Mini-open one-stage flexor digitorum profundus tendon graft for jersey finger under WALANT with ultrasound assistance: a case report of a new technique

Treatment of the late presentation of a jersey finger is a therapeutic challenge. We describe a novel technique of one-stage mini-open reconstruction of avulsed flexor digitorum profundus (FDP) using a palmaris longus tendon graft under WALANT with ultrasound assistance. The graft was passed inside the digital sheath using a compressive tendon guide under ultrasound control, to avoid a large surgical approach. WALANT enabled intraoperative setting of tendon graft tension, with restored tendon gliding in the sheath. Ultrasound-guided active rehabilitation was initiated immediately postoperatively in the surgeon's office.

A novel technique for harvesting tendon grafts: Cheap, simple, and reliable

Tendon grafts often need to be harvested for tendon repair in complex hand surgeries. A tendon stripper is an instrument designed for tendon harvesting. In this study, a metal aspiration cannula was used like a stripper, in a simple and reliable way. With this technique, palmaris longus, plantaris and partial flexor carpi ulnaris tendon grafts were harvested from 11 patients. No problems were encountered in terms of graft quality, donor site or damage to adjacent anatomic structures. The quality of the harvested tendons was quite good, without any damage to the paratenon. Scars at the donor sites ranged between 1-2cm, and they all recovered quite well aesthetically. While tendon repair does not require very specific surgical tools, a tendon stripper and endoscopy tools with are needed for harvesting tendon grafts. This is problematic in small, poorly equipped hospitals, where tendon surgery is performed with simple tools. This study demonstrates that tendon grafts can be harvested with a metal aspiration cannula, thus making it easier to perform tendon repair without specific surgical tools.

Biomechanical study comparing Pulvertaft suture to step-cut suture

Tendon grafts are a component of the therapeutic arsenal for managing chronic flexor tendons injuries in the hand, especially during two-stage Hunter reconstruction. The purpose of this anatomical study was to compare the strength of the Pulvertaft weave versus the step-cut suture used for flexor tendon reconstruction to determine their role in early active mobilization. We performed a biomechanical study with cadaver specimens. Thirty-four hands were randomized and the tendons from both hands were equally assigned to each group. A comparison of the Pulvertaft weave (group 1) versus the step-cut suture (group 2) using the flexor digitorum profundus from the fourth finger and the longus palmaris was carried out. The main variable was the failure load in both repair groups. We also evaluated the cross-sectional area (CSA) and the tensile strength of the repairs. Thirty hands were included in our study. There was no significant difference in the failure load between the two groups (116N for group 1 versus 103N for group 2, P=0.2). The CSA was significantly smaller in the step-cut group compared to Pulvertaft group (19.8mm² versus 35mm², P<0.01). The tensile strength was significantly higher in the step-cut group than in the Pulvertaft group (5.3N/mm² versus 3.4N/mm², P<0.01). Early active mobilization requires a minimum repair strength of 75N. In our study, the step-cut suture appears strong enough and thin enough to decrease the fibrosis, which would lead to better functional results. No other study of this type has been published. The specimens in which the repair strength was less than 75N all involved a thin, weak longus palmaris. Other biomechanical studies should be done to define the anatomical criteria required for use of the palmaris longus tendon. The step-cut suture seems to be strong enough and thin enough to provide sufficient proximal attachment during flexor tendon reconstruction to allow early active mobilization.

Multiple extensor tendons reconstruction with hamstring tendon grafts and flap coverage for severe dorsal hand injuries

Treatment of patients with traumatic loss of skin and multiple extensor tendons on the dorsum of the hand is a challenge. The aim of this study was to assess the outcome after reconstruction of soft tissues and multiple extensor tendons in patients who suffered traumatic loss of skin and multiple extensor tendons. Ten patients were enrolled in the study. These patients underwent single-stage reconstruction with autogenous hamstring tendon grafts for multiple extensor tendon defects and fasciocutaneous flaps for coverage of dorsal hand defects. In total, 25 tendons (2 tendons in 5 patients and 3 tendons in 5 patients) were reconstructed. The semitendinosus tendon was used in all patients and the gracilis tendon was added in five patients for tendon reconstruction. Total tendon length requiring reconstruction was between 9cm and 31cm. Free anterolateral thigh flaps were used in six patients and reverse pedicled forearm flaps were used in four patients. According to Miller's scoring system, 8 fingers had excellent results, 12 fingers had good results and 5 fingers had fair results at the final follow-up. Hamstring tendons can be used satisfactorily for primary reconstruction of multiple digital extensor tendons due to their availability and compatibility, with a fasciocutaneous flap.

LEVEL OF EVIDENCE

IV.

Free tendon grafts in elder patients, a case report of repair of flexor pollicis longus tendon with a free palmaris longus graft in an 89-year-old woman

Flexor tendon rupture is a potential complication after volar plating of distal radius fracture. Palliative procedures such as tenodesis and arthrodesis are usually employed in elder patients with imperfect results. We report a case of delayed flexor pollicis longus rupture seven years after volar plating of a distal radius fracture occurring in an 89-year-old woman. The repair with a free tendon graft of palmaris longus was successful in terms of strength and range of motion. Free tendon grafts should not be limited to younger patients and could be used in elder patients after careful selection.