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Wachtel N, Englbrecht MA, Micheler C, Lang JJ, Burgkart R, Giunta RE, Wilhelm CJ. The minimum required overlap length for tendon transfer A biomechanical study on human tendons. PLoS One 2023; 18:e0289650. [PMID: 37540707 PMCID: PMC10403071 DOI: 10.1371/journal.pone.0289650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 07/23/2023] [Indexed: 08/06/2023] Open
Abstract
In tendon transfer surgeries sufficient stability of the tenorrhaphy is essential. In addition to the choice of a suitable technique, adequate overlap of donor and recipient tendons must be ensured. The aim of this study was to investigate the tensile strength with regard to tendon overlap of a recently published tenorrhaphy, termed Woven-Fridén (WF) tenorrhaphy, which displayed higher tensile strength and lower bulk when compared to the established Pulvertaft technique. For this purpose, WF tenorrhaphies with 1.5 cm, 2 cm, and 3 cm tendon overlap were performed and subsequently tested for different biomechanical properties by tensile testing. Among others, the parameters of ultimate load and stiffness were collected. Native tendons served as controls. A formula was derived to quantify the relation between tendon overlap and ultimate load. We observed that sufficient tensile strength (mean ultimate load of 217 N) is already given with a 2 cm tendon overlap. In addition, with more than 3 cm overlap length only little additional tensile strength is to be expected as the calculated ultimate load of 4 cm overlap (397 N) is approaching the plateau of the maximal ultimate load of 435 N (native tendons).
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Affiliation(s)
- Nikolaus Wachtel
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Marc A Englbrecht
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
- Women's Clinic Dr. Geisenhofer, Munich, Germany
| | - Carina Micheler
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, TUM School of Medicine, Technical University of Munich, Munich, Germany
- Institute for Machine Tools and Industrial Management, TUM School of Engineering and Design, Technical University of Munich, Munich, Germany
| | - Jan J Lang
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, TUM School of Medicine, Technical University of Munich, Munich, Germany
- Chair of Non-Destructive Testing, TUM School of Engineering and Design, Technical University of Munich, Munich, Germany
| | - Rainer Burgkart
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, TUM School of Medicine, Technical University of Munich, Munich, Germany
| | - Riccardo E Giunta
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Christina J Wilhelm
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
- Maria-Theresia-Klinik, Academic Teaching Hospital of Ludwig-Maximilians University Munich, Munich, Germany
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2
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Strömberg J, Berg J, Reinholdt C. Technique and biomechanical properties of the side-to-side Z-lengthening in spasticity-correcting surgery- a study on porcine tendons. J Plast Surg Hand Surg 2023; 57:343-345. [PMID: 35713968 DOI: 10.1080/2000656x.2022.2088543] [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: 10/18/2022]
Abstract
Spasticity-correcting surgery in patients with injuries to upper motor neurons include various techniques, including tenotomies and lengthening of tendons of spastic muscles. Early mobilization including active loading of a lengthened tendon is essential to prevent adhesion formation, which necessitates a lengthening technique that resists the forces produced by the involved muscles. This study on animal tendons reports the biomechanical properties in regards to elongation and load to failure in porcine tendons lengthened by either a 3 or 5 cm overlap and tested in a simple force rig. The lengthening technique used in these tendons is described in step-by-step detail. The mean elongation of 20 lengthened tendons at 100 N was 10 mm for tendons with a 3 cm overlap and 6 mm for tendons with a 5 cm overlap. The mean peak load at failure of the construct was 138 N for lenghened tendons with a 3 cm overlap and 201 N for tendons with a 5 cm overlap. The results of this study indicate that a tendon lengthened by the described technique with a mere overlap of three cm will withstand the estimated forces elicited by muscles in the forearm immediately after surgery.
