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Chinchalkar SJ, Larocerie-Salgado J, Pipicelli JG. Zone-specific pitfalls in flexor tendon rehabilitation: management and prevention. J Hand Surg Eur Vol 2024:17531934241265579. [PMID: 39140224 DOI: 10.1177/17531934241265579] [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: 08/15/2024]
Abstract
Despite significant advancements in flexor tendon repair techniques and rehabilitation strategies, achieving complete restoration of digital motion remains a formidable challenge. The most prevalent complications associated with tendon repair are the development of tendon adhesions and joint contractures. Left unaddressed, these complications can further lead to secondary pathomechanical changes, resulting in fixed deformities significantly affecting hand function. This review of zone-specific considerations in flexor tendon rehabilitation provides an in-depth analysis of the dynamics of tendon motion after repair and strategies to minimize common secondary complications.
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Affiliation(s)
- Shrikant J Chinchalkar
- Hand Therapy Division, Roth-McFarlane Hand & Upper Limb Center, St. Joseph's Health Care London, ON, Canada
- Advanced Clinical Education Inc., Mississauga, ON, Canada
| | - Juliana Larocerie-Salgado
- Hand Therapy Division, Roth-McFarlane Hand & Upper Limb Center, St. Joseph's Health Care London, ON, Canada
| | - Joey G Pipicelli
- Hand Therapy Division, Roth-McFarlane Hand & Upper Limb Center, St. Joseph's Health Care London, ON, Canada
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Demers AJ, Moran TE, Bustos FP, Forster GL, Natal E, DeGeorge BR. Revision of Flexor Tendon Repair: Factors Associated With Flexor Tenolysis. Hand (N Y) 2024; 19:664-670. [PMID: 36564984 PMCID: PMC11141425 DOI: 10.1177/15589447221142890] [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: 12/25/2022]
Abstract
BACKGROUND Tenolysis restores mobility to the flexor tendon through the lysis of adhesions that inhibit and negatively impact functional outcomes following flexor tendon repair. Despite extensive literature on operative techniques and therapy protocols used to minimize adhesion formation, there are limited data examining the association of patient, injury, and postoperative factors with tenolysis. This study aims to: (1) quantify tenolysis rates following flexor tendon repair or reconstruction; and (2) identify patient demographic factors, medical comorbidities, injury characteristics, postoperative diagnoses, and complications associated with tenolysis. METHODS PearlDiver was used to identify patients who underwent a flexor tendon repair or reconstruction from 2010 to 2020. Patients were stratified by whether or not flexor tenolysis was performed. Patient demographics, comorbidities, injury characteristics, postoperative diagnoses, and complications were recorded. Logistic regression analysis was used to identify independent risk factors associated with tenolysis. RESULTS Database review identified 10 264 patients who underwent either flexor tendon repair or reconstruction, with 612 patients (6.0%) subsequently undergoing tenolysis. Logistic regression analysis determined that vascular injury preceding flexor tendon repair, surgical wound disruption, nerve injury diagnosed postoperatively, postoperative tendon rupture, and need for repeat flexor tendon repair were associated with an increased odds of tenolysis. Patient age, sex, and comorbidities were not associated with performance of tenolysis. CONCLUSIONS Although tenolysis rates may differ according to physician and patient preferences, identification of factors associated with tenolysis following flexor tendon repair allows surgeons to risk-stratify patients prior to surgery and help guide postoperative expectations if complications arise.
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Daniels SP, Kirby D, De Tolla J. Diagnosis and treatment of flexor tendon injuries of the hand: what the radiologist needs to know. Skeletal Radiol 2024; 53:597-608. [PMID: 37828095 DOI: 10.1007/s00256-023-04460-y] [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: 05/09/2023] [Revised: 09/20/2023] [Accepted: 09/20/2023] [Indexed: 10/14/2023]
Abstract
This article reviews the diagnosis and treatment of flexor tendon injuries of the hand highlighting flexor tendon anatomy, important pre-operative imaging findings, surgical options, and post-operative complications. Imaging plays a key role in guiding treatment of these difficult to manage injuries. Thus, it is important for radiologists to have a sound understanding of factors important in treatment decision-making. In the pre-operative setting, accurately identifying the location of the torn proximal tendon stump in subacute and chronic injuries helps dictate whether the patient is a candidate for a primary flexor tendon repair or may require a tendon reconstruction to restore function. In the post-operative setting, the status of the repair and presence of surrounding adhesions help dictate if and when the patient will require subsequent surgery and whether that surgery will be a tenolysis, revision repair, reconstruction, or fusion.
