Friction of the gliding surface. Implications for tendon surgery and rehabilitation

Complex regional pain syndrome type II localized to the index finger. A case report translating scientific evidence into clinical practice

BACKGROUND

Complex regional pain syndrome type II (CRPS-II) is a rare condition associated with peripheral nervous system lesions. Its localized distribution in the fingers is unique, and its treatment is unclear.

CASE DESCRIPTION

A 56-year-old male presented to the emergency department with a saw-cut index finger injury with associated tendon and nerve injuries. After surgery, he was admitted to physical therapy (PT) with persistent pain, joint stiffness, allodynia, and trophic changes compatible with CRPS-II localized in the index finger. The diagnosis was confirmed after applying the Budapest Criteria, and PT was progressive and individualized according to the patient's needs, including graded motor imagery, mobilizations, exercises, and education.

OUTCOMES

After 12 weeks of PT, a clinically significant decrease in pain intensity and improvements in mobility and index finger and upper limb functionality was observed, reducing CRPS symptomatology.

DISCUSSION

This report provides information about a unique case of a localized form of CRPS-II. After reviewing the literature on clinical cases of both CRPS-II and localized forms of CRPS, we highlight that the clinical features of this patient and his positive therapeutic response support the importance of translating the scientific evidence on CRPS into clinical practice.

Person-centred management of upper limb complex regional pain syndrome: an integrative review of non-pharmacological treatment

Introduction

Complex Regional Pain Syndrome (CRPS) is most common in the upper limb and associated with high disability. The purpose of this review was to critically appraise and synthesise literature exploring non-pharmacological treatment for upper limb CRPS, to guide upper-limb-specific management.

Methods

Using an integrative review methodology, 13 databases were searched to identify all published studies on non-pharmacological management of upper limb CRPS. The Crowe Critical Appraisal Tool was used to provide quality ratings for included studies, and analysis employed a qualitative descriptive approach.

Results

From 236 abstracts reviewed, 113 full texts were read, and 38 articles selected for data extraction. Designs included single case (n = 14), randomised controlled trial (n = 8), prospective cohort (n = 8), case series (n = 4), retrospective (n = 3), and mixed methods (n = 1). Interventions were categorised as sensory retraining (n = 13), kinesiotherapy (n = 7), manual therapies (n = 7), physical modalities (n = 6), and interdisciplinary treatment programmes (n = 5). All studies measured pain intensity, and most (n = 24) measured physical parameters such as strength, movement, or perceptual abilities. Few measured patient-rated function (n = 13) or psychological factors (n = 4). Quality ratings ranged from 30% to 93%, with a median of 60%.

Conclusion

Methodological quality of non-pharmacological treatment approaches for upper limb CRPS is overall poor. Movement, desensitisation, and graded functional activity remain the mainstays of intervention. However, despite the impact of CRPS on wellbeing and function, psychological factors and functional outcomes are infrequently addressed. Further robust research is required to determine which aspects of treatment have the greatest influence on which symptoms, and when and how these should be introduced and progressed.

Fine tuning of the side-to-side tenorrhaphy: A biomechanical study assessing different side-to-side suture techniques in a porcine tendon model

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.

Polytetrafluoroethylene (PTFE) suture vs fiberwire and polypropylene in flexor tendon repair

BACKGROUND

In this study, we evaluate the value of novel suture material based on monofilamentous-extruded polyfluoroethylene (PTFE) compared to polypropylene (PPL) and Fiberwire (FW).

MATERIALS AND METHODS

60 flexor tendons were harvested from fresh cadaveric upper extremities. 4-0 sutures strands were used in the PPL, FW and PTFE group. Knotting properties and mechanical characteristics of the suture materials were evaluated. A 4-strand locked cruciate (Adelaide) or a 6-strand (M-Tang) suture technique was applied as core sutures for a tendon repair. Two-way ANOVA tests were performed with the Bonferroni correction.

RESULTS

Stable knotting was achieved with 5 throws with the PPL material, 7 throws for FW and 9 throws for PTFE. In the PPL group, linear tensile strength was 45.92 ± 12.53 N, in the FW group 80.11 ± 18.34 N and in the PTFE group 76.16 ± 29.10 N. FW and PTFE are significantly stronger than PPL but show no significant difference among each other. Similar results were obtained in the subgroup comparisons for different repair techniques. The Adelaide and the M-Tang knotting technique showed no significant difference.

CONCLUSION

Fiberwire showed superior handling and knotting properties in comparison to PTFE. However, PTFE allows easier approximation of the stumps. In both, M-Tang and Adelaide repairs, PTFE was equal to FW in terms of repair strength. Both PTFE and FW provide for a robust tendon repair so that early active motion regimens for rehabilitation can be applied.

Multicenter survey of symptoms, work life, economic status, and quality of life of complex regional pain syndrome patients

Background

Complex regional pain syndrome (CRPS) is an intractable pain disease with various symptoms. Here, we investigated the disease status, work life, sleep problems, medical insurance, economic status, psychological problems, and quality of life (QOL) of CRPS patients.