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Affiliation(s)
- Joakim Strömberg
- Department of Orthopaedics, University of Gothenburg, Sahlgrenska Academy, Institution of Clinical Sciences, Gothenburg, Sweden.,Department of Surgery and Orthopaedics, Alingsås Lasarett, Alingsås, Sweden
| | - Johan Berg
- Department of Orthopaedics, University of Gothenburg, Sahlgrenska Academy, Institution of Clinical Sciences, Gothenburg, Sweden.,Centre for Advanced Reconstruction of Extremities, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Carina Reinholdt
- Department of Orthopaedics, University of Gothenburg, Sahlgrenska Academy, Institution of Clinical Sciences, Gothenburg, Sweden.,Centre for Advanced Reconstruction of Extremities, Sahlgrenska University Hospital, Mölndal, Sweden
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3
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Tian J, Leng M, Wang K, Huang Q. Pronator teres nerve branch transfer to the extensor carpi radialis brevis nerve branch for wrist extension reconstruction in proximal radial nerve injury following humeral shaft fractures. BMC Musculoskelet Disord 2022; 23:980. [DOI: 10.1186/s12891-022-05950-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 11/04/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Tendon and nerve transfers are used for functional reconstruction in cases of proximal radial nerve injury complicated by humeral fractures in patients who do not show functional recovery after primary nerve repair. The effectiveness of pronator teres (PT) nerve branch transfer to the extensor carpi radialis brevis (ERCB) nerve branch for wrist extension reconstruction was investigated and compared to the results of tendon transfer.
Methods
This study included 10 patients with proximal radial nerve injury, who did not show functional recovery after primary nerve repair at our hospital between April 2016 and May 2019. The nerve transfer procedure included PT nerve branch transfer to the ECRB nerve branch to restore wrist extension and the flexor carpi radialis (FCR) nerve branch to the posterior interosseous nerve (PIN) to restore thumb and finger extension. Tendon transfer procedures included PT transfer to the ECRB for wrist extension, FCR transfer to the extensor digitorum communis (EDC) for finger extension and palmaris longus (PL) transfer to the extensor pollicis longus (EPL) for thumb extension.
Results
Five patients recovered Medical Research Council grade M4 muscle strength in the ECRB and EPL in both tendon and nerve groups. Two patients recovered grade M3 strength and three patients recovered grade M4 strength in the EDC in the tendon transfer group, and all five patients recovered grade M4 strength in the EDC in the nerve transfer group. Limited wrist flexion was observed only in one patient in the tendon transfer group.
Conclusion
PT nerve branch transfer to the ECRB nerve branch combined with FCR nerve branch transfer to PIN is a useful strategy for wrist and fingers extension reconstruction in patients with proximal radial nerve injuries.
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Lieber RL, Fridén J. Teamwork Pays! Ten Tips for a Great Surgeon-Scientist Collaboration. J Hand Surg Am 2022; 47:673-676. [PMID: 35221173 PMCID: PMC9271536 DOI: 10.1016/j.jhsa.2022.01.001] [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: 01/07/2021] [Revised: 07/25/2021] [Accepted: 01/03/2022] [Indexed: 02/02/2023]
Abstract
This review represents our summary of what makes a great collaboration between a surgeon and a scientist. At first, with no perspective, such a collaboration seems easy and natural. But as time goes on, with more perspective, you realize how special it is. Now, in our 60s, with approximately 35 years of collaboration and 75 coauthored papers (most of them in The Journal of Hand Surgery), we are thankful and humbled for this tremendously fruitful and, importantly, enjoyable collaboration. We are not so foolish to think that we made this great collaboration-it was a gift. However, we now recognize many characteristics that make it great and have developed the following 10 tips.
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Affiliation(s)
- Richard L. Lieber
- Shirley Ryan AbilityLab,Departments of Physical Medicine and Rehabilitation and Biomedical Engineering, Northwestern University, Chicago, IL, USA
| | - Jan Fridén
- Swiss Paraplegic Center, Nottwil, Switzerland
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5
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Wilhelm CJ, Englbrecht MA, Burgkart R, Micheler C, Lang J, Hagen CS, Giunta RE, Wachtel N. Fine tuning of the side-to-side tenorrhaphy: A biomechanical study assessing different side-to-side suture techniques in a porcine tendon model. PLoS One 2021; 16:e0257038. [PMID: 34610029 PMCID: PMC8491917 DOI: 10.1371/journal.pone.0257038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 08/17/2021] [Indexed: 11/19/2022] Open
Abstract
Recent studies conclude that a new technique for tendon transfers, the side-to-side tenorrhaphy by Fridén (FR) provides higher biomechanical stability than the established standard first described by Pulvertaft (PT). The aim of this study was to optimize side-to-side tenorrhaphies. We compared PT and FR tenorrhaphies as well as a potential improvement, termed Woven-Fridén tenorrhaphy (WF), with regard to biomechanical stability. Our results demonstrate superior biomechanical stability and lower bulk of FR and, in particular, WF over PT tenorrhaphies. The WF and FR technnique therefore seem to be a notable alternative to the established standard tenorrhaphy as they display lower bulk and higher stability, permitting successful immediate active mobilization after surgery.
