1
|
Sensitivity analysis guided improvement of an electromyogram-driven lumped parameter musculoskeletal hand model. J Biomech 2022; 141:111200. [PMID: 35764012 DOI: 10.1016/j.jbiomech.2022.111200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 05/16/2022] [Accepted: 06/11/2022] [Indexed: 11/23/2022]
Abstract
EMG-driven neuromusculoskeletal models have been used to study many impairments and hold great potential to facilitate human-machine interactions for rehabilitation. A challenge to successful clinical application is the need to optimize the model parameters to produce accurate kinematic predictions. In order to identify the key parameters, we used Monte-Carlo simulations to evaluate the sensitivities of wrist and metacarpophalangeal (MCP) flexion/extension prediction accuracies for an EMG-driven, lumped-parameter musculoskeletal model. Four muscles were modeled with 22 total optimizable parameters. Model predictions from EMG were compared with measured joint angles from 11 able-bodied subjects. While sensitivities varied by muscle, we determined muscle moment arms, maximum isometric force, and tendon slack length were highly influential, while passive stiffness and optimal fiber length were less influential. Removing the two least influential parameters from each muscle reduced the optimization search space from 22 to 14 parameters without significantly impacting prediction correlation (wrist: 0.90 ± 0.05 vs 0.90 ± 0.05, p = 0.96; MCP: 0.74 ± 0.20 vs 0.70 ± 0.23, p = 0.51) and normalized root mean square error (wrist: 0.18 ± 0.03 vs 0.19 ± 0.03, p = 0.16; MCP: 0.18 ± 0.06 vs 0.19 ± 0.06, p = 0.60). Additionally, we showed that wrist kinematic predictions were insensitive to parameters of the modeled MCP muscles. This allowed us to develop a novel optimization strategy that more reliably identified the optimal set of parameters for each subject (27.3 ± 19.5%) compared to the baseline optimization strategy (6.4 ± 8.1%; p = 0.004). This study demonstrated how sensitivity analyses can be used to guide model refinement and inform novel and improved optimization strategies, facilitating implementation of musculoskeletal models for clinical applications.
Collapse
|
2
|
Abstract
Flexor tendon injuries are common and occur mostly by penetrating trauma. Suspected flexor tendon injuries require a thorough clinical assessment and often are not isolated injuries. A detailed understanding of flexor tendon anatomy and spatial relationships is essential, especially when repairing multi-tendon injuries. Principles of flexor tendon repair include a strong suture construct, minimising gap formation between tendon ends, preserving tendon blood supply and providing a smooth repair interface. Moreover, adequate exposure of the zone of injury using full-thickness skin flaps and preservation of neurovascular and pulley structures is essential. In this article an overview of contemporary management strategies is presented. Today's hand surgeons and therapists can choose from a variety of treatment options when managing these important and potentially life-changing injuries.
Collapse
Affiliation(s)
- Oliver Pearce
- Trauma Registrar, Trauma & Orthopaedic Department, Southmead Hospital, Southmead Road, Bristol BS10 5NB, UK
| | - Matthew T Brown
- Fellow in Hand & Wrist Surgery, Lothian Hand Unit, St John's Hospital, Livingston, West Lothian EH54 6PP, UK
| | - Katrina Fraser
- Clinical Specialist Occupational Therapist (Hand Therapy), Lothian Hand Unit, St John's Hospital, Livingston, West Lothian EH54 6PP, UK
| | - Luca Lancerotto
- Consultant Hand & Plastic Surgeon, Lothian Hand Unit, St John's Hospital, Livingston, West Lothian EH54 6PP, UK
| |
Collapse
|
3
|
Sustainable Human–Robot Collaboration Based on Human Intention Classification. SUSTAINABILITY 2021. [DOI: 10.3390/su13115990] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Sustainable manufacturing plays a role in ensuring products’ economic characteristics and reducing energy and resource consumption by improving the well-being of human workers and communities and maintaining safety. Using robots is one way for manufacturers to increase their sustainable manufacturing practices. Nevertheless, there are limitations to directly replacing humans with robots due to work characteristics and practical conditions. Collaboration between robots and humans should accommodate human capabilities while reducing loads and ineffective human motions to prevent human fatigue and maximize overall performance. Moreover, there is a need to establish early and fast communication between humans and machines in human–robot collaboration to know the status of the human in the activity and make immediate adjustments for maximum performance. This study used a deep learning algorithm to classify muscular signals of human motions with accuracy of 88%. It indicates that the signal could be used as information for the robot to determine the human motion’s intention during the initial stage of the entire motion. This approach can increase not only the communication and efficiency of human–robot collaboration but also reduce human fatigue by the early detection of human motion patterns. To enhance human well-being, it is suggested that a human–robot collaboration assembly line adopt similar technologies for a sustainable human–robot collaboration workplace.
