zone (intermediate) and the distance of the distal marker to the interweaving zone (distal) were measured. RESULTS Pooled data over all nine series, normalized to the immediate postoperative status, demonstrated no significant differences between FW and DC (p ≥ 0.355) for the proximal and distal markers. However, at the intermediate zone, DC was associated with significant length shortening (p < 0.001) compared to FW without significant length changes (p = 0.351). Load to catastrophic failure demonstrated significant higher forces in FW (p = 0.011). Nevertheless, due to failure mainly proximal or distal of the transfer zone, these loads are not informative. CONCLUSION From a biomechanical perspective, DC preserved tissue approximation and might be considered as a valid alternative to conventional high-strength sutures in tendon transfer surgery. DC might allow for a shorter interweaving zone and a more aggressive early postoperative rehabilitation program, possibly avoiding commonly observed postoperative soft tissue adhesions and stiffness.
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Affiliation(s)
- Tatjana Pastor
- AO Research Institute Davos, Davos, 7270, Switzerland.
- Department for Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland.
| | - Ivan Zderic
- AO Research Institute Davos, Davos, 7270, Switzerland
| | - Mehar Dhillon
- AO Research Institute Davos, Davos, 7270, Switzerland
| | | | | | - Torsten Pastor
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Esther Vögelin
- Department for Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
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Farzad M, Abdolrazaghi H, Smaeel Beygi A, Shafiee E, Macdermid JC, Layeghi F. Outcomes at 3 Months of a Place and Active Hold Method of Flexor Tendon Rehabilitation Following Zone II Injury. J Hand Surg Asian Pac Vol 2022; 27:352-358. [PMID: 35404213 DOI: 10.1142/s2424835522500254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Previous studies have shown that outcomes following a place and active hold (PAH) are better than a passive flexion protocol after a two-strand core-suture repair of flexor tendons injuries in zone II. This study aims to determine the outcomes of a PAH protocol of flexor tendon rehabilitation following a four-strand core-suture plus an epitendinous suture repair of the flexor digitorum profundus (FDP) combined with a simple horizontal loop repair of the flexor digitorum superficialis (FDS). Methods: This is a prospective study of patients with complete injury to both flexor tendons in zone II. All tendons were repaired with a simple horizontal loop for FDS and four-strand core-suture plus epitendinous suture for FDP. The PAH protocol was used postoperatively for 6 weeks. The outcome was evaluated using flexion contracture and total active motion (TAM), interpreted using Strickland criteria and categorised as excellent, good, fair and poor at 6 weeks and 3 months. The linear regression model was used to determine predictors of outcomes. Results: The study included 32 patients with flexor tendon injury in 46 fingers. No repairs ruptured, and 24 (52%) digits achieved good or excellent motion 6 weeks after surgery using the Strickland criteria. According to the Strickland criteria, 41 (89%) digits ranked as excellent and good with no poor result at a 3-month follow-up. Four patients had 5-10° of flexion contracture. Age was the predictor of TAM at 6 weeks and accounted for 13% of its variation. Improvement of TAM from 6 weeks to 3 months was related to age and flexion contracture at 6 weeks. Conclusions: The PAH protocol can be considered a safe technique for flexor rehabilitation after four-strand core-suture repair of FDP in zone II. Level of Evidence: Level IV (Therapeutic).