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Affiliation(s)
- Christina J. Wilhelm
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
- * E-mail:
| | - Marc A. Englbrecht
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Rainer Burgkart
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Carina Micheler
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
- Department of Mechanical Engineering, Institute for Machine Tools and Industrial Management, Technical University of Munich, Munich, Germany
| | - Jan Lang
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
- Department of Mechanical Engineering, Chair of Non-Destructive Testing, Technical University of Munich, Munich, Germany
| | - Christine S. Hagen
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Riccardo E. Giunta
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Nikolaus Wachtel
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
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Fridén J, Son J, Koch-Borner S, Lieber RL. Outcome from a brachialis donor for wrist extension in tetraplegia-time to reconsider the International Classification for Surgery of the Hand in Tetraplegia (ICSHT). Spinal Cord Ser Cases 2021; 7:73. [PMID: 34381016 DOI: 10.1038/s41394-021-00436-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 07/24/2021] [Accepted: 07/26/2021] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Surgical reconstruction after quadriplegia represents a powerful solution to restore lost function by injury. A case is presented in which surgical reconstruction of a patient with a C4 level spinal cord injury is performed using the brachialis (BRA) muscle as the donor. CASE PRESENTATION The patient previously had no hand function. This transfer, in combination with fusion of the thumb CMC joint and transfer of the flexor pollicis longus (FPL) tendon to the radius, gives the patient full thumb key pinch powered by BRA transferred to the wrist extensors. Theoretical analysis of muscle architectural properties demonstrates that the BRA has sufficient force and excursion to substitute for both the long and short radial wrist extensors. Furthermore, based on the fact that the BRA has almost twice the excursion compared to the extensor carpi radialis longus (ECRL), wrist extension can occur throughout the entire wrist and elbow ranges of motion. Finally, peak tension is lower than the rupture tension previously measured by us using this type of tendon-to-tendon attachment technique, suggesting that the transfer itself is safe and, importantly, can be immediately mobilized for neuromuscular rehabilitation. DISCUSSION This procedure can thus restore tremendous functional capacity in patients who were previously categorized as group 0 by the International Classification of Hand Surgery in Tetraplegia (ICSHT). We suggest that, based on the BRA being an excellent donor for surgical reconstruction, that the ICHST system be reconsidered.
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Affiliation(s)
- Jan Fridén
- Swiss Paraplegic Centre, Nottwil, Switzerland
| | - Jongsang Son
- Shirley Ryan AbilityLab, Chicago, IL, USA.,Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, USA
| | | | - Richard L Lieber
- Shirley Ryan AbilityLab, Chicago, IL, USA. .,Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, USA. .,Hines VA Medical Center, Maywood, IL, USA.
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Leti Acciaro A, Colzani G, Starnoni M, Adani R. The Challenges in restoration of extensor tendons function at the hand. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021151. [PMID: 33944835 PMCID: PMC8142745 DOI: 10.23750/abm.v92is1.9756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 07/29/2020] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The authors discuss challenges in extensor function restoration at the finger level following distal posterior interosseous or tendon complex injuries, according to the typologies of lesions or the specific patient requirements. MATERIALS The authors report on two cases describing challenging resolutions. One patient with EDC lag from zone 6B to 8 requiring FCU prolonged with cadaveric grafts. One young patient with distal posterior interosseous lesion requiring selective tendon transfers to EPL and EIP to restore selective and autonomous index extension. RESULTS In both cases the main goals were obtained, achieving high index of patient satisfaction and excellent outcomes with the restoration of the extension of the fingers. Conclusions: In distal posterior interosseous nerve lesion, high demanding patients may require selective function to restore fine motor skills, such as autonomous index extension. In extensor tendons loss of substance from zone 6 to 8, involving musculotendinous junction proximally and short remnants distally, by-pass tendon transfer prolonged with cadaveric grafts is required. The authors highlight the techniques available as escape plan according to the necessary solutions.
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Affiliation(s)
| | - Giulia Colzani
- Division of Hand Surgery and Microsurgery - Modena University Hospital.
| | - Marta Starnoni
- Division of Plastic Surgery, Modena University Hospital.
| | - Roberto Adani
- Division of Hand Surgery and Microsurgery - Modena University Hospital.