Methods

CRPS patients from 37 university hospitals in South Korea were surveyed. The survey questionnaire consisted of 24 questions on the following aspects of CRPS patients sex, age, occupation, cause of injury, activities of daily living (ADL), pain severity, sleep disturbance, level of education, economic status, therapeutic effect, and suicidal ideation. Additionally, the abbreviated World Health Organization Quality of Life (WHOQOL-BREF) questionnaire, consisting of 26 questions, was used to identify the status of QOL.

Results

A total of 251 patients completed the questionnaire. According to the survey, 54.2% patients could not perform ADL on their own. Over the previous week, the mean pain score was 7.15 ± 1.78 (out of a total of 10 points); 92.1% of patients had sleep disorders and 80.5% had suicidal ideation, with most patients suffering from psychological problems. The average for each domain of WHOQOL-BREF was as follows 21.74 ± 14.77 for physical, 25.22 ± 17.66 for psychological, 32.02 ± 22.36 for social relationship, and 30.69 ± 15.83 for environmental (out of a total of 100 points each). Occupation, ADL, sleep time, therapeutic effect, and suicidal ideation were statistically correlated with multiple domains.

Conclusions

Most patients had moderate to severe pain, economic problems, limitations of their ADL, sleep problems, psychological problems, and a low QOL score.

Effect of Early Orthopedic Rehabilitation on Development of Complex Regional Pain Syndrome Type 1

Objective

Complex regional pain syndrome (CRPS) is a syndrome usually occurs in one extremity and characterized by pain, tenderness with palpation, and symptoms of autonomic nervous system dysfunction. An essential factor in the etiology of CRPS is immobilization of the extremity as a result of a fracture. Delaying the start of physical medicine and rehabilitation program after removal of the plaster or splint may increase the rates of CRPS development in patients with fractures. This study aims to determine a direct relationship between delay time in rehabilitation and CRPS development.

Materials and Methods

Patients admitted to our physical therapy and rehabilitation outpatient clinic within the last 3 years (January 2016 to January 2018) for orthopedic rehabilitation following fractures were retrospectively analyzed. CRPS development status, the delay time for the rehabilitation program was determined in 38 CRPS patients of 91 patients with fractures. Probit regression was used to reveal the relationship between delay time for rehabilitation and CRPS development.

Results

CRPS development rates were decreased by years (48.71% in 2016, 43.47% in 2017, and 31.03% in 2018). When cases in 2016 were taken as a reference, it was seen that cases in 2017 and 2018 were exposed to CRPS approximately 0.03% and 16.00% lower than the reference year, 2016. A delay of one day exposes the patient to approximately 0.35% more CRPS.

Conclusion

As the delay time for rehabilitation in our clinic decreased, the incidence of CRPS decreased. The awareness of physicians and patients about the importance of early rehabilitation should be improved.

Autoantibodies against P29ING4 are associated with complex regional pain syndrome

INTRODUCTION

Complex regional pain syndrome (CRPS) is a complication following trauma or surgery and may be difficult to diagnose since biomarkers are lacking. Using protein array technology, we found antibodies binding to p29ING4, which we further characterized using ELISA.

METHODS

Thirty-six sera of early-stage type 1 CRPS, 66 sera of rheumatoid arthritis (RA), 53 sera of axial spondyloarthritis (axSpA), 29 sera of psoriatic arthritis (PsA), 22 sera of patients after radial fractures (trauma control), and 100 sera of blood donors (BD) were analyzed for anti-p29ING4. We established ELISAs with 7 different antigens and using different secondary antibodies binding to IgG, IgG1, IgG2, IgG3, IgG4, IgA, and IgM, and 2 different tests to detect immune complexes (IC) of p29ING4 and IgG or IgG1.

RESULTS

The highest likelihood ratios versus CRPS and trauma control were observed considering the A1-23 (sensitivity 19%, specificity 100%, LR > 19) using IgG as a secondary antibody, the A120-165 (sensitivity 17%, specificity 100%, LR = 17) using IgG as a secondary antibody and the A120-165 (sensitivity 31%, specificity 95%, LR = 6.2) using IgA as a secondary antibody. IC of p29ING4 and IgG were present in 11/36 (31%) CRPS sera, 17/64 (27%) RA sera, 13/53 (25%) SpA sera, 5/29 (17%) PsA sera, 1/22 (5%) trauma control sera, and 4/100 (4%) sera of BD. IC of p29ING4 and IgG1 were present in 14/36 (39%) CRPS sera, 19/64 (30%) RA sera, 13/53 (25%) SpA, 1/29 (3%) PsA, 2/22 (9%) trauma control, and 4/100 (4%) of the BD sera.

CONCLUSION

Due to the lack of other biomarkers of type 1 CRPS, P29ING4 autoantibodies could be helpful in its diagnostic work-up.