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Affiliation(s)
- Steven P Daniels
- Department of Radiology, New York University Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA.
| | - David Kirby
- Department of Orthopedic Surgery, New York University Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA
| | - Jadie De Tolla
- Department of Orthopedic Surgery, New York University Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA
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Chen J, Tang JB. Complications of flexor tendon repair. J Hand Surg Eur Vol 2024; 49:158-166. [PMID: 38315135 DOI: 10.1177/17531934231182868] [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] [Indexed: 02/07/2024]
Abstract
This article reviews and highlights complications of flexor tendon repairs. Although the outcomes of flexor tendon repairs have improved over the years, fair or poor functional outcomes are seen, especially in patients whose trauma involves multiple structures of the hand and in zone 5 with multiple tendon lacerations. Rupture of the flexor tendon after repair is no longer a major problem if current repair principles are carefully adhered to. Different degrees of adhesion formations and interphalangeal (IP) joint stiffness still occur in a few patients. Early active postoperative mobilization and use of a shorter splint with sparing of the wrist are effective measures to prevent adhesion formation and IP joint stiffness. Given the overall poor results and high rate of complications with flexor digitorum profundus (FDP) repairs in zone 1, a direct repair of the FDP tendon to any short remnant of the distal insertion with 10-strand or even stronger core suture repair is adopted by many units.
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Affiliation(s)
- Jing Chen
- The Hand Surgery Research Center, Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
| | - Jin Bo Tang
- The Hand Surgery Research Center, Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
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Mohammadhoseini P, Mohammadi SM, Mousavi Nia N. Short-Term and Long-Term Therapeutic Results of Deep Flexor Tendon Repair in Zone II in Patients Referred to Imam Khomeini Hospital, Ahvaz, Southern Iran. World J Plast Surg 2024; 13:82-86. [PMID: 38742036 PMCID: PMC11088727 DOI: 10.61186/wjps.13.1.82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 09/03/2024] [Indexed: 05/16/2024] Open
Abstract
Background Hand injury as an important concern for the surgeon and the patient requires proper and timely treatment to prevent complications such as infection and adhesions, and with a proper rehabilitation program, the patient returns to maximum function as soon as possible. We aimed to investigate the short-term and long-term treatment results of deep flexor tendon repair in in zone II. Methods This retrospective study was performed on 34 patients with 45 injured fingers in the zone II referred to Ahvaz Imam Khomeini Hospital, Ahvaz, Iran during 2017-2019. The results of deep flexor tendons repair in two groups, immediate and delayed primary repair were assessed. Results The mean age of the patients was 27.76 years. There was no significant remarkable between male and female in the incidence of complications such as infection, tendon rupture and adhesions. 29.4% (n=10) had poor outcome, 8.8% (n=3) had fair outcome, 29.4% (n=10) had good outcome and 32.4% (n=11) had excellent outcomes. 26.5% had adhesion and infection rate was 11.8%. Conclusion Among surgeons, there is consensus for the primary repair of tendon injury, but there was no significant difference between the results of immediate and delayed primary repair. Although physiotherapy has been suggested as an effective factor in improving hand function, its positive effect on the range of motion of the fingers has not been proven.