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Boucke PC, Cordier T, Häfeli M, Schibli S. [Simplified active motion protocol following Extensor indicis to Extensor pollicis longus tendon transfer using a side-to-side suture]. HANDCHIR MIKROCHIR P 2021; 53:67-71. [PMID: 33588492 DOI: 10.1055/a-1326-1950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Ruptures of the Extensor pollicis longus tendon are commonly treated by Extensor indicis transfer using Pulvertaft suture technique. Current literature does not yet give evidence for a preferable post-operative therapy protocol. A side-to-side suture technique is significantly stronger than the Pulvertaft repair technique and therefore allows an immediate active postoperative treatment. We present a new postoperative protocol, which is simple, fast and safe, and should make treatment easier for patients and therapists. PATIENTS AND METHODS We treated 10 patients with a transfer of the extensor indicis tendon between 07/2016 and 08/2017 according to the new active protocol. Patients were seen for follow-up at 2, 4 and 8 weeks. Thumb range of motion, pinch and grip strength as well as subjective parameters like pain and general satisfaction were measured. RESULTS All patients regained full function of their thumbs with retropulsion over the level of the palm at 4 weeks. Median pinch strength was 89 % and grip strength 74 % of the contralateral side at week 4. There was no secondary rupture of the reconstructed tendon over a one-year period. All patients were satisfied with the result of the operation and the protocol. CONCLUSION Our new active postoperative protocol for extensor indicis transfer using a side-to-side suture has proven to be safe and less strenuous for patients and therapists and has been established as standard treatment in our clinic.
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9
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Strandenes E, Ellison P, Mølster AO, Gjerdet NR, Moldestad IO, Høl PJ. Strength of side-to-side and step-cut repairs in tendon transfers: biomechanical testing of porcine flexor tendons. J Hand Surg Eur Vol 2020; 45:1061-1065. [PMID: 32686558 DOI: 10.1177/1753193420939068] [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: 02/03/2023]
Abstract
The aim of the study was to compare side-to-side with step-cut repairs to determine how much of the width it is possible to remove and still keep the repair strong enough to start active mobilization. Porcine flexor tendons were used to create side-to-side, one-third step-cut and half step-cut repairs. There were 15 repairs in each group. The tensile properties of the constructs were measured in a biomechanical testing machine. All repairs failed by the sutures splitting the tendon longitudinally. The maximum load and stiffness were highest in the side-to-side group. Our findings suggest that the half step-cut repair can withstand the forces exerted during active unrestricted movement of the digits in tendons of this size. The advantage of the step-cut repair is reduced bulkiness and less friction, which might compensate for the difference in strength.
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Affiliation(s)
- Eivind Strandenes
- Plastic-, Hand- and Reconstructive Department, Haukeland University Hospital, Bergen, Norway
| | - Peter Ellison
- Department of Mechanical Engineering, Imperial College London, London, UK.,Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Anders O Mølster
- Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Nils R Gjerdet
- Department of Clinical Dentistry, University of Bergen, Bergen, Norway
| | - Irene O Moldestad
- Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Paul J Høl
- Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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10
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Bertelli JA. Nerve Versus Tendon Transfer for Radial Nerve Paralysis Reconstruction. J Hand Surg Am 2020; 45:418-426. [PMID: 32093993 DOI: 10.1016/j.jhsa.2019.12.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 10/23/2019] [Accepted: 12/17/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE With radial nerve lesions, the results of nerve transfers and how they objectively compare with the outcomes of tendon transfers remain unstudied. We compared the results after nerve transfer in patients with less than 12 months since radial nerve injury with the results after tendon transfer in patients not eligible for nerve surgery because of longstanding paralysis (minimum of 15 months). METHODS In 14 patients with radial nerve lesions incurred less than 12 months previously, we transferred the anterior interosseous nerve to the nerve of the extensor carpi radialis brevis (ECRB), while the nerve to the flexor carpi radialis was transferred to the posterior interosseous nerve. In 13 patients with lesions of longer duration, we transferred the pronator teres tendon to the ECRB, the flexor carpi ulnaris tendon to the extensor digitorum communis, and the palmaris longus to the rerouted extensor pollicis longus (EPL) tendon. At a final evaluation, we measured passive and active range of motion (ROM) of the wrist, finger, and thumb and grasp strength. RESULTS In a comparison of wrist flexion-extension ROM and grasp strength, we observed better recovery in the nerve transfer than in the tendon transfer group. In the tendon transfer group, we observed limitations in wrist flexion in 9 of the 13 patients and permanent radial deviation in 5. Half of the patients in the tendon transfer group needed to flex their wrist to fully extend their fingers, whereas finger extension was possible with the wrist either extended or at neutral in all patients following nerve transfer. After nerve transfer, extension at the first carpometacarpal joint was restored in 11 of the 14 patients, whereas this occurred in just 4 of the 13 patients following tendon transfer. In both groups, we observed a 30° lag in thumb metacarpophalangeal extension, which reflects poor recovery of EPL function. CONCLUSIONS Overall, we observed better outcomes in those who underwent nerve transfer versus tendon transfer procedures. However, room still remains for improved thumb motion with both procedures. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Jayme Augusto Bertelli
- Center of Biological and Health Sciences, Department of Neurosurgery, University of the South of Santa Catarina (Unisul), Tubarão; Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, SC, Brazil.
