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Smolyak G, Rodenhouse A, Nichols AEC, Ketonis C, Loiselle AE. Pharmacological Antagonism of Ccr2+ Cell Recruitment to Facilitate Regenerative Tendon Healing. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.07.15.603448. [PMID: 39071284 PMCID: PMC11275796 DOI: 10.1101/2024.07.15.603448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
Successful tendon healing requires sufficient deposition and remodeling of new extracellular matrix at the site of injury, with this process mediating in part through fibroblast activation via communication with macrophages. Moreover, resolution of healing requires clearance or reversion of activated cells, with chronic interactions with persistent macrophages impairing resolution and facilitating the conversion the conversion to fibrotic healing. As such, modulation of the macrophage environment represents an important translational target to improve the tendon healing process. Circulating monocytes are recruited to sites of tissue injury, including the tendon, via upregulation of cytokines including Ccl2, which facilitates recruitment of Ccr2+ macrophages to the healing tendon. Our prior work has demonstrated that Ccr2-/- can modulate fibroblast activation and myofibroblast differentiation. However, this approach lacked temporal control and resulted in healing impairments. Thus, in the current study we have leveraged a Ccr2 antagonist to blunt macrophage recruitment to the healing tendon in a time-dependent manner. We first tested the effects of Ccr2 antagonism during the acute inflammatory phase and found that this had no effect on the healing process. In contrast, Ccr2 antagonism during the late inflammatory/ early proliferative period resulted in significant improvements in mechanical properties of the healing tendon. Collectively, these data demonstrate the temporally distinct impacts of modulating Ccr2+ cell recruitment and Ccr2 antagonism during tendon healing and highlight the translational potential of transient Ccr2 antagonism to improve the tendon healing process.
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Affiliation(s)
- Gilbert Smolyak
- University of Rochester School of Medicine and Dentistry, Rochester, NY 14642
| | - Andrew Rodenhouse
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, NY 14642
| | - Anne E C Nichols
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, NY 14642
| | - Constantinos Ketonis
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, NY 14642
| | - Alayna E Loiselle
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, NY 14642
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Aljasim O, Yener C, Demirkoparan M, Bilge O, Küçük L, Günay H. Comparison of pulley plasty, pulley venting and resection of flexor digitorum superficialis slip after zone II flexor tendon repair: a cadaver study. J Hand Surg Eur Vol 2023:17531934231215789. [PMID: 38000014 DOI: 10.1177/17531934231215789] [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: 11/26/2023]
Abstract
LEVEL OF EVIDENCE V.
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Affiliation(s)
- Omar Aljasim
- Department of Orthopedic Surgery, Gebze Medikal Park Hospital, Kocaeli, Turkey
| | - Can Yener
- Department of Orthopedic Surgery, EMOT Hospital, Izmir, Turkey
| | - Mesut Demirkoparan
- Department of Orthopedic Surgery, Ege University Faculty of Medicine, Izmir, Turkey
| | - Okan Bilge
- Department of Anatomy, Ege University Faculty of Medicine, Izmir, Turkey
| | - Levent Küçük
- Department of Orthopedic Surgery, Medicana International Hospital, Izmir, Turkey
| | - Hüseyin Günay
- Department of Orthopedic Surgery, Ege University Faculty of Medicine, Izmir, Turkey
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Wang Y, Qian L, Liu ZF, Chen W, Shen X, Wu JN, Yang WX, Wang XH, Wang J, Xu YW. Safety and efficacy of ultrasonography of tension after zone II flexor tendon repair: A randomized controlled trial. J Hand Ther 2023; 36:786-795. [PMID: 37598094 DOI: 10.1016/j.jht.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 05/15/2023] [Accepted: 05/15/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND Primary flexor tendon repairs of lacerations in zone II of the hand are fraught with problems. Traditionally, exercise (active and passive), orthoses, and physical agents are common interventions for the rehabilitation of patients experiencing these issues. One area of focus in this field is how to safely utilize tension to lengthen gliding distance following zone II injury. Finding effective solutions in this area is a key priority for improving patient outcomes and quality of life. PURPOSE To identify the optimal immobilization position that meets safety standards for tension and is the most efficient, and consequently, to validate our clinical effectiveness. STUDY DESIGN A cross-sectional study was adopted for the first part of the research (Research 1). A prospective, parallel, 2-group, randomized trial was conducted with concealed allocation and single blinding in the second part of the research (Research 2). METHODS A total of 60 healthy adults were recruited to select the best-fit protective immobilization position in Research 1, which was confirmed by tendon tension (via Young's modulus) and excursion (via gliding distance). We then randomly assigned 45 patients after zone II flexor tendon repair into two groups in Research 2 to compare functional outcomes. The control group underwent the conventional modified Duran protocol with early passive motion, while the experimental group received the protocol (optimized by Research 1) with early active motion. Ultrasonography was used to measure the tension and excursion of the flexor tendons. The outcomes measured at 16 weeks post-repair included total active motion, strength, the Disabilities of the Arm, Shoulder and Hand, and Strickland scores. RESULTS Three participants were unable to participate in Research 2 due to medical issues and poor attendance. The investigation found that the safe tendon threshold was 345.09 ± 87.74 kPa for partial active digital motion among the 60 participants. The optimal immobilization position requires the wrist to be neutral with a flexion angle of 30° at the metacarpophalangeal joint. The grip strengths (p = 0.012), ratio of grip strength (p = 0.015), the Disabilities of the Arm, Shoulder and Hand (p = 0.036), and total active motion (p = 0.023) differed significantly between the two groups. CONCLUSIONS Protective immobilization of the wrist in a neutral flexion position and with the metacarpophalangeal joint flexed at 30° can secure the repaired flexor tendon safely and efficiently. The effects of an early active motion protocol may improve the grip strength and upper limb mobility of individuals after zone II flexor tendon repair. CLINICAL TRIAL REGISTRATION ChiCTR2000030592.
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Affiliation(s)
- Ying Wang
- Department of Rehabilitation, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Lei Qian
- Department of Rehabilitation, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Zhen-Feng Liu
- Department of Rehabilitation, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Wei Chen
- Department of Rehabilitation, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Xia Shen
- Department of Rehabilitation, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Jia-Ni Wu
- Sports Rehabilitation, Soochow University, Suzhou, China
| | - Wei-Xiang Yang
- Department of Rehabilitation, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Xin-Hao Wang
- Department of Rehabilitation and Health Care, Wuxi Vocational and Technology College: Wuxi Institute of Technology, Wuxi, China
| | - Jun Wang
- Department of Rehabilitation, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China.
| | - Yan-Wen Xu
- Department of Rehabilitation, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China.
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Townsend CB, Henry TW, Matzon JL, Seigerman D, Sodha SC, Beredjiklian PK. Functional Outcomes of Flexor Tendon Repair in the Fingers: A Comparison of Wide-Awake Local Anesthesia No Tourniquet Versus Traditional Anesthesia. Hand (N Y) 2023; 18:635-640. [PMID: 34991396 PMCID: PMC10233644 DOI: 10.1177/15589447211064364] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Flexor tendon lacerations in the fingers are challenging injuries that can be repaired using the wide-awake local anesthesia no tourniquet (WALANT) technique or under traditional anesthesia (TA). The purpose of our study was to compare the functional outcomes and complication rates of patients undergoing flexor tendon repair under WALANT versus TA. METHODS All patients who underwent a primary flexor tendon repair in zone I and II without tendon graft for closed avulsions or open lacerations between 2015 and 2019 were identified. Electronic medical records were reviewed to record and compare patient demographics, range of motion, functional outcomes, complications, and reoperations. RESULTS Sixty-five zone I (N = 21) or II (N = 44) flexor tendon repairs were included in the final analysis: 23 WALANT and 42 TA. There were no statistical differences in mean age, length of follow-up, proportion of injured digits, or zone of injury between the groups. The final Quick Disabilities of the Arm, Shoulder, and Hand score in the WALANT group was 17.2 (SD: 14.4) versus 23.3 (SD: 18.5) in the TA group. There were no statistical differences between the groups with any final range of motion (ROM) parameters, grip strength, or Visual Analog Scale pain scores at the final follow-up. The WALANT group was found to have a slightly higher reoperation rate (26.1% vs 7.1%; P = .034) than the TA group. CONCLUSIONS This study represents one of the first clinical studies reporting outcomes of flexor tendon repairs performed under WALANT. Overall, we found no difference in rupture rates, ROM, and functional outcomes following zone I and II flexor tendon repairs when performed under WALANT versus TA.
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Affiliation(s)
- Clay B. Townsend
- Rothman Orthopaedic Institute at Thomas
Jefferson University, Philadelphia, PA, USA
| | - Tyler W. Henry
- Rothman Orthopaedic Institute at Thomas
Jefferson University, Philadelphia, PA, USA
| | - Jonas L. Matzon
- Rothman Orthopaedic Institute at Thomas
Jefferson University, Philadelphia, PA, USA
| | - Daniel Seigerman
- Rothman Orthopaedic Institute at Thomas
Jefferson University, Philadelphia, PA, USA
| | - Samir C. Sodha
- Rothman Orthopaedic Institute at Thomas
Jefferson University, Philadelphia, PA, USA
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Cholok D, Burgess J, Fox PM, Chang J. Tenolysis and Salvage Procedures. Hand Clin 2023; 39:203-214. [PMID: 37080652 DOI: 10.1016/j.hcl.2022.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
Complications in flexor tendon repair are common and include tendon rupture, adhesion formation, and joint contracture. Risk factors include preexisting conditions, gross contamination, concurrent fracture, early unplanned loading of the repaired tendon, premature cessation of splinting, and aggressive early active range of motion protocols with insufficient repair strength. Rupture of a repaired tendon should be followed by early operative exploration, debridement, and revision with a four-core strand suture and nonbraided epitendinous suture. Wide-awake flexor tenolysis should be considered when adhesion formation results in the plateaued range of motion, and passive motion exceeds active motion. Two-staged reconstruction is recommended when injury results in excessive scaring, joint contracture, or an incompetent pulley apparatus.