Collapse
|
4
|
Neiduski RL, Powell RK. Flexor tendon rehabilitation in the 21st century: A systematic review. J Hand Ther 2020; 32:165-174. [PMID: 30545730 DOI: 10.1016/j.jht.2018.06.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 05/31/2018] [Accepted: 06/01/2018] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Systematic review. INTRODUCTION The rehabilitation of patients following flexor tendon injury has progressed from immobilization to true active flexion with the addition of wrist motion over the last 75 years. PURPOSE OF THE STUDY This review specifically intended to determine whether there is evidence to support one type of exercise regimen, early passive, place and hold, or true active, as superior for producing safe and maximal range of motion following flexor tendon repair. METHODS The preferred reporting items for systematic review and meta-analysis (PRISMA-P 2015) checklist was utilized to format the review. Both reviewers collaborated on all aspects of the research, including identifying inclusion/exclusion factors, search terms, reading and scoring articles, and authoring the paper. Articles were independently scored by each reviewer using the Structured Effectiveness Quality Evaluation Scale (SEQES). RESULTS A total of nine intervention studies that included a rehabilitative comparison group were systematically reviewed: one pediatric, four comparing passive flexion protocols to place and hold flexion, and four comparing true active flexion to passive and/or place and hold flexion. DISCUSSION This review provides moderate to strong evidence that place and hold exercises provide better outcomes than passive flexion protocols for patients with two to six-strand repairs. The studies included in this review suffered from methodological limitations including short timeframes for follow-up, unequal group distribution, and limited attention to repair site strength. CONCLUSIONS Based on a lack of superior benefits following true active motion regimens, there is not sufficient evidence to support true active motion as an effective or preferable choice for flexor tendon rehabilitation at this time.
Collapse
Affiliation(s)
| | - Rhonda K Powell
- Milliken Hand Rehabilitation Center, Washington University, St. Louis, MO, USA
| |
Collapse
|
5
|
Waitayawinyu T, Numnate W, Boonyasirikool C, Niempoog S. Outcomes of Endoscopic Carpal Tunnel Release With Ring Finger Flexor Digitorum Superficialis Opponensplasty in Severe Carpal Tunnel Syndrome. J Hand Surg Am 2019; 44:1095.e1-1095.e7. [PMID: 31072662 DOI: 10.1016/j.jhsa.2019.02.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 01/01/2019] [Accepted: 02/11/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the outcomes of endoscopic CTR with ring finger flexor digitorum superficialis (FDS) opponensplasty for the treatment of patients with severe carpal tunnel syndrome (CTS). METHODS We prospectively studied 52 patients who were graded as having severe CTS by physical examination and electrodiagnostic studies and who underwent endoscopic CTR-ring finger FDS opponensplasty. Preoperative and postoperative data were collected for active perpendicular thumb abduction; Kapandji score for thumb opposition; grip, key, and tip pinch strength; Medical Research Council score on sensory and motor recovery; Semmes-Weinstein monofilament testing; thenar muscle bulk recovery; and work status. RESULTS Follow-up was 17.5 months on average (range, 7-34 months). Thumb abduction improved significantly from 13.2° (±4.6°) before surgery to 61.7° (±6.4°) afterward. Mean thumb opposition (as measured by Kapandji score) improved significantly from grade 1.5 to 8.7. Tip pinch strength significantly improved from 38.9% to 72.9% of the contralateral side. Medical Research Council scores improved to S3+ and S4 in 85% of patients and to M4 and M5 in 96% of patients. Sensory threshold recovery to 3.61 and 4.31 monofilament occurred in 85% of patients. We observed thenar muscle bulk recovery in 51.9% of patients. Time to return to work was 5 weeks after surgery, on average. Two patients reported scar pain, 2 reported pillar pain, and we found ring finger proximal interphalangeal joint contracture in 3. CONCLUSIONS Endoscopic CTR with FDS opponensplasty provides satisfactory outcomes of improved thumb abduction and opposition, sensory and motor recovery, and early return to work in patients with severe CTS. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
Collapse
Affiliation(s)
- Thanapong Waitayawinyu
- Department of Orthopaedics, Faculty of Medicine, Thammasat University, Pathumthani, Thailand.