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11
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Willkomm LM, Bickert B, Wendt H, Kneser U, Harhaus L. [Postoperative treatment and rehabilitation following flexor tendon injuries]. Unfallchirurg 2020; 123:126-133. [PMID: 31915878 DOI: 10.1007/s00113-019-00758-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The ideal surgical and postoperative treatment for flexor tendon injuries, especially in zone 2, is still subject to continuous modifications and professional discussions. OBJECTIVE Presentation of established rehabilitation concepts, specific problems and new treatment approaches with practical recommendations for application. MATERIAL AND METHODS Comparison of commonly used treatment concepts by assessing surgical flexor tendon repair, splint choice and clinical application in patients. Discussion of new surgical approaches and standards and their influence on postoperative therapy after flexor tendon injuries. RESULTS The Washington regimen has retained its status as the standard in the current follow-up treatment of flexor tendon injuries. New suture materials and techniques enable early active rehabilitation of sutured flexor tendons with good clinical results, such as increased range of motion for interphalangeal joint extension and improved distal interphalangeal joint flexion with overall acceptable frequencies of suture rupture. CONCLUSION A stable tendon repair with smooth gliding is the foundation for treatment after flexor tendon injuries. After intraoperative active digital extension-flexion testing of the sutured tendon an early active rehabilitation approach should follow. New splint designs in combination with primary stable tendon suture techniques have the potential to improve the postoperative outcome, presupposing a reliable cooperation of the patient.
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Affiliation(s)
- L-M Willkomm
- Klinik für Hand‑, Plastische und Rekonstruktive Chirurgie, BG Klinik Ludwigshafen, Ludwigshafen, Deutschland.
| | - B Bickert
- Sektion Handchirurgie, Klinik für Hand‑, Plastische und Rekonstruktive Chirurgie, BG Klinik Ludwigshafen, Ludwigshafen, Deutschland
| | - H Wendt
- Klinik für Hand‑, Plastische und Rekonstruktive Chirurgie, BG Klinik Ludwigshafen, Ludwigshafen, Deutschland
| | - U Kneser
- Klinik für Hand‑, Plastische und Rekonstruktive Chirurgie, BG Klinik Ludwigshafen, Ludwigshafen, Deutschland
| | - L Harhaus
- Klinik für Hand‑, Plastische und Rekonstruktive Chirurgie, BG Klinik Ludwigshafen, Ludwigshafen, Deutschland
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12
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Strandenes E, Ellison P, Mølster A, Gjerdet NR, Moldestad IO, Høl PJ. Strength of Pulvertaft modifications: tensile testing of porcine flexor tendons. J Hand Surg Eur Vol 2019; 44:795-799. [PMID: 30971158 DOI: 10.1177/1753193419841522] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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 the study was to present two new modifications of the Pulvertaft weave, allowing a higher number of weaves without the need for a longer overlap. The mechanical properties were measured and compared with the traditional technique. Forty-five pairs of porcine flexor tendons were randomized to a Pulvertaft repair with three weaves, a Double Pulvertaft and Locking Pulvertaft repairs. In the last two repairs one of the tendons in each repair was split in two before weaving. A difference in the maximum stiffness was observed between the three groups (p = 0.024). All repairs failed by the sutures being sheared through the tendons splitting the tendon fibres longitudinally. The two modifications were both stronger than the Pulvertaft weave and provide an alternative when a strong connection is needed and a longer overlap is impossible.