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Affiliation(s)
- David Cholok
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, 770 Welch Road, Suite 400, Palo Alto, CA 94304, USA.
| | - Jordan Burgess
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, 770 Welch Road, Suite 400, Palo Alto, CA 94304, USA
| | - Paige M Fox
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, 770 Welch Road, Suite 400, Palo Alto, CA 94304, USA; Division of Plastic and Reconstructive Surgery, Chase Hand and Upper Limb Center, Stanford University Medical Center, 770 Welch Road, Suite 400, Palo Alto, CA 94304, USA
| | - James Chang
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, 770 Welch Road, Suite 400, Palo Alto, CA 94304, USA; Division of Plastic and Reconstructive Surgery, Chase Hand and Upper Limb Center, Stanford University Medical Center, 770 Welch Road, Suite 400, Palo Alto, CA 94304, USA
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Abstract
Over the years, various physical and chemical/biological methods of inhibiting adhesion formation have been developed, focusing on how to suppress healing around the tendon and not inhibit healing within the tendon. Unfortunately, however, these methods are accompanied by drawbacks, both large and small, and no absolute antiadhesion method capable of maintaining tendon repair strength has yet been developed. Recent innovations in biomaterials science and tissue engineering have produced new antiadhesion technologies, such as barriers combined with cytokines and cells, which have improved outcomes in animal models, and which may find clinical relevance in the future.
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Affiliation(s)
- Tomoyuki Kuroiwa
- Department of Orthopedic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, USA
| | - Peter C Amadio
- Department of Orthopedic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, USA.
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McLaughlin WM, Cravez E, Caruana DL, Wilhelm C, Modrak M, Gardner EC. An Epidemiological Study of Cell Phone–Related Injuries of the Hand and Wrist Reported in United States Emergency Departments From 2011 to 2020. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2023; 5:184-188. [PMID: 36974296 PMCID: PMC10039299 DOI: 10.1016/j.jhsg.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 11/28/2022] [Indexed: 02/10/2023] Open
Abstract
Purpose Increasing ownership and use of mobile phones has been recently linked to reports of hand and wrist pain from overuse, as well as more serious injuries related to distracted behaviors, such as falls and texting while driving. We describe the epidemiology of hand and wrist injuries presenting to US emergency departments from 2011 to 2020, which were associated with cell phone use using the Consumer Product Safety Commission's National Electronic Injury Surveillance System. Methods The National Electronic Injury Surveillance System database was queried for treatment records from 2011 through to 2020 for all cell phone-related injuries of the lower arm, wrist, hand, and fingers. Using parameters provided by the National Electronic Injury Surveillance System database, there were 1,213 unique cases, yielding a total weighted estimate of 50,487 national cases presenting to emergency departments in the United States. Results Between 2011 and 2020, the weighted estimate of annual cell phone-related injuries ranged from 3,389 to 7,320 cases. Falls were the most common cause of injury, accounting for 29.8% of estimated cases. The most common types of injuries were lacerations (22.3%). The national estimate of cell phone-related injury was the highest in the age range of 11-20 years (26.4%), followed by 21-30 years (22.2%). Women were affected more frequently than men (59.6% vs 40.4%). Conclusions Upper extremity injuries related to cell phone use represent an increasing burden of disease to the US healthcare system. Raising awareness regarding cell phone-related injuries and in-home fall-prevention strategies, especially among elderly individuals, should be considered as means of decreasing the number of such injuries. Strategies for decreasing the burden of cell phone-related injuries occurring as a result of falls among teenagers and young adults should focus on minimizing distractions while using a cell phone. Limitations of the study include inaccuracies related to probability-weighted case estimation and limitations in reporting injuries. Clinical relevance Knowledge of the burden of upper extremities injuries associated with this common handheld device can help to both raise awareness of this issue, as well as to potentially inform injury-prevention strategies.
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Jia Q, Chen D, Guo J, Luo X, Alimujiang A, Zhang J, Hu N, Liu Y, Xie Z, Ma C. Risk factors associated with tendon adhesions after hand tendon repair. Front Surg 2023; 10:1121892. [PMID: 37143766 PMCID: PMC10151704 DOI: 10.3389/fsurg.2023.1121892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/03/2023] [Indexed: 05/06/2023] Open
Abstract
Background Tendon adhesions after hand tendon repair are one of the most difficult complications of hand surgery and can cause severe disability. This study aimed to assess the risk factors associated with tendon adhesions after hand tendon repair to provide a theoretical foundation for the early prevention of tendon adhesions in patients with tendon injuries. Moreover, this study intends to increase doctors' awareness of the issue and serves as a reference for developing new prevention and treatment strategies. Methods We retrospectively analyzed 1,031 hand trauma cases that underwent repair after finger tendon injury in our department between June 2009 and June 2019. Tendon adhesions, tendon injury zones, and other relevant information were collected, summarized, and analyzed. The significance of data was determined using a t-test or Pearson's chi-square test, and odds ratios (OR) were calculated using logistic regression tests to describe factors associated with post-tendon repair adhesions. Results A total of 1,031 patients were enrolled in this study. There were 817 males and 214 females with an average age of 34.98 (2-82) years. The injured side included 530 left and 501 right hands. Postoperative finger tendon adhesions occurred in 118 cases (11.45%), including 98 males and 20 females, 57 left and 61 right hands. The risk factors for the total sample in the descending order were degloving injury, no functional exercise, zone II flexor tendon injury, time from injury to surgery >12 h, combined vascular injury, and multiple tendon injuries. The flexor tendon sample shared the same risk factors as the total sample. Risk factors for the extensor tendon sample were degloving injury, no functional exercise. Conclusions Clinicians should pay close attention to patients with tendon trauma in hand having the following risk factors: degloving injury, zone II flexor tendon injury, lack of functional exercise, time from injury to surgery >12 h, combined vascular injury, and multiple tendon injuries. Due to the high risk of post-repair adhesions in patients with the conditions mentioned above, individualized treatment measures should be designed for the risk factors, and postoperative functional exercise of the hand is required.
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Affiliation(s)
- Qiyu Jia
- Department of Trauma Orthopedics, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Dongsheng Chen
- Department of Orthopedics, Dingxi People's Hospital, Dingxi, China
| | - Jian Guo
- Department of Microrepair and Reconstruction, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Xuefeng Luo
- Department of Trauma Orthopedics, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Abudusalamu Alimujiang
- Department of Microrepair and Reconstruction, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Jun Zhang
- Department of Microrepair and Reconstruction, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Ningning Hu
- Department of Orthopedics, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Yanshi Liu
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Correspondence: Chuang Ma Zengru Xie Yanshi Liu
| | - Zengru Xie
- Department of Trauma Orthopedics, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Correspondence: Chuang Ma Zengru Xie Yanshi Liu
| | - Chuang Ma
- Department of Microrepair and Reconstruction, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Correspondence: Chuang Ma Zengru Xie Yanshi Liu
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Lee YJ, Ryoo HJ, Shim HS. Prevention of postoperative adhesions after flexor tendon repair with acellular dermal matrix in Zones III, IV, and V of the hand: A randomized controlled (CONSORT-compliant) trial. Medicine (Baltimore) 2022; 101:e28630. [PMID: 35060544 PMCID: PMC8772763 DOI: 10.1097/md.0000000000028630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/30/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Various techniques have been attempted for preventing postoperative flexor tendon adhesion, such as modification of suture technique, pharmacological agents, and mechanical barriers. However, there is no evidence of the efficacy of these methods in clinical settings. In this study, we present the long-term outcomes of a randomized prospective study in which acellular dermal matrix (ADM) was used to prevent postoperative adhesions after tendon injury in the hand. METHODS From January 2017 to January 2020, all patients with an acute single flexor tendon injury in hand Zones III, IV, or V were candidates. A single-digit, total tendon rupture repaired within 48 hours, from the index finger to the little finger, was included in the study. Patients were randomly allocated to either a control or ADM group. Complications and the range of movements were recorded. Functional outcomes and a patient satisfaction questionnaire were evaluated after 12 months following the tendon repair surgery. The present study is adhered to the CONSORT guidelines. RESULTS A total of 25 patients was enrolled in the study: 13 patients in the ADM group and 12 in the control group. According to Buck-Gramcko II criteria, the postoperative functional outcome score was 14.38 ± 1.71 in the ADM group and 13.08 ± 1.82 in the control group (P value = .0485). Patient satisfaction was recorded at 8.38 ± 1.44 in the ADM group and 7.08 ± 1.58 in the control group (P value = .0309), a significant difference. There were no differences in complications between the 2 groups. CONCLUSION The beneficial effects of ADM after tendon repair were confirmed by improved postoperative functional outcome at flexor Zones III, IV, and V, preventing peritendinous adhesions and acting effectively as an anti-adhesive barrier.
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Secondary Procedures following Flexor Tendon Reconstruction. Plast Reconstr Surg 2022; 149:108e-120e. [PMID: 34936631 DOI: 10.1097/prs.0000000000008692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Understand the indications and management options for secondary flexor tendon reconstruction, including tenolysis, tendon grafting, and tendon transfers. 2. Understand the reconstructive options for pulley reconstruction. 3. Understand the options for management of isolated flexor digitorum profundus injuries. SUMMARY Despite current advances in flexor tendon repair, complications can still occur following surgery. This article presents the spectrum of treatment options for secondary flexor tendon reconstruction ranging from tenolysis to one- and two-stage tendon grafting, and tendon transfers. In addition, an overview of pulley reconstruction and the treatment of isolated flexor digitorum profundus injuries are discussed. A management algorithm for secondary flexor tendon reconstruction is provided.
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Zhou Y, Krishna S, Sharplin PK. Management and outcomes of flexor tendon repairs at a peripheral hospital: a New Zealand case series study. ANZ J Surg 2021; 92:1668-1674. [PMID: 34854200 DOI: 10.1111/ans.17398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 11/08/2021] [Accepted: 11/13/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Current evidence for flexor tendon repair management and outcomes performed at peripheral centres is unclear. Most studies are based on evidence from specialist hand centres. This study evaluated a peripheral hospital in New Zealand; where all flexor tendon repairs were performed by a generalist Orthopaedic service. The purpose of the study was to benchmark management and outcomes from a peripheral hospital in comparison to international standards. METHODS A retrospective single-centre consecutive case series of Zones I and II flexor tendon repairs was extracted between 1 January 2014 and 1 January 2018. Medical records were used to evaluate management and outcomes of repairs. Hand therapy notes were used to evaluate rehabilitation protocols provided. The primary objective was to measure re-rupture and re-operation rates. Secondary objectives included auditing operative management and hand therapy compliance. RESULTS Forty-six patients (76 tendon repairs) were included in our final analysis. Mean follow up time to last clinical appointment was 11.8 weeks, and to last patient episode was 4.9 years. Most patients received timely surgery with a four-core repair using 3-0 or larger suture. All hand therapy followed a controlled active motion protocol. The re-operation rate was 19.6% (P = <0.05) and the re-rupture rate was 8.7% (P = 0.28). CONCLUSIONS Most flexor tendon injuries at this peripheral centre were managed according to international standards. However, high complication rates including re-operation and re-rupture occurred. Due to a lack of local comparison studies, confounding factors cannot be excluded as a contributor for these results.
