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Oeckenpöhler S, Langer MF, Aitzetmüller-Klietz MM, Aitzetmüller-Klietz ML, Nottberg V, Riesenbeck O. Three-Loop Technique for Pulley Reconstruction-A Retrospective Cohort Analysis of 23 Patients. J Clin Med 2023; 12:5154. [PMID: 37568556 PMCID: PMC10419726 DOI: 10.3390/jcm12155154] [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: 06/29/2023] [Revised: 07/19/2023] [Accepted: 08/03/2023] [Indexed: 08/13/2023] Open
Abstract
Twenty-three patients with a mean age of 52.7 years underwent pulley reconstruction using the Okutsu double- or triple-loop technique after iatrogenic or traumatic rupture of at least two adjacent flexor tendon pulleys in the finger and distal palm; mean age of injury was 4.77 years. The mean follow-up was 4.66 years after reconstruction of mostly A2 pulleys in a single surgeon setting. Outcome measures included ROM, NRS pain, satisfaction, Disabilities of Arm, Shoulder and Hand Questionnaire (DASH) and Krimmer score, Buck-Gramcko score, Jamar grip strength, pinch grip, and vigorimetry compared to the uninjured side. The median patient satisfaction score was 6.6/10. Hand function using the DASH score was 9.5. Grip strength on the Jamar Dynamometer showed only a slight reduction of 13% compared to the uninjured side. The resultant force of the operated fingers on the vigorimeter is almost 60% of that of the contralateral side, and the finger-palm distance of the operated finger was reduced from 2.2 cm to 1.45 cm. Other functional scores, such as Krimmer (82.2) and Buck-Gramcko (10.9), support these good results. The follow-up of patients more than 4.5 years after reconstruction of the A2 and A3 flexor tendon pulley using the double- or triple-loop technique showed acceptable patient satisfaction and good function of the finger in everyday life.
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Affiliation(s)
- Simon Oeckenpöhler
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Waldeyer Str. 1, 48149 Münster, Germany; (S.O.)
| | - Martin Franz Langer
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Waldeyer Str. 1, 48149 Münster, Germany; (S.O.)
| | - Matthias Michael Aitzetmüller-Klietz
- Section for Plastic and Reconstructive Surgery, Department of Traumatology, University Hospital Münster, Waldeyer Str. 1, 48149 Münster, Germany; (M.M.A.-K.); (M.-L.A.-K.)
| | - Marie-Luise Aitzetmüller-Klietz
- Section for Plastic and Reconstructive Surgery, Department of Traumatology, University Hospital Münster, Waldeyer Str. 1, 48149 Münster, Germany; (M.M.A.-K.); (M.-L.A.-K.)
| | - Valerie Nottberg
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg, Martinistrasse 52, 20246 Hamburg, Germany
| | - Oliver Riesenbeck
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Waldeyer Str. 1, 48149 Münster, Germany; (S.O.)
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MRI of Finger Pulleys at 7T-Direct Characterization of Pulley Ruptures in an Ex Vivo Model. Diagnostics (Basel) 2021; 11:diagnostics11071206. [PMID: 34359289 PMCID: PMC8303165 DOI: 10.3390/diagnostics11071206] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 06/29/2021] [Accepted: 06/30/2021] [Indexed: 11/18/2022] Open
Abstract
The aim of this study was to evaluate 7 Tesla (7T) magnetic resonance imaging (MRI) for direct visualization and specific characterization of the finger flexor pulleys A2, A3, and A4 before and after ex vivo pulley rupture. Thirty fingers of human cadavers were examined before and after pulley disruption with a 26 min clinical 7T pulse sequence protocol. Images were assessed by two experienced radiologists for the presence of pulley rupture. Injury characterization included definition of rupture location, morphology, and complications. Image quality was evaluated according to a 4-point Likert-type scale from “not evaluable” to “excellent”. Macroscopic preparations were used as the reference standard. Direct characterization of intact A2, A3, and A4 pulleys and the corresponding pulley lesions was possible in all cases. The rupture location was distributed equally at the radial, ulnar, and central parts of the pulleys. A dislocation and intercalation of the pulley stump between the flexor tendon and finger phalanges was observed as a complication in 62.5% of cases. The average Likert score for direct visualization of pulleys was 2.67 before rupture and 2.79 after rupture creation, demonstrating adequate image quality for routine application. 7T MRI enables a direct characterization of A2, A3, and A4 pulleys before and after artificial disruption, including the definition of rupture morphology and location as well as the detection of rupture complications. This promises a precise presurgical evaluation of pulley injuries and complicated pulley stump dislocations.