| | - Wuthidetch Numnate
- Department of Orthopaedics, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | | | - Sunyarn Niempoog
- Department of Orthopaedics, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| |
Collapse
|
6
|
Athlani L, Detammaecker R, Touillet A, Dautel G, Foisneau A. Effect of different positions of splinting on flexor tendon relaxation: a cadaver study. J Hand Surg Eur Vol 2019; 44:833-837. [PMID: 31370772 DOI: 10.1177/1753193419865123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We performed a cadaver study to evaluate how six different static heat-moulded splints affect flexor tendon relaxation. Each splint positioned the wrist and metacarpophalangeal (MCP) joints in different positions. We evaluated the tendon relaxation in 12 fresh adult cadaver forearms by measuring the flexor tendon displacement between two solid markers for each splint. The wrist position ranged from 30° flexion to 45° extension and the MCP joints from 30° to 60° flexion. For each splint, tendon relaxation was achieved relative to the neutral reference position. Tendon relaxation was greatest when the MCP joints were positioned in 60° flexion. We also noted the persistence of tendon relaxation when the wrist was positioned in extension (30° or 45°) as long as MCP joint flexion was maintained (30° or 60°). We conclude that the wrist extension with the MCP joints flexion may optimize tendon relaxation during immobilization after flexor tendon repairs.
Collapse
Affiliation(s)
- Lionel Athlani
- Department of Hand Surgery, Plastic and Reconstructive Surgery, Centre Chirurgical Emile Gallé, CHU de Nancy, Nancy, France
| | - Romain Detammaecker
- Department of Hand Surgery, Plastic and Reconstructive Surgery, Centre Chirurgical Emile Gallé, CHU de Nancy, Nancy, France
| | - Amélie Touillet
- Centre Louis Pierquin, Institut Régional de Médecine Physique et de Réadaptation, UGECAM Nord-Est, Nancy, France
| | - Gilles Dautel
- Department of Hand Surgery, Plastic and Reconstructive Surgery, Centre Chirurgical Emile Gallé, CHU de Nancy, Nancy, France
| | - Anne Foisneau
- Centre Louis Pierquin, Institut Régional de Médecine Physique et de Réadaptation, UGECAM Nord-Est, Nancy, France
| |
Collapse
|
7
|
Linderman SW, Shen H, Yoneda S, Jayaram R, Tanes ML, Sakiyama-Elbert SE, Xia Y, Thomopoulos S, Gelberman RH. Effect of connective tissue growth factor delivered via porous sutures on the proliferative stage of intrasynovial tendon repair. J Orthop Res 2018; 36:2052-2063. [PMID: 29266404 PMCID: PMC6013340 DOI: 10.1002/jor.23842] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 11/27/2017] [Indexed: 02/04/2023]
Abstract
Recent growth factor, cell, and scaffold-based experimental interventions for intrasynovial flexor tendon repair have demonstrated therapeutic potential in rodent models. However, these approaches have not achieved consistent functional improvements in large animal trials due to deleterious inflammatory reactions to delivery materials and insufficient induction of targeted biological healing responses. In this study, we achieved porous suture-based sustained delivery of connective tissue growth factor (CTGF) into flexor tendons in a clinically relevant canine model. Repairs with CTGF-laden sutures were mechanically competent and did not show any evidence of adhesions or other negative inflammatory reactions based on histology, gene expression, or proteomics analyses at 14 days following repair. CTGF-laden sutures induced local cellular infiltration and a significant biological