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Affiliation(s)
- Payam Mohammadhoseini
- Department of Orthopedics, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Seyed Mohammad Mohammadi
- Department of Orthopedics, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Narjes Mousavi Nia
- Department of Orthopedics, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Li Y, Wang X, Hu B, Sun Q, Wan M, Carr A, Liu S, Cao X. Neutralization of excessive levels of active TGF-β1 reduces MSC recruitment and differentiation to mitigate peritendinous adhesion. Bone Res 2023; 11:24. [PMID: 37156778 PMCID: PMC10167238 DOI: 10.1038/s41413-023-00252-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 01/31/2023] [Accepted: 02/10/2023] [Indexed: 05/10/2023] Open
Abstract
Peritendinous adhesion formation (PAF) can substantially limit the range of motion of digits. However, the origin of myofibroblasts in PAF tissues is still unclear. In this study, we found that the concentration of active TGF-β1 and the numbers of macrophages, mesenchymal stromal cells (MSCs), and myofibroblasts in human and mouse adhesion tissues were increased. Furthermore, knockout of TGF-β1 in macrophages or TGF-β1R2 in MSCs inhibited PAF by reducing MSC and myofibroblast infiltration and collagen I and III deposition, respectively. Moreover, we found that MSCs differentiated into myofibroblasts to form adhesion tissues. Systemic injection of the TGF-β-neutralizing antibody 1D11 during the granulation formation stage of PAF significantly reduced the infiltration of MSCs and myofibroblasts and, subsequently, PAF. These results suggest that macrophage-derived TGF-β1 recruits MSCs to form myofibroblasts in peritendinous adhesions. An improved understanding of PAF mechanisms could help identify a potential therapeutic strategy.
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Affiliation(s)
- YuSheng Li
- Department of Orthopedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
| | - Xiao Wang
- Department of Orthopedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
| | - Bo Hu
- Department of Orthopedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
| | - Qi Sun
- Department of Orthopedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
| | - Mei Wan
- Department of Orthopedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
| | - Andrew Carr
- Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK
| | - Shen Liu
- Department of Orthopedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA.
| | - Xu Cao
- Department of Orthopedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA.
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Nichols AE, Wagner NW, Ketonis C, Loiselle AE. Epitenon-derived cells comprise a distinct progenitor population that contributes to both tendon fibrosis and regeneration following acute injury. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.01.30.526242. [PMID: 36778469 PMCID: PMC9915485 DOI: 10.1101/2023.01.30.526242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Flexor tendon injuries are common and heal poorly owing to both the deposition of function- limiting peritendinous scar tissue and insufficient healing of the tendon itself. Therapeutic options are limited due to a lack of understanding of the cell populations that contribute to these processes. Here, we identified a bi-fated progenitor cell population that originates from the epitenon and goes on to contribute to both peritendinous fibrosis and regenerative tendon healing following acute tendon injury. Using a combination of genetic lineage tracing and single cell RNA-sequencing (scRNA-seq), we profiled the behavior and contributions of each cell fate to the healing process in a spatio-temporal manner. Branched pseudotime trajectory analysis identified distinct transcription factors responsible for regulation of each fate. Finally, integrated scRNA-seq analysis of mouse healing with human peritendinous scar tissue revealed remarkable transcriptional similarity between mouse epitenon- derived cells and fibroblasts present in human peritendinous scar tissue, which was further validated by immunofluorescent staining for conserved markers. Combined, these results clearly identify the epitenon as the cellular origin of an important progenitor cell population that could be leveraged to improve tendon healing.
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Svingen J, Wiig M, Turesson C, Farnebo S, Arner M. Risk factors for reoperation after flexor tendon repair: a registry study. J Hand Surg Eur Vol 2022; 47:1071-1076. [PMID: 35579214 PMCID: PMC9634328 DOI: 10.1177/17531934221101563] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The aim of this study was to identify risk factors for reoperations after Zones 1 and 2 flexor tendon repairs. A multiple logistic regression model was used to identify risk factors from data collected via the Swedish national health care registry for hand surgery (HAKIR). The studied potential risk factors were age and gender, socio-economics and surgical techniques. Included were 1372 patients with injuries to 1585 fingers and follow-up of at least 12 months (median 37 IQR 27-56). Tendon ruptures occurred in 80 fingers and tenolysis was required in 76 fingers. Variables that affected the risk of rupture were age >25 years (p < 0.001), flexor pollicis longus tendon injuries (p < 0.001) and being male (p = 0.004). Injury to both finger flexors had an effect on both rupture (p = 0.005) and tenolysis (p < 0.001). Understanding the risk factors may provide important guidance both to surgeons and therapists when treating patients with flexor tendon injuries.Level of evidence: III.