Influence of vitamin C on the incidence of CRPS-I after subacromial shoulder surgery

PURPOSE

The primary aim of this study was to determine whether postoperative administration of vitamin C (VC) is associated with reduced risk of complex regional pain syndrome type I (CRPS-I) after subacromial shoulder surgery (SaSS). The secondary objective of the study was to identify risk factor for the development of CRPS-I after SaSS.

MATERIALS AND METHODS

A retrospective cohort study was performed to evaluate 542 patients undergoing SaSS from January 2015 to December 2016. The cohort was divided into two groups based on VC administration [Group I (no VC) and Group II (500 mg/day oral VC for 50 days postoperatively)]. The relationship between VC administration and development of CRPS-I was assessed. Demographics, preoperative clinical parameters, and operative variables were evaluated to determine their effect on the incidence of CRPS-I.

RESULTS

A total of 267 patients (Group II) undergoing SaSS received VC, and 266 patients (Group I) did not. The incidence of CRPS-I was significantly different between two groups (36(13%) vs 18(7%), p = 0.009). Multivariable regression, however, demonstrated that VC reduced the risk of CRPS-I after SaSS by > 50% (aOR = 0.49; 95% CI 0.27-0.91). Patients undergoing open surgery (aOR = 2.19; 95% CI 1.2-4.0) were more likely to develop CRPS-I postoperatively. Higher preoperative Constant score (aOR = 0.94; 95% CI 0.91-0.98) was associated with lower risk for CRPS-I development.

CONCLUSIONS

The present study found that VC administered prophylactically for 50 days postoperatively is effective in preventing CRPS-I development after SaSS. CRPS-I is a common complication following SaSS, especially in the setting of an open approach. The authors recommend preventive management with VC and arthroscopic approaches when possible for SaSS.

LEVEL OF EVIDENCE III

Retrospective comparative study.

National Trends in the Diagnosis of CRPS after Open and Endoscopic Carpal Tunnel Release

Background  Complex regional pain syndrome (CRPS) occurs in 2 to 8% of patients that receive open or endoscopic carpal tunnel release (CTR). Because CRPS is difficult to treat after onset, identifying risk factors can inform prevention. We determined the incidence of CRPS following open and endoscopic CTR using a national claims database. We also examined whether psychosocial conditions were associated with CRPS after CTR. Methods  We accessed insurance claims using diagnostic and procedural codes. We calculated the incidence of CRPS following open carpal tunnel release and endoscopic carpal tunnel release within 1 year. The response variable was the presence of CRPS after CTR. Explanatory variables included procedure type, age, gender, and preoperative diagnosis of anxiety or depression. Results  The number of open CTRs (85% of total) outweighs the number of endoscopic procedures. In younger patients, the percentage of endoscopic CTRs is increasing. Rates of CRPS are nearly identical between surgery types for both privately insured (0.3%) and Medicare patients (0.1%). Middle aged (range: 40-64 years) and female patients had significantly higher rates of CRPS than did the general population. Preoperative psychosocial conditions did not correlate with the presence of CRPS in surgical patients. Clinical Relevance  The decision between endoscopic and open CTR should not be made out of concern for development of CRPS postsurgery, as rates are low and similar for both procedures. Rates of CRPS found in this study are much lower than rates found in previous studies, indicating inconsistency in diagnosis and reporting or generalizability of prior work. Preoperative psychosocial disorders and CRPS are unrelated.

Allodynography: Reliability of a New Procedure for Objective Clinical Examination of Static Mechanical Allodynia

Objective

There is a need for reliable and valid clinical assessment tools for quantifying allodynia in neuropathic pain. Allodynography has been proposed as a useful standardized procedure for clinical assessment of mechanical allodynia. This study (www.clinicaltrials.gov NCT02070367) undertook preliminary investigation of the measurement properties of allodynography, a new standardized clinical examination procedure for mapping the area of cutaneous allodynia.

Methods

Persons with pain in one upper extremity after complex regional pain syndrome, a peripheral nerve injury, or who had recently experienced a hand fracture were recruited for assessment of static mechanical allodynia (based on perception of a 15g force stimulus delivered by Semmes-Weinstein monofilament #5.18 as painful) by two raters at baseline; the assessment was repeated one week later.

Results

Single-measures estimates suggested inter-rater reliability for allodynography was excellent at an intraclass correlation coefficient (ICC) of 0.97 (N = 12); test–retest reliability was also excellent at ICC = 0.89 (N = 10) for allodynography (P < 0.001 for both). Confidence intervals’ lower bounds confirm inter-rater reliability as excellent (0.90) but were less definitive for test–retest (0.59).

Conclusions

This preliminary study supports the inter-rater and test–retest reliability of allodynography. Studies on larger samples in multiple contexts and reporting other measurement properties are warranted.