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Primarily conservative treatment for triple (A2-A3-A4) finger flexor tendon pulley disruption. HAND SURGERY & REHABILITATION 2021; 40:314-318. [DOI: 10.1016/j.hansur.2020.12.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 12/08/2020] [Accepted: 12/12/2020] [Indexed: 01/03/2023]
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Abstract
Closed pulley ruptures are rare in the general population but occur more frequently in rock climbers due to biomechanical demands on the hand. Injuries present with pain and swelling over the affected pulley, and patients may feel or hear a pop at the time of injury. Sequential pulley ruptures are required for clinical bowstringing of the flexor tendons. Ultrasound confirms diagnosis of pulley rupture and evaluates degree of displacement of the flexor tendons. Isolated pulley ruptures frequently are treated conservatively with early functional rehabilitation. Sequential pulley ruptures require surgical reconstruction. Most climbers are able to return to their previous activity level.
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Affiliation(s)
- Elizabeth A King
- Department of Orthopaedic Surgery, University of Cincinnati, TriHealth Hospital System, 538 Oak Street, Suite 200, Cincinnati, OH 45219, USA
| | - John R Lien
- Section of Plastic Surgery, Department of Orthopaedic Surgery, University of Michigan, 2098 South Main Street, Ann Arbor, MI 48103, USA.
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Schneeberger M, Schweizer A. Pulley Ruptures in Rock Climbers: Outcome of Conservative Treatment With the Pulley-Protection Splint—A Series of 47 Cases. Wilderness Environ Med 2016; 27:211-8. [DOI: 10.1016/j.wem.2015.12.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 12/22/2015] [Accepted: 12/30/2015] [Indexed: 01/20/2023]
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Desaldeleer AS, Le Nen D. Bilateral fracture of the base of the middle phalanx in a climber: Literature review and a case report. Orthop Traumatol Surg Res 2016; 102:409-11. [PMID: 26993857 DOI: 10.1016/j.otsr.2016.01.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 12/15/2015] [Accepted: 01/07/2016] [Indexed: 02/02/2023]
Abstract
During climbing, tears of the annular pulley are the most common injuries, while fractures of the dorsal base of the middle phalanx are rare and atypical. Only a few cases have been reported in international literature. The authors present a case of a Salter-Harris type III fracture of the base of the middle phalanx of the middle finger in a young climber and a review of the literature. The patient was a 17-year-old boy who regularly and intensively practiced climbing. He consulted for a non-traumatic history of proximal pain of the interphalangeal joints of the middle fingers. On clinical examination, there was pain on the dorsal surface of the proximal interphalangeal joints, with no decrease in range of motion of the fingers. X-rays showed a Salter-Harris type III, displaced epiphyseal fracture of the dorsal base of the middle phalanx of the middle fingers. Conservative treatment resulted in fracture union and the patient had recovered normal activity of his hand at the 6-month follow-up. Stress fractures are common in athletes like climbers in response to repetitive and prolonged sports. Epiphyseal fractures are the most common injuries in young climbers.
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Affiliation(s)
- A-S Desaldeleer
- Hôpital de la Cavale-Blanche, CHRU de Brest, boulevard Tanguy-Prigent, 29200 Brest, France.