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Affiliation(s)
- Eivind Strandenes
- Plastic-, Hand- and Reconstructive Department, Haukeland University Hospital, Bergen, Norway
| | - Peter Ellison
- Department of Mechanical Engineering, Imperial College London, London, UK.,Biomatlab, Haukeland University Hospital, Bergen, Norway
| | - Anders Mølster
- Biomatlab, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Nils R Gjerdet
- Department of Clinical Dentistry, University of Bergen, Bergen, Norway
| | | | - Paul J Høl
- Biomatlab, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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13
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Abstract
Reconstructive upper extremity surgeries in tetraplegia are technically challenging because of the many complicated real-time decisions that need to be made, e.g. extent of release of donor muscle-tendon complex, routing of donor muscles, tissue preparation and optimization, tensioning of muscle-tendon units, balancing joints and suturing tendon-to-tendon attachments. Nerve transfer surgeries can add functionality but also make the reconstruction planning more complex. In this overview, we present some of the fundamental muscle-tendon-joint mechanics studies that allow for single-stage surgical reconstruction of hand function as well as early postoperative activity-based training in patients with cervical spinal cord injuries. We foresee an increased need for studies addressing combined nerve and tendon transfer reconstructions in parallel with patient-perceived outcome investigations. These should be combined with implementation of assistive technology such as functional electrical stimulation for diagnostic, prognostic and training purposes.
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Affiliation(s)
- Jan Fridén
- Swiss Paraplegic Centre, Nottwil, Switzerland,Center for Advanced Reconstruction of Extremities and Department of Hand Surgery, Sahlgrenska University Hospital and University of Gothenburg, Gothenburg, Sweden
| | - Richard L. Lieber
- Shirley Ryan Ability Lab, Northwestern University and Hines VA Medical Center Chicago, IL, USA
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14
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Abstract
Spasticity affects more than 80% of patients with spinal cord injury. Neural mechanisms and musculotendinous alterations lead to typical upper extremity features including shoulder adduction/internal rotation, forearm pronation, and elbow, wrist, and finger flexion. Long-standing spasticity may lead to soft tissue and joint contractures and further impairment of upper extremity function. Surgical management involves tendon lengthening, release, and transfer, as well as selective neurotomy, in an effort to reduce spastic muscle hypertonicity, restore balance, prevent further contracture, and improve posture and function. This article summarizes surgical strategies to improve function of the upper extremity in patients with tetraplegia.
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Affiliation(s)
- Andreas Gohritz
- Department of Hand Surgery, Swiss Paraplegic Centre, Guido A. Zäch Str. 1, Nottwil CH-6207, Switzerland; Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Universitätsspital, Spitalstraße 21, Basel CH-4031, Switzerland
| | - Jan Fridén
- Department of Hand Surgery, Swiss Paraplegic Centre, Guido A. Zäch Str. 1, Nottwil CH-6207, Switzerland; Institute of Clinical Sciences, Center for Advanced Reconstruction of Extremities, University of Gothenburg, Gothenburg, Sweden.
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15
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Abstract
Rheumatoid arthritis is one common form of inflammatory arthritis that affects about 1% of the population. Few conditions in hand surgery have undergone such fundamental changes within the last two decades as rheumatoid arthritis has with regard to clinical presentations and treatments. This article provides a personal practice-guided review of the author's decision making and treatment for patients with rheumatoid arthritis in the past two decades.
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Minimally Invasive Palmaris Longus Abductorplasty for Severe Carpal Tunnel Syndrome. Tech Hand Up Extrem Surg 2017; 21:149-154. [PMID: 28914668 DOI: 10.1097/bth.0000000000000176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Camitz abductorplasty is the most commonly used tendon transfer in patients with severe carpal tunnel syndrome with significant muscle wasting and loss of opposition. This procedure requires a long incision in the palm to harvest a strip of palmar aponeurosis to lengthen the palmaris longus tendon, allowing it to reach the abductor pollicis brevis insertion. Several complications have been attributed to this extensive dissection in the palm. We describe a minimally invasive palmaris longus abductorplasty using a strip of free flexor carpi radialis tendon graft to achieve the necessary length. This can be done together with carpal tunnel release in patients with severe carpal tunnel syndrome.