Incidence of and Risk Factors for Complex Regional Pain Syndrome Type 1 after Surgery for Distal Radius Fractures: A Population-based Study

This study aimed to evaluate the incidence rates of and risk factors for complex regional pain syndrome type 1 (CRPS-1) after surgery for distal radius fractures (DRFs). Using data from January 2007 to December 2014, we analysed the data from the Korean Health Insurance Review and Assessment (HIRA) service. After extracting the data of patients aged ≥18 years whose diagnostic and operation codes for DRFs were entered into the HIRA database, we analysed the incidence rates of and risk factors for CRPS-1. From 2007 to 2014, 172,194 DRFs were treated surgically. Within 1 year postoperatively, 1,103 CRPS-1 cases were diagnosed, with an incidence of 0.64%. On univariate and multivariate analyses, the risk factors that significantly correlated with the incidence of CRPS-1 included female sex, rheumatoid arthritis, open reduction, open fracture, and accompanying ulnar fracture, whereas old age, psychiatric disease, and external fixation were not statistically significant. The incidence of CRPS-1 after surgery for DRF was very low (0.64%) in South Korea. Careful monitoring is necessary for patients with complex fractures and rheumatoid arthritis who are at increased risk of developing CRPS-1.

The effect of modified locking methods and suture materials on Zone II flexor tendon repair-An ex vivo study

The failure rate of intrasynovial tendon repair is high due to substantial elongation at the repair site and to the development of adhesions between the tendon’s surface and the surrounding digital sheath. To minimize these complications, we sought to reduce the incidence of gapping and to facilitate the initiation of early motion by improving the time zero structural properties of repair. The Winters-Gelberman 8-strand repair technique was modified by adding surface lock loops and by using Fiberwire suture material. Forty-eight canine flexor digitorum profundus tendons were transected and repaired with one of three 8-strand techniques (Pennington modified Kessler, half hitch loops, or surface locking Kessler) using either 3–0 Supramid or 4–0 Fiberwire suture. Biomechanical testing was performed to determine the physiologic and failure mode properties of the repairs. The surface locking Kessler technique improved repair maximum load, load necessary to create a 2 mm repair site gap, and yield force compared to the modified Kessler and half hitch loop techniques. Fiberwire suture improved maximum load, the load necessary to create a 2 mm repair site gap, stiffness, and yield force compared to Supramid suture. Failure occurred by both suture pull out and by suture breakage in the modified Kessler, Supramid suture repair group. Failure occurred consistently by suture breakage in the surface locking Kessler, Supramid suture repair group. These results reveal that a novel locking Kessler repair is significantly stronger than the current state-of-the art flexor tendon suture repair technique. The use of a surface locking Kessler technique with Fiberwire suture markedly improves the mechanical properties of intrasynovial tendon repair by reducing the risk of post-operative gapping and rupture.

Obesity/Type II Diabetes Promotes Function-limiting Changes in Murine Tendons that are not reversed by Restoring Normal Metabolic Function

Type II Diabetes (T2DM) negatively alters baseline tendon function, including decreased range of motion and mechanical properties; however, the biological mechanisms that promote diabetic tendinopathy are unknown. To facilitate identification of therapeutic targets we developed a novel murine model of diabetic tendinopathy. Mice fed a High Fat Diet (HFD) developed diet induced obesity and T2DM and demonstrated progressive impairments in tendon gliding function and mechanical properties, relative to mice fed a Low Fat Diet (LFD). We then determined if restoration of normal metabolic function, by switching mice from HFD to LFD, was sufficient to halt the pathological changes in tendon due to obesity/T2DM. However, switching from a HFD to LFD resulted in greater impairments in tendon gliding function than mice maintained on a HFD. Mechanistically, IRβ signaling is decreased in obese/T2DM murine tendons, suggesting altered IRβ signaling as a driver of diabetic tendinopathy. However, knock-down of IRβ expression in S100a4-lineage cells (IRcKO^S100a4) was not sufficient to induce diabetic tendinopathy as no impairments in tendon gliding function or mechanical properties were observed in IRcKO^S100a4, relative to WT. Collectively, these data define a murine model of diabetic tendinopathy, and demonstrate that restoring normal metabolism does not slow the progression of diabetic tendinopathy.

Pathomechanics and Management of Secondary Complications Associated with Tendon Adhesions Following Flexor Tendon Repair in Zone II

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.

A Novel Compound Analgesic Cream (Ketamine, Pentoxifylline, Clonidine, DMSO) for Complex Regional Pain Syndrome Patients

BACKGROUND

Evidence suggests that complex regional pain syndrome (CRPS) is a manifestation of microvascular dysfunction. Topical combinations of α2-adrenergic receptor agonists or nitric oxide donors with phosphodiesterase or phosphatidic acid inhibitors formulated to treat microvascular dysfunction have been shown to reduce allodynia in a rat model of CRPS-I. Driven by these findings, we assessed the outcomes of CRPS patients treated with a compound analgesic cream (CAC) consisting of ketamine 10%, pentoxifylline 6%, clonidine 0.2%, and dimethyl sulfoxide 6% to 10%.

METHODS

An audit was conducted on 13 CRPS patients who trialed the CAC. A detailed report was compiled for each patient which comprised baseline characteristics, including CRPS description, previous treatments, and pain scores (numerical pain rating scale; 0 to 10). Recorded outcomes consisted of pain scores, descriptive outcomes, and concurrent medications/treatments, for which basic analysis was performed to determine the effectiveness of the CAC. Case reports are presented for 3 patients with varying outcomes.