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Affiliation(s)
- Jonas Svingen
- Karolinska Institutet, Department of Clinical
Science and Education, Södersjukhuset, Stockholm, Sweden,Department of Hand Surgery, Södersjukhuset,
Stockholm, Sweden,Jonas Svingen, Department of Hand Surgery,
Södersjukhuset, Sjukhusbacken 10, SE 188 83 Stockholm, Sweden.
| | - Monica Wiig
- Department of Surgical Science, Hand surgery,
Uppsala University, and Uppsala University Hospital, Sweden
| | - Christina Turesson
- Department of Hand Surgery, Plastic Surgery and
Burns, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping,
Sweden,Department of Health, Medicine and Caring
Sciences, Division of Prevention, Rehabilitation and Community Medicine, Linköping University,
Linköping, Sweden
| | - Simon Farnebo
- Department of Hand Surgery, Plastic Surgery and
Burns, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping,
Sweden
| | - Marianne Arner
- Karolinska Institutet, Department of Clinical
Science and Education, Södersjukhuset, Stockholm, Sweden,Department of Hand Surgery, Södersjukhuset,
Stockholm, Sweden
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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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Liu Y, Yang H, Wei S, Gong H, Lu Z. [Clinical application of Wide-awake technique in flexor tendon tenolysis]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:567-572. [PMID: 33998209 DOI: 10.7507/1002-1892.202012015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To discuss the method and effectiveness of Wide-awake technique in flexor tendon tenolysis. Methods The clinical data of 16 patients (22 fingers) with flexor tendon adhesion treated by Wide-awake technique for flexor tendon tenolysis between May 2019 and December 2019 were retrospectively analyzed. The patients were all male, aged from 18 to 55 years old, with an average of 35 years old. Among them, 4 cases (7 fingers) after replantation of severed fingers, 4 cases (7 fingers) after flexor tendon rupture repair, and 8 cases (8 fingers) after open reduction and internal fixation of proximal fractures. The time from the original operation to this operation was 6-18 months, with an average of 8 months. The visual analogue scale (VAS) score was used to evaluate the patient's pain during local anesthesia (when the first needle penetrated the skin), intraoperative, and 24 hours postoperatively; and the recovery of finger movement was evaluated by total finger joint active range of motion (TAM) evaluation system and Strickland (1980) standard after operation. Results Intraoperative hemostasis and anesthesia were satisfactory, and the patient could fully cooperate with the surgeon in active finger movements. There were different degrees of pain during local anesthesia (VAS score was 2-4), no pain during operation (VAS score was 0), and different degrees of pain after operation (VAS score was 1-8, 9 patients needed analgesics). All incisions healed by first intention after operation. All 16 cases were followed up 9-15 months with an average of 12 months. Finger function was significantly improved, no tendon rupture occurred. At last follow-up, the patients after proximal fracture open reduction and internal fixation were rated as excellent in 4 fingers and good in 4 fingers according to the TAM standard, and both were excellent according to the Strickland (1980) standard; and the patients after replantation of severed fingers and flexor tendon rupture repair were rated as excellent in 4 fingers and good in 10 fingers according to TAM standard, and as excellent in 6 fingers and good in 8 fingers according to Strickland (1980) standard. Conclusion Wide-awake technique applied in flexor tendon tenolysis can accurately judge the tendon adhesion and release degree through the patient's active activity, achieve the purpose of complete release, and the effectiveness is satisfactory; the effectiveness of tendon adhesion release surgery after fracture internal fixation is better than that of patients after tendon rupture suture and replantation.
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Affiliation(s)
- Yuzhou Liu
- Department of Hand Surgery, Wuxi No.9 Hospital (Wuxi Orthopedic Hospital), Wuxi Jiangsu, 214062, P.R.China
| | - Haoyu Yang
- Department of Hand Surgery, Wuxi No.9 Hospital (Wuxi Orthopedic Hospital), Wuxi Jiangsu, 214062, P.R.China
| | - Suming Wei
- Department of Hand Surgery, Wuxi No.9 Hospital (Wuxi Orthopedic Hospital), Wuxi Jiangsu, 214062, P.R.China
| | - Hao Gong
- Department of Hand Surgery, Wuxi No.9 Hospital (Wuxi Orthopedic Hospital), Wuxi Jiangsu, 214062, P.R.China
| | - Zhengfeng Lu
- Department of Hand Surgery, Wuxi No.9 Hospital (Wuxi Orthopedic Hospital), Wuxi Jiangsu, 214062, P.R.China
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