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Affiliation(s)
- Yuxuan Zhou
- Department of Orthopaedic Surgery, Whangarei Hospital, Northland District Health Board, Whangarei, New Zealand
| | - Sanjeev Krishna
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Paul Kenneth Sharplin
- Department of Orthopaedic Surgery, Whangarei Hospital, Northland District Health Board, Whangarei, New Zealand
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Girón Mariñas M, Formigo Couceiro J, Alonso Bidegain M. [Ultrasound-Guided Peritendinous Hydrodissection, an Alternative to Tenolysis Adhesions?]. Rehabilitacion (Madr) 2021; 56:395-398. [PMID: 34736761 DOI: 10.1016/j.rh.2021.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 09/14/2021] [Accepted: 09/21/2021] [Indexed: 11/18/2022]
Abstract
Flexor tendon injuries of the hand treatment remains an important and common clinical problem. The rate of adhesions after flexor tendon tenorrhaphy is high. Today the treatment is surgical tenolysis, not always with satisfactory results. Ultrasound-guided hydrodissection is a novel interventional technique that consists of introducing a solution to free a compromised space or to distend and mechanically separate compressed or adhered structures. Ultrasound-guided hydrodissection is considered as an alternative to reoperation or after surgery failure. We report the first published case of ultrasound-guided peritendinous hydrodissection of adhesions after flexor tendon injury. We propose as an alternative to surgery or tenolysis, with encouraging results.
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Affiliation(s)
- M Girón Mariñas
- Servicio de Medicina Física y Rehabilitación, Complexo Hospitalario Universitario de A Coruña, A Coruña, Galicia, España.
| | - J Formigo Couceiro
- Servicio de Medicina Física y Rehabilitación, Complexo Hospitalario Universitario de A Coruña, A Coruña, Galicia, España
| | - M Alonso Bidegain
- Servicio de Medicina Física y Rehabilitación, Complexo Hospitalario Universitario de A Coruña, A Coruña, Galicia, España
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Li P, Zhou H, Tu T, Lu H. Dynamic exacerbation in inflammation and oxidative stress during the formation of peritendinous adhesion resulted from acute tendon injury. J Orthop Surg Res 2021; 16:293. [PMID: 33952274 PMCID: PMC8097959 DOI: 10.1186/s13018-021-02445-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 04/22/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Peritendinous adhesion is among the common complications after tendon injury. Numerous studies have been carried out to prevent its formation, including modifications of surgical procedures, postoperative cares, application of medicines, etc. This study dynamically monitored fluctuations of inflammation, state of oxidative stress, and histopathologic changes around injured tendon to provide theoretical basis for further exploration in mechanisms of peritendinous adhesion formation. METHODS Eighteen mature Sprague-Dawley male rats were randomly allocated into 6 equal groups. Compared with control and sham group, every rat's right hind Achilles tendon in experimental groups was cut and repaired by the modified Kessler technique. Besides control and sham group, samples of tendon margin and serum were collected at different time points after the surgery. Content of TNF-α, IL-1β, and TGF-β were assayed in harvested serum. Reactive oxygen species (ROS) were detected, expression levels of related genes (IL-1β, IL-6, SOD1, SOD2, COL1, HIF1A) were quantified by qPCR, and various histopathological evaluations were performed. RESULTS Indicators (TNF-α, IL-1β, TGF-β1, ROS) were noticed to have a similar trend of significant rising 24 h after the surgery except TGF-β which was rising 72 h later. So were the expression trends of IL-1β, IL-6, SOD1, SOD2, and COL1. HIF1A, inversely correlated with SOD2, showed the progressive relief of regional tissue hypoxia. Histological evaluation showed the same tendency that fibrosis and inflammation were getting serious 48 h later after the surgery. CONCLUSIONS Inflammation, oxidative stress in injured tendon resulted from acute trauma, would be getting intense in 24 h. Peritendinous adhesion emerges and aggravates after 48 h. Thus, prompt efficient measures are advised to be taken after the injury as soon as possible.
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Affiliation(s)
- Pengfei Li
- Department of Plastic and Aesthetic Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, #79 Qingchun Road, Hangzhou, 310003 Zhejiang Province China
| | - Haiying Zhou
- Department of Orthopedics, The First Affiliated Hospital, College of Medicine, Zhejiang University, #79 Qingchun Road, Hangzhou, 310003 Zhejiang Province China
| | - Tian Tu
- Department of Plastic and Aesthetic Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, #79 Qingchun Road, Hangzhou, 310003 Zhejiang Province China
| | - Hui Lu
- Department of Orthopedics, The First Affiliated Hospital, College of Medicine, Zhejiang University, #79 Qingchun Road, Hangzhou, 310003 Zhejiang Province China
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14
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Mosallam KH. Neglected flexor tendon injury for 10 years, un-usual finding and one stage repair without free tendon graft: Case report. Int J Surg Case Rep 2021; 82:105902. [PMID: 33965758 PMCID: PMC8114111 DOI: 10.1016/j.ijscr.2021.105902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 04/13/2021] [Accepted: 04/16/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction In delayed or neglected cases of flexor tendon injury, reconstruction of flexor digitorum profundus (FDP) is usually performed using free tendon graft due to the retraction of tendon ends and shortening of the tendon. Flexor digitorum superficialis (FDS), palmaris longus or plantaris tendons can be used as a free tendon graft [1–3]. Presentation of case This is a case report of female patient 17 years old with neglected cut of her left Ring finger's FDP and FDS tendons zone II with suspected concomitant digital nerve injury, the injury was neglected for 10 years in the patient's non-dominant hand. Discussion Upon exploration unusual finding of spontaneous healing of the proximal stumps of FDS and FDP tendons raised the idea of doing the repair one stage without free graft by using pedicled intra-synovial graft from the sublimis tendon to reconstruct the FDP tendon. The patient after 4 months follow-up and after completion of the physiotherapy program regained the ability to actively flex her finger to near full flexion with improved function and cosmesis. Conclusion Delayed flexor tendon reconstruction in neglected cases is still offering good results even after long periods of delay provided that the finger's joints are still supple and mobile. In neglected cases of flexor tendon injury, reconstruction of FDP tendon is usually performed using free tendon graft. The presence of two repair sites with free graft in between carries the risk of rupture or adhesion formation around the tendon graft. In this case report we succeed in doing the repair one stage without free graft.We used pedicled intra-synovial graft from the sublimis tendon to reconstruct the FDP tendon.
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Affiliation(s)
- Khaled H Mosallam
- Hand and Reconstructive Microsurgery, Department of Orthopedic Surgery, Qena Faculty of Medicine, South Valley University, Egypt.
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15
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Abstract
Fingertip injuries in the military are common and often hinder the fighting force and support personnel. Injuries range from small subungual hematomas to proximal finger amputations. Treatment modalities are dictated by injury patterns, anatomic considerations, and the need to return to duty. Nail bed injuries should be repaired when possible and exposed bone or tendon is treated with appropriate soft tissue coverage. If soft tissue coverage is unobtainable, revision amputation should be performed with attention given to maintaining as much finger length as possible. Antibiotics may not be required, however they are often utilized in the deployed setting.
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Affiliation(s)
- Matthew E Wells
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, 5005 North Piedras Street, El Paso, TX 79902, USA; Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, 4801 Alberta Avenue, El Paso, TX 79905, USA.
| | - John P Scanaliato
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, 5005 North Piedras Street, El Paso, TX 79902, USA; Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, 4801 Alberta Avenue, El Paso, TX 79905, USA
| | - Nicholas A Kusnezov
- Department of Orthopaedic Surgery, Blanchfield Army Community Hospital, 650 Joel Drive, Fort Campbell, KY 42223, USA
| | - Leon J Nesti
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889, USA; Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - John C Dunn
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, 5005 North Piedras Street, El Paso, TX 79902, USA; Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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16
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Abstract
BACKGROUND Various rehabilitation treatments may be offered following surgery for flexor tendon injuries of the hand. Rehabilitation often includes a combination of an exercise regimen and an orthosis, plus other rehabilitation treatments, usually delivered together. The effectiveness of these interventions remains unclear. OBJECTIVES To assess the effects (benefits and harms) of different rehabilitation interventions after surgery for flexor tendon injuries of the hand. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials, the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, MEDLINE, Embase, two additional databases and two international trials registries, unrestricted by language. The last date of searches was 11 August 2020. We checked the reference lists of included studies and relevant systematic reviews. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs that compared any postoperative rehabilitation intervention with no intervention, control, placebo, or another postoperative rehabilitation intervention in individuals who have had surgery for flexor tendon injuries of the hand. Trials comparing different mobilisation regimens either with another mobilisation regimen or with a control were the main comparisons of interest. Our main outcomes of interest were patient-reported function, active range of motion of the fingers, and number of participants experiencing an adverse event. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion, extracted data, assessed risk of bias and assessed the quality of the body of evidence for primary outcomes using the GRADE approach, according to standard Cochrane methodology. MAIN RESULTS We included 16 RCTs and one quasi-RCT, with a total of 1108 participants, mainly adults. Overall, the participants were aged between 7 and 72 years, and 74% were male. Studies mainly focused on flexor tendon injuries in zone II. The 17 studies were heterogeneous with respect to the types of rehabilitation treatments provided, intensity, duration of treatment and the treatment setting. Each trial tested one of 14 comparisons, eight of which were of different exercise regimens. The other trials examined the timing of return to unrestricted functional activities after surgery (one study); the use of external devices applied to the participant to facilitate mobilisation, such as an exoskeleton (one study) or continuous passive motion device (one study); modalities such as laser therapy (two studies) or ultrasound therapy (one study); and a motor imagery treatment (one study). No trials tested different types of orthoses; different orthosis wearing regimens, including duration; different timings for commencing mobilisation; different types of scar management; or different timings for commencing strengthening. Trials were generally at high risk of bias for one or more domains, including lack of blinding, incomplete outcome data and selective outcome reporting. Data pooling was limited to tendon rupture data in a three trial comparison. We rated the evidence available for all reported outcomes of all comparisons as very low-certainty evidence, which means that we have very little confidence in the estimates of effect. We present the findings from three exercise regimen comparisons, as these are commonly used in clinical current practice. Early active flexion plus controlled passive exercise regimen versus early controlled passive exercise regimen (modified Kleinert protocol) was compared in one trial of 53 participants with mainly zone II flexor tendon repairs. There is very low-certainty evidence of no clinically important difference between the two groups in patient-rated function or active finger range of motion at 6 or 12 months follow-up. There is very low-certainty evidence of little between-group difference in adverse events: there were 15 overall. All three tendon ruptures underwent secondary surgery. An active exercise regimen versus an immobilisation regimen for three weeks was compared in one trial reporting data for 84 participants with zone II flexor tendon repairs. The trial did not report on self-rated function, on range of movement during three to six months or numbers of participants experiencing adverse events. The very low-certainty evidence for poor (under one-quarter that of normal) range of finger movement at one to three years follow-up means we are uncertain of the finding of zero cases in the active group versus seven cases in the immobilisation regimen. The same uncertainty applies to the finding of little difference between the two groups in adverse events (5 tendon ruptures in the active group versus 10 probable scar adhesion in the immobilisation group) indicated for surgery. Place and hold exercise regimen performed within an orthosis versus a controlled passive regimen using rubber band traction was compared in three heterogeneous trials, which reported data for a maximum of 194 participants, with mainly zone II flexor tendon repairs. The trials did not report on range of movement during three to six months, or numbers of participants experiencing adverse events. There was very low-certainty evidence of no difference in self-rated function using the Disability of the Arm, Shoulder and Hand (DASH) functional assessment between the two groups at six months (one trial) or at 12 months (one trial). There is very low-certainty evidence from one trial of greater active finger range of motion at 12 months after place and hold. Secondary surgery data were not available; however, all seven recorded tendon ruptures would have required surgery. All the evidence for the other five exercise comparisons as well as those of the other six comparisons made by the included studies was incomplete and, where available, of very low-certainty. AUTHORS' CONCLUSIONS There is a lack of evidence from RCTs on most of the rehabilitation interventions used following surgery for flexor tendon injuries of the hand. The limited and very low-certainty evidence for all 14 comparisons examined in the 17 included studies means that we have very little confidence in the estimates of effect for all outcomes for which data were available for these comparisons. The dearth of evidence identified in this review points to the urgent need for sufficiently powered RCTs that examine key questions relating to the rehabilitation of these injuries. A consensus approach identifying these and establishing minimum study conduct and reporting criteria will be valuable. Our suggestions for future research are detailed in the review.