RESULTS

Nine patients (69%) reported pain/symptom reduction (4.4 ± 2.1 vs. 6.3 ± 1.9) with use of the CAC. Six patients reported sustained benefits after 2 months of CAC use, and 2 patients reported complete resolution of pain/symptoms: one had early CRPS-I and the other received a partial CRPS diagnosis. An otherwise medication refractory and intolerant patient found partial benefit with the CAC.

CONCLUSIONS

These results demonstrate promise for this topical combination as a useful treatment in multimodal therapy for patients with CRPS, with the potential to resolve pain/symptoms in early CRPS patients.

Biomechanical and Macroscopic Evaluations of the Effects of 5-Fluorouracil on Partially Divided Flexor Tendon Injuries in Rabbits

Background:

The main goals of flexor tendon surgery are to restore digital motion by providing tendon healing and to preserve tendon gliding. Our purpose was to investigate the effects of 5-fluorouracil (5-FU) on tendon adhesions in partially divided profundus flexor tendons (flexor digitorum profundus [FDPs]) following surgical repair and in partially divided FDPs without surgical repair, and to compare the results of the repair versus the nonrepair of zone two injuries via macroscopic and biomechanical evaluations of tendon adhesions.

Methods:

We used 32 adult male European rabbits (Oryctolagus cunniculus) weighing from 2.5 to 3.5 kg. The study was performed on the deep flexor tendons of the second and third digits of the right hind paws of the rabbits; thus, a total of 64 tendons were examined in this study.

Results:

Based on the results achieved in our experimental study, the load (N) significantly increased in subgroup 1a in which the tendons were surgically repaired and were not treated with 5-FU compared with subgroup 2a in which tendons were surgically repaired and treated with 5-FU.

Conclusions:

The load (N) significantly increased in subgroup 1a in which the tendons were surgically repaired and were not treated with 5-FU compared to subgroup 2a in which the tendons were surgically repaired and treated with 5-FU. Therefore, these results revealed a decrease in adhesion formation in the subgroup that was treated with 5-FU due to increased resistance to tendon adhesions during their excursion through the tendon sheath, which in this case required greater traction force.

Management of complications with hand fractures

Both operative and nonoperative treatment of hand fractures can result in numerous complications, including stiffness, malunion, nonunion, arthritis, infection, and complex regional pain syndrome. These complications are frequently encountered and are often challenging to treat. This article systematically outlines the diagnosis and treatment of each of these complications to achieve the best possible outcome for the patient's overall hand function.

Biomechanical comparison of double grasping repair versus cross-locked cruciate flexor tendon repair

PURPOSE

This study was conducted to compare the in vitro biomechanical properties of tensile strength and gap resistance of a double grasping loop (DGL) flexor tendon repair with the established four-strand cross-locked cruciate (CLC) flexor tendon repair, both with an interlocking horizontal mattress (IHM) epitendinous suture. The hypothesis is that the DGL-IHM method which utilizes two looped core sutures, grasping and locking loops, and a single intralesional knot will have greater strength and increased gap resistance than the CLC-IHM method.

METHODS

Forty porcine tendons were evenly assigned to either the DGL-IHM or CLC-IHM group. The tendon repair strength, 2-mm gap force and load to failure, was measured under a constant rate of distraction. The stiffness of tendon repair was calculated and the method of repair failure was analyzed.

RESULTS

The CLC-IHM group exhibited a statistically significant greater resistance to gapping, a statistically significant higher load to 2-mm gapping (62.0 N), and load to failure (99.7 N) than the DGL-IHM group (37.1 N and 75.1 N, respectively). Ninety percent of CLC-IHM failures were a result of knot failure whereas 30 % of the DGL-IHM group exhibited knot failure.

CONCLUSIONS

This study demonstrates that the CLC-IHM flexor tendon repair method better resists gapping and has a greater tensile strength compared to the experimental DGL-IHM method. The authors believe that while the DGL-IHM provides double the number of sutures at the repair site per needle pass, this configuration does not adequately secure the loop suture to the tendon, resulting in a high percentage of suture pullout and inability to tolerate loads as high as those of the CLC-IHM group.

Rehabilitation of the upper extremity following nerve and tendon reconstruction: when and how

Following upper extremity nerve and tendon reconstruction, rehabilitation is necessary to achieve optimal function and outcome. In this review, the authors present current evidence and literature regarding the strategies and techniques of rehabilitation following peripheral nerve and tendon reconstruction.

Factors associated with complex regional pain syndrome type I in patients with surgically treated distal radius fracture

PURPOSE

Wrist fracture is considered a typical initiating trauma for complex regional pain syndrome type I (CRPS I). However, few studies have comprehensively evaluated factors associated with the occurrence of CRPS I after the surgical treatment of a distal radius fracture (DRF). This study evaluates the factors influencing the occurrence of CRPS I after the surgical treatment of a DRF.