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17
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Abstract
Closed tendon ruptures of the thumb that require secondary reconstruction can affect the extensor pollicis longus (EPL), extensor pollicis brevis (EPB) and flexor pollicis longus (FPL) tendons. Treatment of rupture of the EPB tendon consists of refixation to the bone and temporary transfixation of the joint. In the case of preexisting or posttraumatic arthrosis, definitive arthrodesis of the thumb is the best procedure. Closed ruptures of the EPL and FPL tendons at the wrist joint cannot be treated by direct tendon suture. Rupture of the EPL tendon occurs after distal radius fractures either due to protruding screws or following conservative treatment especially in undisplaced fractures. Transfer of the extensor indicis tendon to the distal EPL stump is a good option and free interposition of the palmaris longus tendon is a possible alternative. The tension should be adjusted to slight overcorrection, which can be checked intraoperatively by performing the tenodesis test. Closed FPL ruptures at the wrist typically occur 3-6 months after osteosynthesis of distal radius fractures with palmar plates and are mostly characterized by crepitation and pain lasting for several weeks. They can be prevented by premature plate removal, synovectomy and carpal tunnel release. For treatment of a ruptured FPL tendon in adult patients the options for tendon reconstruction should be weighed up against the less complicated tenodesis or arthrodesis of the thumb interphalangeal joint.
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Affiliation(s)
- B Bickert
- Sektion Handchirurgie, Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland.
| | - T Kremer
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, BG Klinik Ludwigshafen, Ludwigshafen, Deutschland
| | - U Kneser
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, BG Klinik Ludwigshafen, Ludwigshafen, Deutschland
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18
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Abstract
BACKGROUND The extensor tendons of the hand are located in a superficial position on the dorsal aspect of the hand and are highly susceptible to injury. Laceration, crush and avulsion injuries are common extensor tendon injuries presenting for acute care. Such injuries that involve tendon loss or gaps in the extensor tendons require specialised attention and can be some of the most challenging to repair, as extensor tendons have less excursion than flexor tendons. Reconstructive techniques for such defects may differ according to the location of the defect, especially in Verdan's extensor zones 1-5. Adequate repair of extensor tendon defects in zones 1-5 is especially important because (a) even a 1 mm tendon gap in those zones may cause 20° extension loss, and (b) shortening of the extensor tendon by as little as 1 mm may cause decreased finger flexion. REVIEW This article reviews and discusses the literature on the various approaches and techniques for extensor tendon reconstruction, delineated by zone of injury (zones 1-8). CONCLSIONS: Awareness of the various techniques available to repair defects in each zone of injury is important so that surgeons can choose the technique most in alignment with the type of injury, the surgeon's skills, and patient characteristics, and optimise the repair of such injuries.
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Affiliation(s)
| | - Kareem Hassan
- b College of Medicine , The University of Arizona , Tucson , AZ , USA , and
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19
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Weber JF, Agur AMR, Fattah AY, Gordon KD, Oliver ML. Tensile mechanical properties of human forearm tendons. J Hand Surg Eur Vol 2015; 40:711-9. [PMID: 25940499 DOI: 10.1177/1753193415584715] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 04/01/2015] [Indexed: 02/03/2023]
Abstract
Previous studies of the mechanical properties of tendons in the upper limb have used embalmed specimens or sub-optimal methods of measurement. The aim of this study was to determine the biomechanical properties of all tendons from five fresh frozen cadaveric forearms using updated methodology. The cross-sectional area of tendons was accurately measured using a laser reflectance system. Tensile testing was done in a precision servo-hydraulic device with cryo-clamp fixation. We determined that the cross-sectional area of some tendons is variable and directly influences the calculated material properties; visual estimation of this is unreliable. Data trends illustrate that digital extensor tendons possess the greatest tensile strength and a higher Young's modulus than other tendon types.
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Affiliation(s)
- J F Weber
- Department of Mechanical and Materials Engineering, Queen's University, Kingston, Ontario, Canada
| | - A M R Agur
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - A Y Fattah
- Regional Paediatric Burns and Plastic Surgery Service, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - K D Gordon
- School of Engineering, University of Guelph, Guelph, Ontario, Canada
| | - M L Oliver
- School of Engineering, University of Guelph, Guelph, Ontario, Canada
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