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Affiliation(s)
- Maryam Farzad
- School of Physical Therapy, University of Western Ontario, Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Hospital, London, Ontario, Canada.,Department of Occupational Therapy, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Hosseinali Abdolrazaghi
- Department Hand and Reconstructive Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Erfan Shafiee
- School of Physical Therapy, University of Western Ontario, Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Hospital, London, Ontario, Canada
| | - Joy C Macdermid
- School of Physical Therapy, University of Western Ontario, Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Hospital, London, Ontario, Canada
| | - Fereydoun Layeghi
- University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
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Kanchanathepsak T, Wairojanakul W, Suppaphol S, Watcharananan I, Tuntiyatorn P, Tawonsawatruk T. Evaluation of biomechanical properties on partial and complete epitendinous suture in human cadaver flexor tendon repair. J Orthop Surg Res 2021; 16:489. [PMID: 34384476 PMCID: PMC8359622 DOI: 10.1186/s13018-021-02645-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 07/28/2021] [Indexed: 11/30/2022] Open
Abstract
Objective This study was designed to compare the ultimate tensile strength and force to 2 mm gap formation among 50% partial, 75% partial, and complete circumferential epitendinous suture with a combination of 4-strand core suture in human cadaver flexor tendon. Materials and methods Forty-five flexor tendons from four soft human cadavers were used to evaluate the biomechanical property among 50% partial, 75% partial, and complete circumferential epitendinous suture with a combination of 4-strand core suture. Results The force to 2 mm gap of complete epitendinous was significantly greater than partial epitendinous suture (P < 0.05); however, there was no difference between 50% partial and 75% partial epitendinous suture (P > 0.05). For the ultimate strength, there was no significant difference between partial and complete epitendinous suture (P > 0.05). The partial epitendinous was approximately 60% of the complete epitendinous suture in force to 2 mm gap and also 70% of complete epitendinous suture in ultimate tensile strength with a combination of core sutures. Conclusions The complete epitendinous suture showed better ultimate tensile strength and force to 2 mm gap compared with a partial 50% and 75% epitendinous suture. However, in some clinical scenario which the complete epitendinous suture is not possible to perform, the authors suggested only partial epitendinous suture with 50% circumference is recommended as the additional epitendinous repair up 75% circumference cannot provide any mechanical benefit to the repaired site.
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Affiliation(s)
- Thepparat Kanchanathepsak
- Hand and Microsurgery Unit, Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Wilarat Wairojanakul
- Hand and Microsurgery Unit, Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Sorasak Suppaphol
- Hand and Microsurgery Unit, Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Ittirat Watcharananan
- Hand and Microsurgery Unit, Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Panithan Tuntiyatorn
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samutprakan, Thailand
| | - Tulyapruek Tawonsawatruk
- Hand and Microsurgery Unit, Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand.
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Gillis JA, Athens CM, Rhee PC. Biomechanical Comparison of Tendon Coaptation Methods With a Meshed Suture Construct. J Hand Surg Am 2021; 46:343.e1-343.e10. [PMID: 33279324 DOI: 10.1016/j.jhsa.2020.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 07/29/2020] [Accepted: 10/09/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE Tendon-to-tendon attachment constructs for tendon reconstructions or transfers need to be secure in order to allow early mobilization after surgery. The purpose of this study was to biomechanically compare 2 common constructs secured with a novel mesh suture versus a nonabsorbable braided suture. METHODS We used 100 cadaveric tendons to create 5 different tendon coaptation constructs (a to e) (10 coaptations per group): (a) Pulvertaft weave with a braided suture (PTe); (b) mesh suture (PTm); (c) single-pass, side-to-side (SP-STS) coaptation with 30-mm overlap using a mesh suture (SP-STS-30m); (d) SP-STS 50-mm overlap with a mesh suture (SP-STS-50m); and (e) SP-STS with 30-mm tendon overlap using a braided suture (SP-STS-30e). The tensile strength, bulk, gliding resistance, and failure type were compared. RESULTS There was no difference between the various tendon constructs and the suture type in terms of coaptation bulk. All SP-STS constructs with mesh suture had higher peak gliding resistance than any of the PT constructs regardless of suture type. Compared with the PT constructs, the SP-STS constructs with mesh or braided suture had a higher peak load, peak load normalized to repair length, and stiffness. Within each tendon coaptation construct group, Pulvertaft or SP-STS, the suture type did not affect any of the investigated parameters. CONCLUSIONS The SP-STS constructs are significantly stronger and stiffer than the PT constructs. The SP-STS with mesh suture exhibited greater gliding resistance than the PT constructs and may result in greater gliding resistance through physiological tissue planes. However, the use of a mesh suture did not affect strength, bulk, gliding resistance, or failure type when compared within a construct group. CLINICAL RELEVANCE The use of SP-STS constructs for tendon coaptations produces a stronger and stiffer construct than the PT weave; however, the use of a mesh suture may not provide any benefit over a braided suture.