METHODS

A total of 477 patients with a DRF who had been treated surgically were enrolled in this prospective observational study. Patients were followed for 6 months after surgery, and CRPS I was diagnosed using the Budapest diagnostic criteria for research. The factors assessed for the development of CPRS I were age, gender, the body mass index, the type of fracture, the energy of trauma, the number of trial reductions, the type of surgery, and the duration of immobilization. A multivariate logistic regression analysis was conducted to identify independent predictors of the occurrence of CRPS I.

RESULTS

Among the 477 patients, 42 (8.8 %) satisfied the Budapest criteria for CRPS I within 6 months of surgery. Female patients developed CRPS I more frequently, and the patients who developed CRPS I were older and more likely to sustain a high energy injury or have a comminuted fracture. According to the multivariate analysis, female patients and those with a high energy trauma or severe fracture type were significantly more likely to develop CRPS I (p = 0.02, 0.01, and 0.01, respectively).

CONCLUSIONS

High energy injuries, severe fractures, and the female gender contribute to the development of CRPS I after the surgical treatment of DRF. The results have important implications for physicians who wish to identify patients at high risk for CRPS I after operative fixation for DRF and instigate treatment accordingly.

Allergy/hypersensitivity reactions as a predisposing factor to complex regional pain syndrome I in orthopedic patients

Several predisposing conditions have been associated with complex regional pain syndrome I (CRPS I). The purpose of this study was to determine the relationship between a history of allergy/hypersensitivity reactions and CRPS I in orthopedic patients. Orthopedic patients with CRPS I (n=115) who experienced pain relief after a successful sympathetic nerve blockade were identified for study inclusion; a control group (n=115) matched to the CRPS I group by age, sex, and location of injury was also included. All patients in the study had an average age of 42 years. In the CRPS I group, all participants were Caucasian and the majority (80.8%) were women. The skin of patients with CRPS I was described as fair (57.7%), mottled (57.7%), or sensitive (80.8%). Of the patients with CRPS I, 78 (67.8%) reported a statistically significant history of allergies compared with the 39 (33.9%) patients in the control group (P<.0001). Patients with CRPS I who experienced complete pain relief for at least 1 month following a single sympathetic nerve block were asked to answer a questionnaire (n=35), and some then underwent immediate hypersensitivity testing using a skin puncture technique (n=26). Skin hypersensitivity testing yielded an 83.3% positive predictive value with an accuracy of 76.9%. Based on these results, a positive history for allergy/hypersensitivity reactions is a predisposing condition for CRPS I in this subset of orthopedic patients. These hypersensitivity reactions may prove important in gaining a better understanding in the pathophysiology of CRPS I as a regional pain syndrome.

Type I complex regional pain syndrome

First described by Ambroise Paré in the mid-17th century complex, regional pain syndrome (CRPS) can be defined as an articular and periarticular pain syndrome associated with vasomotor deregulation triggered by various stresses with no relationship between the intensity of the initial injury and severity of the continuing pain. Several names have been given to Type 1 complex regional pain syndrome (CRPS-I): causalgia, reflex sympathetic dystrophy, shoulder-hand syndrome and algodystrophy. The reported incidence of CRPS-I is about 25 per 100,000. Predisposing factors are tobacco consumption and being female (W/M ratio=4). Although all the limbs can be affected, the upper limb is by far the most affected. CRPS-I is a classic complication of distal radius fractures (4-37%) and carpal tunnel surgery (2-4%). Early diagnosis and management are the most important elements of treatment because this syndrome has a long and disabling course. Some of the proposed treatments include NSAIDs, antidepressants and anticonvulsants. The latter, despite their good analgesic effects, do not cure CRPS-I. In select cases, a surgical procedure aiming at removing a nociceptive stimulus can lead to spectacular improvements.

Suture techniques for tendon repair; a comparative review

Over the past five decades we have seen numerous iterations of suture repair methods for tendon. The pursuit of the ultimate repair has led to many repair methods being described. This comprehensive compilation of the suture repair techniques will describe the factors that affect repair success, including repair strength, gapping resistance, glide and rehabilitation. Different approaches to rejoining severed tendons will be critiqued on their biomechanical ability to improve tendon repair strength, maintaining glide, reducing tendon damage, and minimising adhesion formation. It is important to highlight how the suture repairs have evolved and improved but also review how they may contribute to their own trauma. The apparent paradox between providing mechanical strength and minimising adhesions require refinements in the field to improve on functional outcomes.

Suture techniques for tendon repair; a comparative review

Over the past five decades we have seen numerous iterations of suture repair methods for tendon. The pursuit of the ultimate repair has led to many repair methods being described. This comprehensive compilation of the suture repair techniques will describe the factors that affect repair success, including repair strength, gapping resistance, glide and rehabilitation. Different approaches to rejoining severed tendons will be critiqued on their biomechanical ability to improve tendon repair strength, maintaining glide, reducing tendon damage, and minimising adhesion formation. It is important to highlight how the suture repairs have evolved and improved but also review how they may contribute to their own trauma. The apparent paradox between providing mechanical strength and minimising adhesions require refinements in the field to improve on functional outcomes.