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Affiliation(s)
- Susan E Peters
- Brisbane Hand and Upper Limb Research Institute, Brisbane, Australia
- Center for Work, Health and Wellbeing, Harvard TH Chan School of Public Health, Boston, USA
| | - Bhavana Jha
- Brisbane Hand and Upper Limb Research Institute, Brisbane, Australia
- Sunshine Coast University Hospital, Queensland Health, Birtinya, Australia
- Advanced Hand Clinic, Maroochydore, Australia
| | - Mark Ross
- Brisbane Hand and Upper Limb Research Institute, Brisbane, Australia
- Department of Surgery, School of Medicine, The University of Queensland, Herston, Australia
- Orthopaedic Department, Princess Alexandra Hospital, Woolloongabba, Australia
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17
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Samade R, Colvell K, Goyal KS. An Update on Loss to Follow-up After Upper Extremity Surgery: Survey of Patient Responses. Hand (N Y) 2021; 16:104-109. [PMID: 30947548 PMCID: PMC7818034 DOI: 10.1177/1558944719840743] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Incomplete patient follow-up is a common problem after hand and upper extremity (HUE) surgery and is influenced by many demographic factors. The aims of this investigation are to determine patient-stated factors for lack of follow-up, identify potential interventions, and measure satisfaction following operations. Methods: A prospective survey sampling of 173 of 655 patients lost to follow-up after HUE operations in a single institution between June 2014 and July 2015 was performed. Demographic variables collected included age, sex, distance to clinic, insurance payor, and length of time to last follow-up visit. Survey responses regarding reasons for insufficient follow-up, future recommendations, and overall satisfaction were recorded. Statistical results were reported as P values, odds ratios (ORs), and 95% confidence intervals (CIs). Results: More than half (65.3%) of 173 patients erroneously thought that they had completed follow-up, with private insurance being the only risk factor (OR = 2.45, P = .010, 95% CI = 1.24-4.85). Other common reasons for insufficient follow-up included not placing the appointment into a personal calendar (7%), excessive costs (6%), and transportation (5%). Approximately half (51%) of 55 patients aware that they had missed follow-up stated that no intervention would have helped. Median patient satisfaction with their operation was 10/10 (interquartile range = 8-10). Conclusions: Most patients lost to follow-up after HUE operations were not aware that they had a follow-up appointment, but were nevertheless satisfied with treatment. Interventions targeted to patients who erroneously thought they had followed up may be the most beneficial.
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Affiliation(s)
- Richard Samade
- The Ohio State University Wexner Medical
Center, Columbus, USA
| | - Kara Colvell
- The Ohio State University Wexner Medical
Center, Columbus, USA
| | - Kanu S. Goyal
- The Ohio State University Wexner Medical
Center, Columbus, USA,Kanu S. Goyal, Division of Hand and Upper
Extremity Surgery, Associate Program Director, Orthopaedic Surgery Residency
Program, Department of Orthopaedics, The Ohio State University Wexner Medical
Center, 915 Olentangy River Road, Columbus, OH 43212, USA.
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18
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Functional and Disability Assessment Among Hispanics With Zone 2 Flexor Tendon Injuries: Comparative Study Between Flexor Digitorum Superficialis Repair and Flexor Digitorum Superficialis Excision. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2020; 4:e20.00081. [PMID: 32890007 PMCID: PMC7470007 DOI: 10.5435/jaaosglobal-d-20-00081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Flexor tendon lacerations in zone II have been reported to be the most complicated of all tendon injuries. Currently, there is no consensus on treatment in surgical management for patients with flexor tendon laceration of flexor digitorum profundus and flexor digitorum superficialis (FDS). The aim of this study was to evaluate whether the repair of FDS tendons provided superior functional outcomes compared with FDS excision in Hispanic patients.
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19
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Zhou H, Jiang S, Li P, Shen H, Yang H, Xu S, Ye C, Chen M, Lu H. Improved tendon healing by a combination of Tanshinone IIA and miR-29b inhibitor treatment through preventing tendon adhesion and enhancing tendon strength. Int J Med Sci 2020; 17:1083-1094. [PMID: 32410838 PMCID: PMC7211157 DOI: 10.7150/ijms.44138] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/05/2020] [Indexed: 12/22/2022] Open
Abstract
Background: Despite significant advances in the materials and methods development used in surgical repair and postoperative rehabilitation, the adhesion formation remains the most common clinical problem in tendon injuries. Therefore, the development of novel therapies is necessary for targeting at preventing tendon adhesion formation and improving tendon strength. Methods: We used rat fibroblasts for in vitro experiments to determine the optimal concentration of TSA in rats, and then set up negative control group, TSA intervention group, mir-29b interference adenovirus intervention group and TSA and mir-29b interference adenovirus co-intervention group. By comparing cell proliferation and protein expression in different group, we verified the effect and mechanism of drugs on fibroblast function. At the same time, the Sprague-Dawley rat Achilles tendon model in vivo was established in this study, which was divided into sham operation group and operation group. Afterwards in the operation group, mir-29b inhibitor and placebo were injected every 3 days respectively. Then the injection inhibitor group was divided into 5 groups which mean TSA was injected into the marked area at 0, 6, 24 and 72 hours after operation for 1 week, finally all of the rats were died at 3 weeks after operation. Through the observation of general properties, histological observation of Achilles tendon injury, biomechanical test and cell and protein expression in rats' tendon cell, the effect of drugs on tendon adhesion formation was analyzed. Results: We demonstrated that the combination of miR-29b inhibitor and tanshinone IIA(TSA) could prevent tendon adhesion and also enhance tendon strength. Mechanically, the miR-29b inhibitor could activate the TGF-β/Smad3 pathway to trigger endogenous pathways and induce a high proliferation of fibroblast. Subsequently, we also found adding TSA after 6 hours of miR-29b treatment gave less cell cytotoxicity in our rat model with better outcome of less tendon adhesion and enhanced strength. Conclusion: We conclude that the use of miR-29b inhibitor at the end of the tendon break could initiate endogenous repair mechanism and subsequently use of TSA should be able to inhibit the exogenous repair mechanism. Therefore, the combination of both treatments could prevent tendon adhesion and ensure tendon strength. Our findings suggested that this approach would be a feasible approach for tendon repair.
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Affiliation(s)
- Haiying Zhou
- Department of Orthopaedics, The First Affiliated Hospital, College of Medicine, Zhejiang University. 79 Qingchun Road, Hangzhou, Zhejiang Province, P.R.China, 310003
| | - Shuai Jiang
- Department of Orthopaedics, The First Affiliated Hospital, College of Medicine, Zhejiang University. 79 Qingchun Road, Hangzhou, Zhejiang Province, P.R.China, 310003
| | - Pengfei Li
- Department of Plastic and Aesthetic Center, The First Affiliated Hospital, College of Medicine, Zhejiang University. 79 Qingchun Road, Hangzhou, Zhejiang Province, P.R.China, 310003
| | - Hui Shen
- Department of Orthopaedics, The First Affiliated Hospital, College of Medicine, Zhejiang University. 79 Qingchun Road, Hangzhou, Zhejiang Province, P.R.China, 310003
| | - Hu Yang
- Department of Orthopaedics, The First Affiliated Hospital, College of Medicine, Zhejiang University. 79 Qingchun Road, Hangzhou, Zhejiang Province, P.R.China, 310003
| | - Shengquan Xu
- Department of Orthopaedics, The First Affiliated Hospital, College of Medicine, Zhejiang University. 79 Qingchun Road, Hangzhou, Zhejiang Province, P.R.China, 310003
| | - Chenyi Ye
- Orthopedics Research Institute, Zhejiang University, Hangzhou 310000, China
| | - Mingjian Chen
- Department of Orthopaedics, The First Affiliated Hospital, College of Medicine, Zhejiang University. 79 Qingchun Road, Hangzhou, Zhejiang Province, P.R.China, 310003
| | - Hui Lu
- Department of Orthopaedics, The First Affiliated Hospital, College of Medicine, Zhejiang University. 79 Qingchun Road, Hangzhou, Zhejiang Province, P.R.China, 310003
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20
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Bond MC, Willis GC. Risk Management and Avoiding Legal Pitfalls in the Emergency Treatment of High-Risk Orthopedic Injuries. Emerg Med Clin North Am 2019; 38:193-206. [PMID: 31757250 DOI: 10.1016/j.emc.2019.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Many orthopedic injuries can have hidden risks that result in increased liability for the emergency medicine practitioner. It is imperative that emergency medicine practitioners consider the diagnoses of compartment syndrome, high-pressure injury, spinal epidural abscess, and tendon lacerations in the right patient. Consideration of the diagnosis and prompt referrals can help to minimize the complications these patients often develop.