| | - D Le Nen
- Hôpital de la Cavale-Blanche, CHRU de Brest, boulevard Tanguy-Prigent, 29200 Brest, France
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Lapegue F, Andre A, Brun C, Bakouche S, Chiavassa H, Sans N, Faruch M. Traumatic flexor tendon injuries. Diagn Interv Imaging 2015; 96:1279-92. [DOI: 10.1016/j.diii.2015.09.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 09/29/2015] [Indexed: 10/22/2022]
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Dy CJ, Lyman S, Schreiber JJ, Do HT, Daluiski A. The epidemiology of reoperation after flexor pulley reconstruction. J Hand Surg Am 2013; 38:1705-11. [PMID: 23845587 PMCID: PMC3932671 DOI: 10.1016/j.jhsa.2013.05.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Revised: 05/12/2013] [Accepted: 05/13/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE We used a statewide database to determine the incidence of pulley reconstruction and to evaluate the influence of demographics on reoperation. We hypothesized that age, insurance status, and concomitant nerve or tendon procedure would influence the likelihood of reoperation. METHODS We used the Statewide Planning and Research Cooperative System ambulatory surgery database from New York, which represents all outpatient surgery in the state. Patients who had flexor pulley reconstruction from 1998 to 2009 were identified using Current Procedural Terminology 4 codes. Subsequent surgery records for these patients were identified through 2010, allowing at least 1 year follow-up. Concomitant nerve procedure and flexor tendon repair/reconstruction were identified. The type and timing of subsequent procedures, including tenolysis and repeat pulley reconstruction, were recorded. Univariate statistics were calculated to compare age, sex, and payer type between patients with and without reoperation. A multivariable, logistic regression model was used to evaluate the association of the demographics with the chances of having reoperation. RESULTS There were 623 patients who had flexor pulley reconstruction from 1998 to 2009. The incidence of pulley reconstruction was 0.27 per 100,000 persons, with an annual frequency of 52 procedures. There were 39 (6%) reoperations. There was no difference in age, concomitant nerve or tendon repair, or workers' compensation between patients with and without reoperation. Regression modeling showed a higher likelihood among men of having reoperation. CONCLUSIONS Flexor pulley reconstructions are rare. One-quarter of surgeons performed only one flexor pulley reconstruction over a 12-year period. The 6% reoperation rate is similar to our previous findings for flexor tendon repair using similar methodology. Our report provides information that may be useful in counseling patients.
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Schöffl V, Küpper T, Hartmann J, Schöffl I. Surgical repair of multiple pulley injuries--evaluation of a new combined pulley repair. J Hand Surg Am 2012; 37:224-30. [PMID: 22209212 DOI: 10.1016/j.jhsa.2011.10.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Revised: 10/07/2011] [Accepted: 10/11/2011] [Indexed: 02/07/2023]
Abstract
PURPOSE We report on a combined repair of multiple annular pulley tears using 1 continuous palmaris longus tendon graft to restore strength and function. METHODS We treated 6 rock climbers with grade 4 pulley injuries (multiple pulley injuries) using the combined repair technique and re-evaluated them after a mean of 28 months. RESULTS All patients had excellent Buck-Gramcko scores; the functional outcome was good in 4, satisfactory in 1, and fair in 1. The sport-specific outcome was excellent in 5 and satisfactory in 1. Proximal interphalangeal joint flexion deficit slightly increased in 1 patient and remained the same in the other 5. Climbing level after the injury was the same as before in 4 and decreased slightly in 2 climbers. CONCLUSIONS The technique is effective with good results and has since become our standard treatment. Nevertheless, it is limited in patients with flexion contracture of the proximal interphalangeal joint. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.
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Affiliation(s)
- V Schöffl
- Department of Orthopedic and Trauma Surgery, Klinikum Bamberg, Friedrich Alexander University Erlangen-Nuremberg, Germany.
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Crowley TP. The flexor tendon pulley system and rock climbing. J Hand Microsurg 2012; 4:25-9. [PMID: 23730085 DOI: 10.1007/s12593-012-0061-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Accepted: 01/03/2012] [Indexed: 01/24/2023] Open
Abstract
Rock climbing has increased in popularity over the past two decades. Closed traumatic rupture of the finger flexor tendon pulleys is rare among the general population but is seen much more commonly in rock climbers. This article reviews the anatomy and biomechanics of the finger flexor tendon pulleys, how they may be injured in rock climbing and how these injuries are best diagnosed and managed.