Gliding resistance and modifications of gliding surface of tendon: clinical perspectives

The smooth gliding of the normal human digital flexor is maintained by synovial fluid lubrication and lubricants bound to the tendon surface. This system can be disrupted by degenerative conditions such as trigger finger, or by trauma. The resistance to tendon gliding after surgical repair of the lacerated digital flexor tendon relates to location of suture knots, exposure of suture materials, and type of surgical repair and materials. Restoration of a functioning gliding surface after injury can be helped by using low-friction, high-strength suture designs, therapy that enables gliding, and the addition of lubricants to the tendon surface.

Relationship between complex regional pain syndrome and working life: a Korean study

Complex regional pain syndrome affects the quality of life of the patient. The aim of this study was to investigate the epidemiological features of this syndrome and evaluate its effect on the patient's working life. We demonstrated that the disease has a male preponderance and is 3 times more likely to affect the lower extremities. In this study, 11 participants (20%) retained their employment, whereas 44 (80%) became unemployed. Mean age and pain score were lower in the employment group than in the unemployment group (29.1 ± 16.8 yr vs 40.1 ± 12.6 yr, P = 0.021, and 4.5 ± 2.9 vs 7.0 ± 2.0, P = 0.002, respectively). Subjects diagnosed within 8 months (P = 0.044), those who had achieved higher levels of education (P = 0.028), and those working in white-collar jobs (P = 0.011) had higher employment-retention rates. Therefore, patients must manage their jobs (lower physical demand and decrease the number of working hours) if they are to improve their occupational life. To achieve satisfactory outcomes and a high employment-retention rate, clinicians must be aware of the importance of an early diagnosis (within 8 months), appropriate treatment, and a reduction in the patient's pain score.

Therapy after injury to the hand

Surgical and nonsurgical management of upper extremity disorders benefits from the collaboration of a therapist, the treating physician, and the patient. Hand therapy plays a role in many aspects of treatment, and patients with upper extremity injuries may spend considerably more time with a therapist than with a surgeon. Hand therapists coordinate edema control; pain management; minimization of joint contractures; maximization of tendon gliding, strengthening, and work hardening; counseling; and ongoing diagnostic evaluation. Modalities used to manage hand injuries include ultrasound, splinting, Fluidotherapy (Chattanooga Group, Chattanooga, TN), cryotherapy, various electrical modalities, phonophoresis, and iontophoresis.

Complex regional pain syndrome after hand surgery

Complex regional pain syndrome (CRPS) after an emergent or elective upper extremity surgery may complicate recovery, delay return to work, diminish health-related quality of life, and increase the likelihood of poor outcomes and/or litigation. CRPS after hand surgery is not uncommon and may complicate postoperative care. Early diagnosis and treatment of CRPS is critical for optimal patient outcomes. This article discusses the diagnosis, physiology, and management of postsurgical CRPS that occurs after hand surgery.

Postoperative management of carpometacarpal joint fracture dislocation of the hand: A case report

Injury to the carpometacarpal joints is rare. The strong ligamentous attachments and carpal bone alignment readily resist displacement. To the authors' knowledge, there are no studies evaluating postoperative recovery regimens of carpometacarpal fracture dislocations. The present study describes a postoperative hand therapy regimen that used a novel carpometacarpal brace permitting early mobilization.

CRPS of the upper or lower extremity: surgical treatment outcomes

The hypothesis is explored that CRPS I (the "new" RSD) persists due to undiagnosed injured joint afferents, and/or cutaneous neuromas, and/or nerve compressions, and is, therefore, a misdiagnosed form of CRPS II (the "new" causalgia). An IRB-approved, retrospective chart review on a series of 100 consecutive patients with "RSD" identified 40 upper and 30 lower extremity patients for surgery based upon their history, physical examination, neurosensory testing, and nerve blocks. Based upon decreased pain medication usage and recovery of function, outcome in the upper extremity, at a mean of 27.9 months follow-up (range of 9 to 81 months), gave results that were excellent in 40% (16 of 40 patients), good in 40% (16 of 40 patients) and failure 20% (8 of 40 patients). In the lower extremity, at a mean of 23.0 months follow-up (range of 9 to 69 months) the results were excellent in 47% (14 of 30 patients), good in 33% (10 of 30 patients) and failure 20% (6 of 30 patients). It is concluded that most patients referred with a diagnosis of CRPS I have continuing pain input from injured joint or cutaneous afferents, and/or nerve compressions, and, therefore, similar to a patient with CRPS II, they can be treated successfully with an appropriate peripheral nerve surgical strategy.