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Affiliation(s)
- Michael C Bond
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, Sixth Floor, Suite 200, Baltimore, MD 21201, USA.
| | - George C Willis
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, Sixth Floor, Suite 200, Baltimore, MD 21201, USA. https://twitter.com/DocWillisMD
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21
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Fox PM, Oliver JD, Nguyen V, Hentz VR, Curtin CM. Electromyographic Analysis of Grip. Orthopedics 2019; 42:e555-e558. [PMID: 31408520 DOI: 10.3928/01477447-20190812-06] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 05/20/2019] [Indexed: 02/03/2023]
Abstract
This prospective cohort study used video electromyography synchronized analysis to determine the dynamic use of extrinsic and intrinsic finger flexion during grasp. Light fist formation primarily involved the flexor digitorum profundus with either the flexor digitorum superficialis or intrinsics. In contrast, both the flexor digitorum superficialis and intrinsics were recruited in all tight fist video electromyography. However, the sequence of recruitment differed between patients in tight fist formation. Injured patients demonstrated a unique pattern of recruitment based on injury. The authors conclude that the flexor digitorum profundus is the workhorse in composite fist formation but the roles of the flexor digitorum superficialis and the intrinsic muscles are less consistent across patients. [Orthopedics. 2019; 42(6):e555-e558.].
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22
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Abstract
Secondary surgery following digital replantation and revascularization is common and is often performed to improve range of motion, tendon gliding, sensibility, and/or contour. In this article, the authors present the most common secondary procedures performed after digital replantation or revascularization and discuss current techniques. The importance of patient selection and postoperative compliance with ongoing hand therapy is paramount to achieving good outcomes.
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23
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Chen SH, Chou PY, Chen ZY, Lin FH. Electrospun Water-Borne Polyurethane Nanofibrous Membrane as a Barrier for Preventing Postoperative Peritendinous Adhesion. Int J Mol Sci 2019; 20:E1625. [PMID: 30939838 PMCID: PMC6480376 DOI: 10.3390/ijms20071625] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 03/26/2019] [Accepted: 03/26/2019] [Indexed: 12/31/2022] Open
Abstract
Peritendinous adhesion is a major complication after tendon injury and the subsequent repairs or reconstructions. The degree of adhesion can be reduced by the interposition of a membranous barrier between the traumatized tendon and the surrounding tissue. In the present study, electrospun water-borne polyurethane (WPU) nanofibrous membranes (NFMs) were created for use after the reparation or reconstruction of tendons to reduce adhesion. In the electrospinning process, water was employed as the solvent for WPU, and this solvent was ecofriendly and nontoxic. The nanofibrous architecture and pore size of the WPU NFMs were analyzed. Their microporosity (0.78⁻1.05 µm) blocked the penetration of fibroblasts, which could result in adhesion and scarring around the tendon during healing. The release of WPU mimicked the lubrication effect of the synovial fluid produced by the synovium around the tendon. In vitro cell studies revealed that the WPU NFMs effectively reduced the number of fibroblasts that became attached and that there was no significant cytotoxicity. In vivo studies with the rabbit flexor tendon repair model revealed that WPU NFMs reduced the degree of peritendinous adhesion, as determined using a gross examination; a histological cross section evaluation; and measurements of the range of motion of interphalangeal joints (97.1 ± 14.7 and 79.0 ± 12.4 degrees in proximal and distal interphalangeal joints respectively), of the length of tendon excursion (11.6 ± 1.9 cm), and of the biomechanical properties.
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Affiliation(s)
- Shih-Heng Chen
- Institute of Biomedical Engineering, College of Medicine and College of Engineering, National Taiwan University, Taipei 100, Taiwan.
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University and Medical College, Taoyuan 333, Taiwan.
| | - Pang-Yun Chou
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University and Medical College, Taoyuan 333, Taiwan.
| | - Zhi-Yu Chen
- Institute of Biomedical Engineering, College of Medicine and College of Engineering, National Taiwan University, Taipei 100, Taiwan.
- Division of Biomedical Engineering and Nanomedicine Research, National Health Research Institutes, Miaoli 35053, Taiwan.
| | - Feng-Huei Lin
- Institute of Biomedical Engineering, College of Medicine and College of Engineering, National Taiwan University, Taipei 100, Taiwan.
- Division of Biomedical Engineering and Nanomedicine Research, National Health Research Institutes, Miaoli 35053, Taiwan.
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24
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Poorpezeshk N, Ghoreishi SK, Bayat M, Pouriran R, Yavari M. Early Low-Level Laser Therapy Improves the Passive Range of Motion and Decreases Pain in Patients with Flexor Tendon Injury. Photomed Laser Surg 2018; 36:530-535. [DOI: 10.1089/pho.2018.4458] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Naghmeh Poorpezeshk
- Department of Plastic Surgery, Research, and Developmental Center, 15 Khordad Educational Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Surgery, Naft Central Hospital, Petroleum Industry Health Organization, Tehran, Iran
| | | | - Mohammad Bayat
- Department of Biology and Anatomical Sciences, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Price Institute of Surgical Research, University of Louisville, and Noveratech LLC of Louisville, Louisville, Kentucky
| | - Ramin Pouriran
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Masoud Yavari
- Department of Plastic Surgery, Research, and Developmental Center, 15 Khordad Educational Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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25
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Two stage reconstruction of flexor tendon injuries in zone II after missed injury or failed repair. CURRENT ORTHOPAEDIC PRACTICE 2018. [DOI: 10.1097/bco.0000000000000651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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26
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Peters SE, Jha B, Ross M. Rehabilitation following surgery for flexor tendon injuries of the hand. Hippokratia 2017. [DOI: 10.1002/14651858.cd012479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Susan E Peters
- Harvard University; TH Chan Harvard School of Public Health; Boston Massachusetts USA
- Brisbane Hand and Upper Limb Research Institute; Level 9, 259 Wickham Terrace Brisbane Queensland Australia QLD 4000
- Liberty Mutual Research Institute for Safety; 71 Frankland Road Hopkinton Massachusetts USA
| | - Bhavana Jha
- Brisbane Hand and Upper Limb Research Institute; Level 9, 259 Wickham Terrace Brisbane Queensland Australia QLD 4000
- EKCO Hand Therapy; Brisbane Queensland Australia
| | - Mark Ross
- Brisbane Hand and Upper Limb Research Institute; Level 9, 259 Wickham Terrace Brisbane Queensland Australia QLD 4000
- The University of Queensland; School of Medicine (Department of Surgery); Herston Queensland Australia
- Princess Alexandra Hospital; Orthopaedic Department; Woolloongabba Brisbane Australia
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27
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Hakim RM, Tunis BG, Ross MD. Rehabilitation robotics for the upper extremity: review with new directions for orthopaedic disorders. Disabil Rehabil Assist Technol 2016; 12:765-771. [DOI: 10.1080/17483107.2016.1269211] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Renée M. Hakim
- Department of Physical Therapy, University of Scranton, Scranton, PA, USA
| | - Brandon G. Tunis
- Department of Physical Therapy, University of Scranton, Scranton, PA, USA
| | - Michael D. Ross
- Department of Physical Therapy, Daemen College, Amherst, NY, USA
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28
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Abstract
This review describes the normal healing process for bone, ligaments, and tendons, including primary and secondary healing as well as bone-to-bone fusion. It depicts the important mediators and cell types involved in the inflammatory, reparative, and remodeling stages of each healing process. It also describes the main challenges for clinicians when trying to repair bone, ligaments, and tendons with a specific emphasis on Charcot neuropathy, fifth metatarsal fractures, arthrodesis, and tendon sheath and adhesions. Current treatment options and research areas are also reviewed.
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Affiliation(s)
- Jessica A Cottrell
- Department of Biological Sciences, Seton Hall University, 400 South Orange Avenue, South Orange, NJ 07101, USA.
| | - Jessica Cardenas Turner
- Department of Biomedical Engineering, New Jersey Institute of Technology, 323 Martin Luther King Boulevard, Newark, NJ 07102, USA
| | - Treena Livingston Arinzeh
- Department of Biomedical Engineering, New Jersey Institute of Technology, 323 Martin Luther King Boulevard, Newark, NJ 07102, USA
| | - J Patrick O'Connor
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Medical Sciences Building, Room E-659, 185 South Orange Avenue, Newark, NJ 07103, USA
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29
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Lu H, Chen Q, Yang H, Shen H, Lin XJ. Tanshinone IIA Prevent Tendon Adhesion in the Rat Achilles Tendon Model. J BIOMATER TISS ENG 2016; 6:739-744. [DOI: 10.1166/jbt.2016.1502] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
Background: Tendon adhesion between the sheath and tendon surface is a common clinical problem. Orthopedist makes the improvement of repair techniques and rehabilitation to treat tendon adhesion, but it fails to cure completely. TSA was one of the major active phytochemicals
because of its anti-inflammatory activity. We used tanshinone IIA (TSA) for the prevention of tendon adhesion in the rat Achilles tendon model and investigated the possible mechanisms, including microRNAs (miRNAs) and protein expression via TGF-β/Smad signaling pathway. Method:
Sprague-Dawley (SD) rat Achilles tendons were half partial lacerated and sutured by a modified Kessler's technique, with TSA and normal saline for control. Macroscopic and histological evaluations were applied to examine the injured tendon six weeks after surgery. We evaluated the degree of
adhesion in Gross observation and the remodeling of collagen fibers by observing microscopically and determining the amount of scar formation. The expression of microRNAs (miRNAs) was quantified by real-time PCR detection and protein expression were quantified by western blotting detection.
Results: In gross evaluation of tendon adhesion, the TSA group had less adhesion appeared. No evidences of tendon rupture or local infection were observed. The content of collagen fibers in tendon tissue was decreased in TSA group compared with the control group, it indicated a significant
difference from the control group, P = 0.0004. The expression of miRNAs including miR-155, miR-29b, miR21, miR-133b and let7 were detected in the repaired tendon tissue, and only miR-29b treated with TSA was observed significantly higher than control group, P <0.0001. The
protein expression of TGF-β1 and p-Smad3 treated with TSA was lower than control group. Conclusions: The usage of TSA may be an efficient approach for preventing tendon adhesion.