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Affiliation(s)
- Joshua Allan Gillis
- Division of Plastic and Reconstructive Surgery, Roth-McFarlane Hand and Upper Limb Centre, London, Ontario, Canada; Division of Hand Surgery, Department of Orthopedic Surgery, Mayo Clinic, Rochester MN
| | - Christian M Athens
- Division of Hand Surgery, Department of Orthopedic Surgery, Mayo Clinic, Rochester MN; Department of Orthopedic Surgery, Aultman Hospital, Canton, OH
| | - Peter C Rhee
- Division of Hand Surgery, Department of Orthopedic Surgery, Mayo Clinic, Rochester MN.
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Farinas A, Stephanides M, Schneeberger S, Pollins A, Cardwell N, Thayer WP. Improving Strength and Quality of Epitendinous Repairs. Hand (N Y) 2020; 15:495-501. [PMID: 30518263 PMCID: PMC7370385 DOI: 10.1177/1558944718813608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Epitendinous sutures not only join the 2 severed tendon edges but also supply strength and support to the repair. Multiple techniques have been described, but none of them include another thread of suture. This could potentially increase the strength of the repair without affecting gliding. Methods: Caprine tendons were harvested, transected, and sutured with 6-0 Prolene. Four groups were created: single thread running (SR), single thread locking (SL), double thread running (DR), and double thread locking (DL). An Instron 5542 was used to pull the repaired tendons apart, and the energy at the break was calculated (gf/mm). For gliding resistance, we harvested a human A2 pulley. A pre- and postrepair value was obtained, and a ratio was elaborated. A single-factor analysis of variance and independent sample t tests were performed. Results: The SR group had a mean energy at break of 9339.71 ± 1630.212 gf/mm; the SL group, 9629.96 ± 1476.45 gf/mm; and the DR group, 9600.221 ± 976.087 gf/mm, with no statistical significance. The DL group was significantly higher at 14 740.664 ± 2596.586 gf/mm (P < .05). When comparing SR with DL for gliding, SR had less than half of the resistance than DL (0.018 ± 0.004 and 0.049 ± 0.015 N/mm, respectively), with statistical significance (P < .05). Conclusion: Using a single suture thread for running epitendinous repair is no different than locking with a single thread or using an extra thread in a running fashion. Performing a double suture thread with a locking technique is significantly stronger than the previously mentioned repairs, with the disadvantage of more resistance at the pulley.
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Affiliation(s)
| | | | | | | | | | - Wesley P. Thayer
- Vanderbilt University, Nashville, TN, USA,Wesley P. Thayer, Department of Plastic Surgery, Vanderbilt University Medical Center, Vanderbilt University, 1161 21st Avenue South, MCN D4207, Nashville, TN 37232-2345, USA.
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Duffy DJ, Cocca CJ, Kersh ME, Kim W, Moore GE. Effect of bite distance of an epitendinous suture from the repair site on the tensile strength of canine tendon constructs. Am J Vet Res 2020; 80:1034-1042. [PMID: 31644343 DOI: 10.2460/ajvr.80.11.1034] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate effects of bite distance of an interlocking horizontal mattress epitendinous suture (IHMES) from the repair site on tensile strength of canine tendon repairs. SAMPLE 72 canine cadaveric superficial digital flexor tendons (SDFTs). PROCEDURES Transverse tenotomy was performed, and SDFTs were repaired with a locking-loop construct (LL construct) or 3 LL constructs with IHMES suture bites placed 5 (LL + 5ES construct), 10 (LL + 10ES construct), or 15 (LL + 15ES construct) mm from the transection site (18 SDFTs/group). Constructs were loaded to failure. Load at 1- and 3-mm gapping, yield force, failure load, and failure mode were evaluated. RESULTS Mean ± SD yield force and failure load for LL constructs were significantly lower than for IHMES constructs. Load at 1- and 3-mm gapping was significantly higher for IHMES constructs. Increasing the bite distance significantly increased construct strength (134.4 ± 26.1 N, 151.0 ± 16.8 N, and 182.1 ± 23.6 N for LL + 5ES, LL + 10ES, and LL + 15ES constructs, respectively), compared with strength for the LL construct. Failure mode differed significantly among constructs when an IHMES was used. CONCLUSIONS AND CLINICAL RELEVANCE Addition of an IHMES to an LL construct led to increased ultimate tensile strength by 2.5 times and significantly reduced gap formation. Increasing the IHMES bite distance increased yield force by 2.1, 2.3, and 2.7 times for bites placed 5, 10, and 15 mm from the tenotomy, respectively. Positioning an IHMES at a greater distance from the repair site provided superior biomechanical strength for tendon repairs in dogs.