Lubricin surface modification improves tendon gliding after tendon repair in a canine model in vitro

This study investigated the effects of lubricin on the gliding of repaired flexor digitorum profundus (FDP) tendons in vitro. Canine FDP tendons were completely lacerated, repaired with a modified Pennington technique, and treated with one of the following solutions: saline, carbodiimide derivatized gelatin/hyaluronic acid (cd-HA-gelatin), carbodiimide derivatized gelatin to which lubricin was added in a second step (cd-gelatin + lubricin), or carbodiimide derivatized gelatin/HA + lubricin (cd-HA-gelatin + lubricin). After treatment, gliding resistance was measured up to 1,000 cycles of simulated flexion/extension motion. The increase in average and peak gliding resistance in cd-HA-gelatin, cd-gelatin + lubricin, and cd-HA-gelatin + lubricin tendons was less than the control tendons after 1,000 cycles (p < 0.05). The increase in average gliding resistance of cd-HA-gelatin + lubricin treated tendons was also less than that of the cd-HA-gelatin treated tendons (p < 0.05). The surfaces of the repaired tendons and associated pulleys were assessed qualitatively with scanning electron microscopy and appeared smooth after 1,000 cycles of tendon motion for the cd-HA-gelatin, cd-gelatin + lubricin, and cd-HA-gelatin + lubricin treated tendons, while that of the saline control appeared roughened. These results suggest that tendon surface modification can improve tendon gliding ability, with a trend suggesting that lubricin fixed on the repaired tendon may provide additional improvement over that provided by HA and gelatin alone.

Comparison of 2 surgical approaches for volar locking plate osteosynthesis of the distal radius

PURPOSE

To determine whether a volar radial (Henry) exposure to the distal radius is associated with less median nerve dysfunction than a direct volar exposure of the distal radius through the carpal tunnel that has been abandoned due to median nerve problems.

METHODS

Over an 18-month period, all patients with distal radius fractures treated with volar locking plate osteosynthesis were consecutively integrated into this therapeutic study. A direct volar midline approach ulnar to the flexor tendons and median nerve including prophylactic carpal tunnel release (CTR) was routinely performed from July 2003 to December 2004 (CTR group). Due to median nerve problems, this approach was abandoned and a distal part of the classical Henry approach (HRY) through the flexor carpi radialis (FCR) tendon sheath was performed for volar locking plate osteosynthesis in a second period from April 2005 to May 2006 (HRY group). In this group, the carpal tunnel was released only in selected cases. Data were collected prospectively for both groups. Analysis included clinical examination, the Patient-Rated Wrist Evaluation, and radiological follow-up up to 1 year after surgery.

RESULTS

Eighty-three patients entered the CTR group during the initial series. Thirty-one patients showed median nerve dysfunction 6 weeks after surgery. In the second period of observation, 91 patients entered the HRY group. The carpal tunnel was therapeutically decompressed in 18 patients, leaving the carpal tunnel untouched in 91 patients. Temporary median nerve paraesthesia was seen in 4 patients without CTR in the HRY group 6 weeks after surgery. After 1 year, persistent median nerve irritation was observed in 4 patients of the CTR group and none of the HRY group. Grip strength, range of motion, and Patient-Rated Wrist Evaluation were similar after 1 year.

CONCLUSIONS

The direct volar approach to the distal radius with routine CTR should be abandoned because it was associated with an increased rate of temporary and persistent median nerve irritation compared to the distal part of the classic Henry approach in our series.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Extensive skin necrosis of the arm in a patient with complex regional pain syndrome

We report a 36-year-old woman with complex regional pain syndrome (CRPS) type 1 presenting with extensive skin necrosis of the left arm. The patient cooled her arm with ice packs to ease severe pain due to CRPS, in spite of repeated cautions against frostbite injury. The regions of skin necrosis corresponded with the sites where she had applied ice packs. We considered that the severe skin necrosis in our case was due to a self-induced frostbite injury.

Structure-function relationships in tendons: a review

The purpose of the current review is to highlight the structure-function relationship of tendons and related structures to provide an overview for readers whose interest in tendons needs to be underpinned by anatomy. Because of the availability of several recent reviews on tendon development and entheses, the focus of the current work is primarily directed towards what can best be described as the 'tendon proper' or the 'mid-substance' of tendons. The review covers all levels of tendon structure from the molecular to the gross and deals both with the extracellular matrix and with tendon cells. The latter are often called 'tenocytes' and are increasingly recognized as a defined cell population that is functionally and phenotypically distinct from other fibroblast-like cells. This is illustrated by their response to different types of mechanical stress. However, it is not only tendon cells, but tendons as a whole that exhibit distinct structure-function relationships geared to the changing mechanical stresses to which they are subject. This aspect of tendon biology is considered in some detail. Attention is briefly directed to the blood and nerve supply of tendons, for this is an important issue that relates to the intrinsic healing capacity of tendons. Structures closely related to tendons (joint capsules, tendon sheaths, pulleys, retinacula, fat pads and bursae) are also covered and the concept of a 'supertendon' is introduced to describe a collection of tendons in which the function of the whole complex exceeds that of its individual members. Finally, attention is drawn to the important relationship between tendons and fascia, highlighted by Wood Jones in his concept of an 'ectoskeleton' over half a century ago - work that is often forgotten today.