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Chinchalkar SJ, Larocerie-Salgado J, Suh N. Pathomechanics and Management of Secondary Complications Associated with Tendon Adhesions Following Flexor Tendon Repair in Zone II. J Hand Microsurg 2016; 8:70-9. [PMID: 27625534 PMCID: PMC5018978 DOI: 10.1055/s-0036-1586173] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 05/12/2016] [Indexed: 10/21/2022] Open
Abstract
Despite the number of rehabilitation strategies and guidelines developed to maximize the gliding amplitude of repaired tendons, secondary complications, such as decreased range of motion and stiffness associated with tendon adhesions, commonly arise. If left untreated, these early complications may lead to secondary pathomechanical changes resulting in fixed deformities and decreased function. Therefore, an appropriate treatment regimen must not only include strategies to maintain the integrity of the repaired tendon, but must also avoid secondary complications due to reduced gliding amplitude. This review presents a biomechanical analysis of the dynamics of tendon gliding following repair in zone II and rehabilitation strategies to minimize secondary complications related with tendon adhesions.
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Affiliation(s)
- Shrikant J. Chinchalkar
- Department of Hand Therapy, Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Hospital, London, Ontario, Canada
- Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Hospital, London, Ontario, Canada
| | - Juliana Larocerie-Salgado
- Department of Hand Therapy, Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Hospital, London, Ontario, Canada
- Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Hospital, London, Ontario, Canada
| | - Nina Suh
- Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Hospital, London, Ontario, Canada
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Chen CH, Chen SH, Shalumon K, Chen JP. Prevention of peritendinous adhesions with electrospun polyethylene glycol/polycaprolactone nanofibrous membranes. Colloids Surf B Biointerfaces 2015; 133:221-30. [DOI: 10.1016/j.colsurfb.2015.06.012] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 06/03/2015] [Accepted: 06/04/2015] [Indexed: 11/17/2022]
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Yaseen Z, English C, Stanbury SJ, Chen T, Messing S, Awad H, Elfar JC. The Effect of the Epitendinous Suture on Gliding in a Cadaveric Model of Zone II Flexor Tendon Repair. J Hand Surg Am 2015; 40:1363-8. [PMID: 25920620 PMCID: PMC5837028 DOI: 10.1016/j.jhsa.2015.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 03/06/2015] [Accepted: 03/07/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE We hypothesized that increasing core sutures (4-6) may be preferable in terms of gliding coefficient (GC) measurements when compared with adding an epitendinous suture to zone II flexor tendon repairs. We hypothesized that the inclusion of epitendinous suture in 2 standard repairs would contribute negatively to the GC of the repaired tendon. METHODS Nineteen fresh-frozen cadaveric fingers were used for testing. We compared a control group (dissected digits without repair) and 4-strand or 6-strand core tendon repairs with and without epitendinous suture. Arc of motion was driven by direct loading, and digital images were acquired and analyzed. Outcomes were defined as the difference in GC between the native uninjured and the repaired state at each load. A linear mixed-model analysis was performed with comparisons between repairs to evaluate the statistically relevant differences between groups. RESULTS The test of fixed effects in the linear model revealed that repair type and the use of epitendinous suture significantly affected the change in GC. The addition of an epitendinous suture produced a significant decrement in gliding regardless of repair type. CONCLUSIONS There was significant improvement in GC with the omission of the epitendinous suture in both repair types (4- or 6-strand). CLINICAL RELEVANCE The epitendinous suture used in this model resulted in poorer gliding of the repair, which may correspond with an expected increase in catching or triggering.
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Affiliation(s)
- Zaneb Yaseen
- Department of Orthopaedic Surgery, Division of Hand and Shoulder and Elbow Surgery, University of Rochester, Rochester, NY
| | - Christopher English
- Department of Orthopaedic Surgery, Division of Hand and Shoulder and Elbow Surgery, University of Rochester, Rochester, NY
| | - Spencer J. Stanbury
- Department of Orthopaedic Surgery, Division of Hand and Shoulder and Elbow Surgery, University of Rochester, Rochester, NY
| | - Tony Chen
- Department of Orthopaedic Surgery, Division of Hand and Shoulder and Elbow Surgery, University of Rochester, Rochester, NY
| | - Susan Messing
- Department of Orthopaedic Surgery, Division of Hand and Shoulder and Elbow Surgery, University of Rochester, Rochester, NY
| | - Hani Awad
- Department of Orthopaedic Surgery, Division of Hand and Shoulder and Elbow Surgery, University of Rochester, Rochester, NY
| | - John C. Elfar
- Department of Orthopaedic Surgery, Division of Hand and Shoulder and Elbow Surgery, University of Rochester, Rochester, NY
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Savvidou C, Tsai TM. Clinical Results of Flexor Tendon Repair in Zone II Using a six Strand Double Loop Technique. J Hand Microsurg 2015; 7:25-9. [PMID: 26078499 DOI: 10.1007/s12593-014-0156-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 08/18/2014] [Indexed: 10/24/2022] Open
Abstract
The purpose of this study is to report the clinical results after repair of flexor tendon zone II injuries utilizing a 6-strand double-loop technique and early post-operative active rehabilitation. We retrospectively reviewed 22 patients involving 51 cases with zone II flexor tendon repair using a six strand double loop technique from September 1996 to December 2012. Most common mechanism of injuries was sharp lacerations (86.5 %). Tendon injuries occurred equally in manual and non-manual workers and were work-related in 33 % of the cases. The Strickland score for active range of motion (ROM) postoperatively was excellent and good in the majority of the cases (81 %). The rupture rate was 1.9 %. The six strand double loop technique for Zone II flexor tendon repair leads to good and excellent motion in the majority of patients and low re- rupture rate. It is clinically effective and allows for early postoperative active rehabilitation.
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Affiliation(s)
- Christiana Savvidou
- Christine M. Kleinert Institute for Hand & Microsurgery, 225 Abraham Flexner Way, Suite 800, Louisville, KY 40202 USA
| | - Tsu-Min Tsai
- Christine M. Kleinert Institute for Hand & Microsurgery, 225 Abraham Flexner Way, Suite 800, Louisville, KY 40202 USA
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Abstract
Innovations in operative techniques, biomaterials, and rehabilitation protocols have improved outcomes after treatment of flexor tendon injuries. However, despite these advances, treatment of flexor tendon injuries remains challenging. The purpose of this review is to highlight the complications of flexor tendon injuries and review the management of these complications.
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Affiliation(s)
- Nicholas Pulos
- Department of Orthopedic Surgery, University of Pennsylvania, 3737 Market Street, 6th Floor, Philadelphia, PA 19104, USA
| | - David J Bozentka
- Hand Surgery, Department of Orthopedic Surgery, University of Pennsylvania, 3737 Market Street, 6th Floor, Philadelphia, PA 19104, USA.
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The Effect of Phospholipids (Surfactant) on Adhesion and Biomechanical Properties of Tendon: A Rat Achilles Tendon Repair Model. BIOMED RESEARCH INTERNATIONAL 2015; 2015:689314. [PMID: 26101776 PMCID: PMC4458519 DOI: 10.1155/2015/689314] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 03/22/2015] [Accepted: 03/30/2015] [Indexed: 12/05/2022]
Abstract
Adhesion of the tendon is a major challenge for the orthopedic surgeon during tendon repair. Manipulation of biological environment is one of the concepts to prevent adhesion. Lots of biochemicals have been studied for this purpose. We aimed to determine the effect of phospholipids on adhesion and biomechanical properties of tendon in an animal tendon repair model.
Seventy-two Wistar rats were divided into 4 groups. Achilles tendons of rats were cut and repaired. Phospholipids were applied at two different dosages. Tendon adhesion was determined histopathologically and biomechanical test was performed. At macroscopic evaluation of adhesion, there are statistically significant differences between multiple-dose phospholipid injection group and Control group and also hyaluronic acid group and Control group (p < 0.008). At microscopic evaluation of adhesion, there was no statistically significant difference (p > 0.008). Ultimate strength was highest at hyaluronic acid injection group and lowest at multiple-dose phospholipid injection group. Single-dose phospholipids (surfactant) application may have a beneficial effect on the tendon adhesion. Although multiple applications of phospholipids seem the most effective regime to reduce the tendon adhesion among groups, it deteriorated the biomechanical properties of tendon.
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Abstract
Flexor tendon repair in zone II is particularly challenging because tendon gliding must be restored within a tight fibro-osseous sheath while minimizing the formation of adhesions in surrounding tissues. Meticulous surgical technique using a multistrand core suture and a peripheral suture is needed to produce a tendon that is strong enough to withstand early mobilization. Mechanical strength increases with the number of strands crossing the repair, regardless of the core suture configuration. Early mobilization after flexor tendon repair enhances the strength of the repair and decreases the risk of adhesions and joint stiffness. Satisfactory results have been achieved with either early passive or early active motion rehabilitation protocols; therefore, the choice of postoperative rehabilitation program is at the discretion of the surgeon. Factors such as repair integrity, concurrent injuries, and anticipated patient compliance should be considered in the decision-making process.
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Prevention of peritendinous adhesions with electrospun chitosan-grafted polycaprolactone nanofibrous membranes. Acta Biomater 2014; 10:4971-4982. [PMID: 25192729 DOI: 10.1016/j.actbio.2014.08.030] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Revised: 06/30/2014] [Accepted: 08/25/2014] [Indexed: 11/22/2022]
Abstract
As one of the common complications after tendon injury and subsequent surgery, peritendinous adhesions could be minimized by directly placing a physical barrier between the injured site and the surrounding tissue. With the aim of solving the shortcomings of current biodegradable anti-adhesion barrier membranes, we propose the use of an electrospun chitosan-grafted polycaprolactone (PCL-g-CS) nanofibrous membrane (NFM) to prevent peritendinous adhesions. After introducing carboxyl groups on the surface by oxygen plasma treatment, the polycaprolactone (PCL) NFM was covalently grafted with chitosan (CS) molecules, with carbodiimide as the coupling agent. Compared with PCL NFM, PCL-g-CS NFM showed a similar fiber diameter, permeation coefficient for bovine serum albumin, ultimate tensile strain, reduced pore diameter, lower water contact angle, increased water sorption and tensile strength. With its submicrometer pore diameter (0.6-0.9μm), both NFMs could allow the diffusion of nutrients and waste while blocking fibroblast penetration to prevent adhesion formation after tendon surgery. Cell culture experiments verified that PCL-g-CS NFM can reduce fibroblast attachment while maintaining the biocompatibility of PCL NFM, implicating a synergistic anti-adhesion effect to raise the anti-adhesion efficacy. In vivo studies with a rabbit flexor digitorum profundus tendon surgery model confirmed that PCL-g-CS NFM effectively reduced peritendinous adhesion from gross observation, histology, joint flexion angle, gliding excursion and biomechanical evaluation. An injured tendon wrapped with PCL-g-CS NFM showed the same tensile strength as the naturally healed tendon, indicating that the anti-adhesion NFM will not compromise tendon healing.