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Affiliation(s)
- Timothy P Crowley
- Department of Plastic Surgery, Royal Victoria Infirmary, Newcastle-upon-Tyne, NE1 4LP UK
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Donath L, Roesner K, Schöffl V, Gabriel HHW. Work-relief ratios and imbalances of load application in sport climbing: Another link to overuse-induced injuries? Scand J Med Sci Sports 2011; 23:406-14. [PMID: 22092928 DOI: 10.1111/j.1600-0838.2011.01399.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2011] [Indexed: 11/30/2022]
Affiliation(s)
| | - K. Roesner
- Department of Sports Medicine; Friedrich Schiller University Jena; Jena; Germany
| | | | - H. H. W. Gabriel
- Department of Sports Medicine; Friedrich Schiller University Jena; Jena; Germany
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Flap irritation phenomenon (FLIP): etiology of chronic tenosynovitis after finger pulley rupture. J Appl Biomech 2011; 27:291-6. [PMID: 21896956 DOI: 10.1123/jab.27.4.291] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
After a pulley rupture, most climbers regain the full function of their previously uninjured fingers. However, in some cases of pulley rupture, a persistent inflammation of the tendon sheath is observed. In this study, 16 cadaver fingers were loaded until pulley rupture and then studied for the rupturing mechanism. In addition, two patients with this pathology were investigated using ultrasound and MRI, and received surgery. In 13 fingers, a rupture of one or several pulleys occurred and almost always at the medial or lateral insertion. In one finger, a capsizing of the pulley underneath the intact tendon sheath was observed, leading to an avulsion between tendon and tendon sheath. A similar pathology was observed in the ultrasound imaging, in MRI, and during surgery in two patients with prolonged recovery after minor pulley rupture. In cases of prolonged tenosynovitis after minor pulley rupture, a capsizing of the pulley stump is probably the cause for constant friction leading to inflammation. In those cases, a surgical removal of the remaining pulley stump and sometimes a pulley repair may be necessary.
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Schöffl VR, Einwag F, Strecker W, Schöffl I. Strength measurement and clinical outcome after pulley ruptures in climbers. Med Sci Sports Exerc 2006; 38:637-43. [PMID: 16679977 DOI: 10.1249/01.mss.0000210199.87328.6a] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE Ruptures of the finger flexor pulleys are the most frequent injuries in rock climbers. Whereas multiple pulley injuries demand a surgical reconstruction, single ruptures are mainly treated conservatively. Nevertheless, the question of the clinical outcome or a persisting finger strength deficit after conservative therapy arises. METHODS Twenty-one rock climbers (age 34 +/- 9 yr) with a grade 2-4 pulley injury were reevaluated 3.46 (range: 0.25-18) yr after injury. The clinical evaluation followed a standard questionnaire in combination with an ultrasound examination in extension and forced flexion. In order to determine the finger strengths, the subjects hung with the respective finger in various postures on a ledge attached above a door frame, while standing on a force platform, which measured the relative release. RESULTS The 21 subjects had old (3.46 yr, range: 0.25-18) pulley injuries in 27 fingers (10 A2, 1 A3, 11 A4, 3 A2/3, 2 A3/4). The clinical outcome was excellent (Buck-Gramcko score of 3) in all cases; the subjects regained their climbing level within a year. There was no difference between the initial ultrasound examination and the follow-up during the study. For 17 finger pairs, data for the relative strength of the injured and the respective healthy finger could be gathered. The finger strength was not significantly different for the injured and the healthy finger in either the hanging or the crimping finger position. CONCLUSIONS Nonsurgical treatment of single pulley ruptures is recommended. The clinical outcome was good to excellent, and no long-term strength deficit for the injured finger could be observed.
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Schöffl VR, Schöffl I. Injuries to the finger flexor pulley system in rock climbers: current concepts. J Hand Surg Am 2006; 31:647-54. [PMID: 16632061 DOI: 10.1016/j.jhsa.2006.02.011] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2003] [Accepted: 01/06/2004] [Indexed: 02/02/2023]
Abstract
Closed traumatic ruptures of finger flexor tendon pulleys began to be recognized specifically over the past several decades. This injury, although rare in the general population, is seen more commonly in rock climbers. This article analyzes this type of injury and the current diagnostic and therapeutic criteria. Ultrasound and magnetic resonance imaging are used to differentiate between a pulley strain, partial rupture, complete rupture, or multiple ruptures. Grade I to III injuries (strains, partial rupture, single ruptures) are treated conservatively with initial immobilization and early functional therapy under pulley protection. Grade IV injuries (multiple ruptures) require surgical repair.
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