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Henry M, Lundy FH. Flexor Subzone II A-D Range of Motion Progression during Healing on a No-Splint, No-Tenodesis Protection, Immediate Full Composite Extension Regimen. J Hand Surg Asian Pac Vol 2019; 24:405-411. [PMID: 31690202 DOI: 10.1142/s2424835519500516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: The objective was to study the hypotheses that an advanced zone II flexor tendon rehabilitation protocol would avoid rupture, achieve a high range of excursion, and minimize interphalangeal contracture during both the early phases and at the conclusion of healing. We also proposed the null hypothesis of no difference between any two of the zone II subdivisions. Methods: Fifty-one consecutive adult patients with zone II flexor tendon repairs of a single finger were retrospectively evaluated on an active contraction rehabilitation protocol with no splint, no tenodesis protection, and immediate full composite extension. There were 38 males and 13 females with a mean age of 39 years (range 18-69) involving 15 index, 7 long, 6 ring, and 23 small fingers. Repairs were located in flexor subzone IIA for 8 fingers; subzone IIB, 14; subzone IIC, 19; and subzone IID, 10. Differences in outcome between any two subzones were compared by T-test with p < 0.05. Results: Mean active arcs of motion in degrees at 3 weeks post repair were PIP 1-93; DIP 0-44; and total active motion (TAM) 221. At 6 weeks PIP 2-98; DIP 1-51; and TAM 236. At 10-12 weeks PIP 1-101; DIP 1-56; and TAM 246. Final TAM by flexor subzone IIA was 243; IIB, 251; IIC, 246; and IID, 246. There were no significant differences between any two subzones. Mean final DASH score was 5. There were no ruptures. Conclusions: The results support the hypotheses. Outcomes of the therapy protocol demonstrated the lack of interphalangeal joint flexion contractures, high range of total active motion achieved early and sustained, and no ruptures. No differences were identified between and two of the flexor subzones.
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Affiliation(s)
- Mark Henry
- Hand and Wrist Center of Houston, Houston, TX, United States
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Ishak A, Rajangam A, Khajuria A. The evidence-base for the management of flexor tendon injuries of the hand: Review. Ann Med Surg (Lond) 2019; 48:1-6. [PMID: 31660149 PMCID: PMC6806617 DOI: 10.1016/j.amsu.2019.10.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 09/30/2019] [Accepted: 10/06/2019] [Indexed: 11/27/2022] Open
Abstract
There is no consensus on the optimal flexor tendon repair technique at each anatomical flexor zone. There is paucity of high quality evidence. Heterogenous study designs limit inter-study comparisons. Patient reported outcome measures are crucial but there is a perennial need for robust disease-specific tools to be utilised.
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Affiliation(s)
- Athanasius Ishak
- Faculty of Life Sciences and Medicine, Centre for Human and Applied Physiological Science (CHAPS), King's College London, Strand, London, WC2R 2LS, United Kingdom
| | - Akshaya Rajangam
- Faculty of Life Sciences and Medicine, Centre for Human and Applied Physiological Science (CHAPS), King's College London, Strand, London, WC2R 2LS, United Kingdom
| | - Ankur Khajuria
- Department of Plastic Surgery, St Thomas' Hospital, London, UK.,Kellogg College, University of Oxford, Oxford, UK
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