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Chen SH, Chen CH, Shalumon KT, Chen JP. Preparation and characterization of antiadhesion barrier film from hyaluronic acid-grafted electrospun poly(caprolactone) nanofibrous membranes for prevention of flexor tendon postoperative peritendinous adhesion. Int J Nanomedicine 2014; 9:4079-92. [PMID: 25187711 PMCID: PMC4149458 DOI: 10.2147/ijn.s67931] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Peritendinous adhesion is one of the common complications encountered after tendon injury and subsequent surgery, and it can be minimized by introducing a physical barrier between the injured site and the surrounding tissue. An electrospun hyaluronic acid-grafted poly(caprolactone) (PCL-g-HA) nanofibrous membrane (NFM) is proposed as an alternative to current antiadhesion barrier films. HA is covalently grafted to surface-aminolyzed PCL nanofibers, using carbodiimide as the coupling agent. Pristine PCL and PCL-g-HA NFMs were characterized by scanning electron microscopy, thermogravimetric analysis, X-ray photoelectron spectroscopy, Fourier-transform infrared spectroscopy, and mechanical testing. In vitro cell culture with fibroblasts showed that PCL-g-HA NFMs reduced cellular adhesion on the membrane surface while maintaining cell proliferation. Animal experiments using a rabbit flexor digitorum profundus tendon model confirmed the efficacy of PCL-g-HA in reducing peritendinous adhesion, based on gross observation, histology, joint flexion-angle measurements, gliding tests, and biomechanical evaluation.
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Affiliation(s)
- Shih-Hsien Chen
- Department of Chemical and Materials Engineering, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taiwan, Republic of China
| | - Chih-Hao Chen
- Department of Chemical and Materials Engineering, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taiwan, Republic of China ; Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taiwan, Republic of China
| | - K T Shalumon
- Department of Chemical and Materials Engineering, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taiwan, Republic of China
| | - Jyh-Ping Chen
- Department of Chemical and Materials Engineering, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taiwan, Republic of China ; Research Center for Industry of Human Ecology, Chang Gung University of Science and Technology, Taoyuan, Taiwan, Republic of China
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Superimposed electrical stimulation improves mobility of pre-stiff thumbs after ulnar collateral ligament injury of the metacarpophalangeal joint: a randomized study. Ann Phys Rehabil Med 2014; 57:373-80. [PMID: 24894392 DOI: 10.1016/j.rehab.2014.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 04/16/2014] [Accepted: 04/19/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study aimed at testing the ability of the superimposed electrical stimulation technique to restore the mobility of pre-stiff thumbs after operative repair for rupture of the ulnar collateral ligament. MATERIAL AND METHODS Eight patients demonstrating a pre-stiff metacarpophalangeal joint were involved in two rehabilitation sessions of a counterbalanced design. In the voluntary contraction session, they performed 20min of repeated active flexions of the impaired metacarpophalangeal joint. In the superimposed electrical stimulation session, they performed 20min of percutaneous neuromuscular electrical stimulations which were superimposed to voluntary flexion. RESULTS Mean active range of motion improvement from pre- to post-session was significantly greater in the superimposed electrical stimulation condition compared to the voluntary contraction condition (11±5 deg versus 3±4 deg; P<0.01). CONCLUSION Superimposing electrical stimulation to voluntary contractions is an efficient technique to improve active range of motion of the pre-stiff metacarpophalangeal joint of the thumb.
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The outcomes of peritendon tissue free-grafted on the tendon surface. Injury 2014; 45:970-3. [PMID: 24629704 DOI: 10.1016/j.injury.2014.02.019] [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: 01/04/2014] [Accepted: 02/08/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The objective of this study is to observe the gross and histological changes of free-grafted peritendon tissue. METHODS The incisions were made in the bilateral Achilles tendon sites in six healthy rabbits weighing 2.0-2.5kg. The peritendon tissue flaps of about 2.0cm×0.5cm size were harvested and free-grafted into the contralateral donor sites. After 3 weeks, three animals were sacrificed, and after 6 weeks the remaining three animals were sacrificed. The peritendon tissue specimens were sampled for gross observation and histological observation. RESULTS Gross observation after 3 weeks: the peritendon tissue became thick, there was tissue proliferation, and the deep surface was smooth. Histological observation after 3 weeks: inflammatory cells in the peritendon tissue were observed, many fibroblasts proliferated in the superficial surface, and some neovascularization was observed. Tissue growth could be seen in the suture site. Gross observation after 6 weeks: the peritendon tissue looked thick and the deep surface was smooth. Histological observation after 6 weeks: inflammatory cells in the peritendon tissue were significantly reduced and there were still more fibroblasts in the tissues. Neovascularization was obvious and the suture site was firmly healed. No signs of necrosis were found at the two time points, and the structure of the free-grafted peritendon tissue was almost the same as the structure of the peripheral tissue. CONCLUSION The peritendon tissue can survive well after being free-grafted into the tendon surface and the structure shows no obvious changes.
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Abstract
BACKGROUND Nonadherence to postoperative therapy protocols can adversely affect the outcome after flexor tendon surgery. In this study, we hypothesize that patients with partial or no insurance coverage for their aftercare are less likely to attend postoperative therapy sessions and have a higher incidence of a poorer outcome than those who have full insurance coverage. METHODS We analyzed 159 patients with flexor tendon injuries at a level 1 trauma center. Demographic variables along with the clinical outcome data were collected and cross-tabulated. Associations among descriptive and clinical variables were assessed using Fisher's Exact tests and chi-square analyses. Comparisons for continuous variables were performed using the Kruskal-Wallis Test. RESULTS Eighteen patients (11.3 %) had an injury in zone 1, followed by 68 (42.8 %) in zone 2, 15 (9.4 %) in zone 3, 9 (5.7 %) in zone 4, 38 (23.9 %) in zone 5, and 11 (6.9 %) in zone 6. Patients completed 8.2 therapy sessions on average. Patients had state assistance program (40.3 %), private insurance (35.2 %), Medicaid/Medicare (11.3 %), worker's compensation (8.8 %) insurance, or paid themselves (13.2 %). Fifty-three (33.3 %) patients had excellent outcomes, 46 (29 %) had good, 40 (25 %) had fair, and 20 (12.5 %) had a poor outcome. Patients responsible to pay for their aftercare were significantly less likely to be adherent to therapy and had poorer outcomes than those with full coverage. CONCLUSION Patients responsible for the pay of their postoperative rehabilitation are less likely to participate in therapy and may be at a higher risk of having a poor outcome.
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Stanbury SJ, English C, Yaseen Z, Reed JD, Chen T, Awad H, Elfar JC. The Effect of Pulley Reconstruction on Maximum Flexion, Bowstringing, and Gliding Coefficient in the Setting of Zone II Repair of FDS and FDP: a Cadaveric Investigation. Hand (N Y) 2014; 9:99-104. [PMID: 24570645 PMCID: PMC3928377 DOI: 10.1007/s11552-013-9560-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE The purpose of this experiment was to determine the effect of A2 pulley reconstruction on gliding coefficient (GC), bowstringing, and proximal interphalangeal (PIP) joint maximum flexion angle after zone II repair of flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) lacerations. METHODS Fresh frozen cadaver forearms were mounted, and the wrist and MCP joints fixed. FDS and FDP tendons were dissected free, and sequential loads were applied while digital images were captured. The dissected digit with intact native A2 pulley, FDS, and FDP tendons was used as the control (group 1). Zone II lacerations followed by four-stranded repair of FDP plus epitendinous suture and repair of FDS were then performed, and the data recorded (group 2). A2 pulley excision and reconstruction with a loop of palmaris longus autograft was then completed and the specimens sequentially loaded and photographed (group 3). Using the digital images, GC, bowstringing, and maximum flexion angle were calculated. RESULTS No difference in maximum flexion angle was observed across the three testing conditions. Zone II laceration and subsequent FDS and FDP tendon repair significantly increased the GC for group 2 specimens; however, pulley reconstruction alleviated some of this increase for group 3. Bowstringing was significantly greater after pulley reconstruction, with a mean increase of 1.9 mm at maximum flexion for group 3 specimens relative to group 1 controls. DISCUSSION Strong flexor tendon repairs are needed to prevent gap formation and subsequent triggering; however, the increased bulk from these large repairs can itself produce deleterious triggering, as well as tendon abrasion. Pulley reconstruction, in the setting FDP and FDS repair (group 3), significantly reduced the GC relative to tendon repair alone (group 2). While bowstringing was significantly greater after pulley reconstruction (group 3), it averaged only 1.9 mm over group 1 specimens and did not compromise maximum flexion angle compared to the uninjured controls (group 1) or the isolated tendon repair digits (group 2).
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Affiliation(s)
- Spencer J. Stanbury
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, 601 Elmwood Ave, Box 665, Rochester, NY 14642 USA
| | - Christopher English
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, 601 Elmwood Ave, Box 665, Rochester, NY 14642 USA
| | - Zaneb Yaseen
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, 601 Elmwood Ave, Box 665, Rochester, NY 14642 USA
| | - Jeffrey D. Reed
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, 601 Elmwood Ave, Box 665, Rochester, NY 14642 USA
| | - Tony Chen
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, 601 Elmwood Ave, Box 665, Rochester, NY 14642 USA
| | - Hani Awad
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, 601 Elmwood Ave, Box 665, Rochester, NY 14642 USA
| | - John C. Elfar
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, 601 Elmwood Ave, Box 665, Rochester, NY 14642 USA
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Abstract
BACKGROUND Flexor tendon injury is a common problem that plastic surgeons are called on to treat. Despite their common nature, they present a challenge, not necessarily in the surgical treatment per se but in the ability to achieve a "normal" finger as the end result. Because of the difficulty in attaining good outcomes, much continues to be studied and written about flexor tendon injury. METHODS The current literature on flexor tendon repair, rehabilitation, and reconstruction is reviewed. RESULTS Aspects reviewed include type of anesthesia, suture material and configuration, repairs in the different flexor tendon zones, types of tendon rehabilitation, complications of flexor tendon surgery, and flexor tendon reconstruction. CONCLUSION This review provides an update on the current standards in the treatment of flexor tendon injury.
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Reese SP, Kubiak EN. A nitinol based flexor tendon fixation device: gapping and tensile strength measurements in cadaver flexor tendon. J Biomech Eng 2013; 136:014501. [PMID: 24141662 DOI: 10.1115/1.4025779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Indexed: 11/08/2022]
Abstract
In this study, a new nitinol based fixation device was investigated for use in repairing severed digital flexor tendons. The device, composed of superelastic nitinol, is tubular in shape with inward facing tines for gripping tissue. Its cellular structure was designed such that it has a large effective Poisson's ratio, which facilitates a “finger trap” effect. This allows for reduced tendon compression during a resting state (to permit vascular perfusion) and increased compression during loading (to drive the tines into the tissue for gripping). To test the feasibility of using this device for flexor tendon repair, it was tested on cadaver flexor digitorum profundus tendons. The tendons were excised, cut in the region corresponding to a zone II laceration, and repaired using the device. The device was easy to install and did not prevent the tendon from bending. Constant strain rate tensile testing revealed a mean tensile strength of 57.6 ± 7.7 N, with a force of 53.2 ± 7.8 N at a 2 mm gap. This exceeds the suggested primary repair strength of 45 N, which has been proposed as the necessary strength for enabling early mobilization. Although considerable future studies will be needed to determine the suitability of the new repair device for clinical use, this study demonstrates the feasibility of utilizing a tubular, nitinol repair device for flexor tendon fixation.
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Abstract
Intrinsic contracture of the hand may result from trauma, spasticity, ischemia, rheumatologic disorders, or iatrogenic causes. In severe cases, the hand assumes a posture with hyperflexed metacarpophalangeal joints and hyperextended proximal interphalangeal joints as the contracted interossei and lumbrical muscles deform the natural cascade of the fingers. Considerable disability may result because weakness in grip strength, difficulty with grasping larger objects, and troubles with maintenance of hygiene commonly encumber patients. Generally, the diagnosis is made via history and physical examination, but adjunctive imaging, rheumatologic testing, and electromyography may aid in determining the underlying cause or assessing the severity. Nonsurgical management may be appropriate in mild cases and consists of occupational therapy, orthoses, and botulinum toxin injections. The options for surgical management are diverse and dictated by the cause and severity of contracture.
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Juneja SC. Cellular distribution and gene expression profile during flexor tendon graft repair: A novel tissue engineering approach(*). J Tissue Eng 2013; 4:2041731413492741. [PMID: 23762501 PMCID: PMC3677358 DOI: 10.1177/2041731413492741] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
To understand scar and adhesion formation during postsurgical period of intrasynovial tendon graft healing, a murine model of flexor digitorum longus tendon graft repair was developed, by utilizing flexor digitorum longus tendon allograft from donor Rosa26/+ mouse, and the healing process at days 3, 7, 14, 21, 28, and 35 post surgery of host wild-type mouse was followed. Using X-gal staining, β-galactosidase positive cells of allograft origin were detectable in tissue sections of grafted tendon post surgery. Graft healing was assessed for the cellular density, scar and adhesion formation, and their interaction with surrounding tissue. From histological analysis, it was evident that the healing of intrasynovial flexor digitorum longus tendon graft takes place in an interactive environment of donor graft, host tendon, and host surrounding tissue. A total of 32 genes, analyzed by RNA analysis, expressed during healing process. Particularly, Alk1, Postn, Tnc, Tppp3, and Mkx will be further investigated for therapeutical value in reducing scars and adhesions.
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Affiliation(s)
- Subhash C Juneja
- The Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA ; Division of Orthopaedic Surgery, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
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Gordon L, Matsui J, McDonald E, Gordon JA, Neimkin R. Analysis of a knotless flexor tendon repair using a multifilament stainless steel cable-crimp system. J Hand Surg Am 2013; 38:677-83. [PMID: 23453895 DOI: 10.1016/j.jhsa.2013.01.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Revised: 01/05/2013] [Accepted: 01/07/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the biomechanical and technical properties of flexor tendon repairs using a 4-strand cruciate FiberWire (FW) repair and a 2-strand multifilament stainless steel (MFSS) single cross-lock cable-crimp system. METHODS Eight tests were conducted for each type of repair using cadaver hand flexor digitorum profundus tendons. We measured the required surgical exposure, repair time, and force of flexion (friction) with a custom motor system with an inline load cell and measured ultimate tensile strength (UTS) and 2-mm gap force on a servo-hydraulic testing machine. RESULTS Repair time averaged less than 7 minutes for the 2-strand MFSS cable crimp repairs and 12 minutes for the FW repairs. The FW repair was performed with 2 cm of exposure and removal of the C-1 and A-3 pulleys. The C-1 and A-3 pulleys were retained in each of the MFSS cable crimp repairs with less than 1 cm of exposure. Following the FW repair, the average increase in friction was 89% compared with an average of 53% for the MFSS repairs. Six of the 8 MFSS specimens achieved the UTS before any gap had occurred, whereas all of the FW repairs had more than 2 mm of gap before the UTS, indicating that the MFSS was a stiffer repair. The average UTS appeared similar for both groups. CONCLUSIONS We describe a 2-strand multifilament stainless steel single cross-lock cable crimp flexor repair system. In our studies of this cable crimp system, we found that surgical exposure, average repair times, and friction were reduced compared to the traditional 4-strand cruciate FW repair. While demonstrating these benefits, the crimp repair also produced a stiff construct and high UTS and 2-mm gap force. CLINICAL RELEVANCE A cable crimp flexor tendon repair may offer an attractive alternative to current repair methods. The benefits may be important especially for flexor tendon repair in zone 2 or for the repair of multiple tendons.
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Affiliation(s)
- Leonard Gordon
- Department of Anatomy and Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA 94115, USA
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Juneja SC, Schwarz EM, O’Keefe RJ, Awad HA. Cellular and molecular factors in flexor tendon repair and adhesions: a histological and gene expression analysis. Connect Tissue Res 2013; 54:218-26. [PMID: 23586515 PMCID: PMC3697755 DOI: 10.3109/03008207.2013.787418] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Flexor tendon healing is mediated by cell proliferation, migration, and extracellular matrix synthesis that contribute to the formation of scar tissue and adhesion. The biological mechanisms of flexor tendon adhesion formation have been linked to transforming growth factor β (TGF-β). To elucidate the cellular and molecular events in this pathology, we implanted live flexor digitorum longus grafts from the reporter mouse Rosa26(LacZ/+) in wild-type recipients, and used histological β-galactosidase (β-gal) staining to evaluate the intrinsic versus extrinsic cellular origins of scar, and reverse transcription-polymerase chain reaction to measure gene expression of TGF-β and its receptors, extracellular matrix proteins, and matrix metalloproteinases (MMPs) and their regulators. Over the course of healing, graft cellularity and β-gal activity progressively increased, and β-gal-positive cells migrated out of the Rosa26(LacZ/+) graft. In addition, there was an evidence of influx of host cells (β-gal-negative) into the gliding space and the graft, suggesting that both graft and host cells contribute to adhesions. Interestingly, we observed a biphasic pattern in which Tgfb1 expression was the highest in the early phases of healing and gradually decreased thereafter, whereas Tgfb3 increased and remained upregulated later. The expression of TGF-β receptors was also upregulated throughout the healing phases. In addition, type III collagen and fibronectin were upregulated during the proliferative phase of healing, confirming that murine flexor tendon heals by scar tissue. Furthermore, gene expression of MMPs showed a differential pattern in which inflammatory MMPs were the highest early and matrix MMPs increased over time. These findings offer important insights into the complex cellular and molecular factors during flexor tendon healing.
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Affiliation(s)
- Subhash C. Juneja
- The Center for Musculoskeletal Research, University of Rochester, Rochester, NY, USA,Division of Orthopaedic Surgery, TWH, UHN, Toronto, ON M5T 2S8
| | - Edward M. Schwarz
- The Center for Musculoskeletal Research, University of Rochester, Rochester, NY, USA,Department of Orthopaedics, University of Rochester, Rochester, NY, USA
| | - Regis J. O’Keefe
- The Center for Musculoskeletal Research, University of Rochester, Rochester, NY, USA,Department of Orthopaedics, University of Rochester, Rochester, NY, USA
| | - Hani A. Awad
- The Center for Musculoskeletal Research, University of Rochester, Rochester, NY, USA,Department of Orthopaedics, University of Rochester, Rochester, NY, USA,Department of Biomedical Engineering, University of Rochester, Rochester, NY, USA
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Starnes T, Saunders RJ, Means KR. Clinical outcomes of zone II flexor tendon repair depending on mechanism of injury. J Hand Surg Am 2012; 37:2532-40. [PMID: 23174066 DOI: 10.1016/j.jhsa.2012.09.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Revised: 09/18/2012] [Accepted: 09/18/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether mechanism of injury affects outcomes of Zone II flexor tendon repairs. METHODS We retrospectively analyzed patients who underwent Zone II flexor tendon repair between 2001 and 2010 with a minimum of 12-month follow-up. Exclusion criteria included fingers with fracture, pulley reconstruction, or flexor tendon bowstringing. The saw group injuries were from saws or from tearing mechanisms; the sharp group had clean transection injuries from knives or glass. At final evaluation, primary outcomes were total passive motion (TPM) and total active motion (TAM) at the proximal interphalangeal and distal interphalangeal joints. Secondary comparisons included strength, Disabilities of the Shoulder, Arm, and Hand (DASH) score, percentage of postoperative tendon rupture, and percentage of patients requiring secondary surgery. The saw group had 13 patients with 17 fingers studied. The sharp group had 21 patients with 24 fingers studied. All patients had primary flexor digitorum profundus repairs in Zone II. Operative records review confirmed for all but 1 patient that flexor digitorum profundus injuries were repaired with a minimum of a 4-strand core suture technique. In the saw group, 9 of 14 fingers with a 50% or greater laceration of flexor digitorum superficialis were repaired; in the sharp group, 15 of 18 such flexor digitorum superficialis injuries were repaired. Average follow-up was 4 years (range, 1-9 y). RESULTS The saw group had significantly less TAM and TPM compared with the sharp group. There was no significant difference in DASH scores, strength measurements, or tendon rupture rates. The rate of secondary surgery was significantly higher in the saw group. CONCLUSIONS Tearing types of injury, such as those caused by saws, led to poorer outcomes for Zone II flexor tendon injuries compared with sharp injuries at an average follow-up of 4 years. Our results can be useful when discussing expected outcomes. Mechanism of injury in Zone II flexor tendon lacerations may eventually help define optimal treatment.
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Affiliation(s)
- Trevor Starnes
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, Maryland 21218, USA
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