response immediately adjacent to the suture, including histological signs of angiogenesis and collagen deposition. There were no evident widespread biological effects throughout the tendon substance. There were significant differences in gene expression of the macrophage marker CD163 and anti-apoptotic factor BCL2L1; however, these differences were not corroborated by proteomics analysis. In summary, this study provided encouraging evidence of sustained delivery of biologically active CTGF from porous sutures without signs of a negative inflammatory reaction. With the development of a safe and effective method for generating a positive local biological response, future studies can explore additional methods for enhancing intrasynovial tendon repair. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2052-2063, 2018.
Collapse
Affiliation(s)
- Stephen W. Linderman
- Department of Orthopaedic Surgery, Washington University, 660 S. Euclid Avenue, Campus Box 8233, St. Louis 63110 Missouri,Department of Biomedical Engineering, Washington University, St. Louis, Missouri
| | - Hua Shen
- Department of Orthopaedic Surgery, Washington University, 660 S. Euclid Avenue, Campus Box 8233, St. Louis 63110 Missouri
| | - Susumu Yoneda
- Department of Orthopaedic Surgery, Washington University, 660 S. Euclid Avenue, Campus Box 8233, St. Louis 63110 Missouri
| | - Rohith Jayaram
- Department of Orthopaedic Surgery, Washington University, 660 S. Euclid Avenue, Campus Box 8233, St. Louis 63110 Missouri
| | - Michael L. Tanes
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | | | - Younan Xia
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - Stavros Thomopoulos
- Department of Orthopedic Surgery, Department of Biomedical Engineering, Columbia University, 650 W 168 ST, Black Building 1408, New York 10025 New York
| | - Richard H. Gelberman
- Department of Orthopaedic Surgery, Washington University, 660 S. Euclid Avenue, Campus Box 8233, St. Louis 63110 Missouri
| |
Collapse
|
8
|
Linderman SW, Golman M, Gardner TR, Birman V, Levine WN, Genin GM, Thomopoulos S. Enhanced tendon-to-bone repair through adhesive films. Acta Biomater 2018; 70:165-176. [PMID: 29427745 DOI: 10.1016/j.actbio.2018.01.032] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 01/04/2018] [Accepted: 01/23/2018] [Indexed: 12/16/2022]
Abstract
Tendon-to-bone surgical repairs have unacceptably high failure rates, possibly due to their inability to recreate the load transfer mechanisms of the native enthesis. Instead of distributing load across a wide attachment footprint area, surgical repairs concentrate shear stress on a small number of suture anchor points. This motivates development of technologies that distribute shear stresses away from suture anchors and across the enthesis footprint. Here, we present predictions and proof-of-concept experiments showing that mechanically-optimized adhesive films can mimic the natural load transfer mechanisms of the healthy attachment and increase the load tolerance of a repair. Mechanical optimization, based upon a shear lag model corroborated by a finite element analysis, revealed that adhesives with relatively high strength and low stiffness can, theoretically, strengthen tendon-to-bone repairs by over 10-fold. Lap shear testing using tendon and bone planks validated the mechanical models for a range of adhesive stiffnesses and strengths. Ex vivo human supraspinatus repairs of cadaveric tissues using multipartite adhesives showed substantial increase in strength. Results suggest that adhesive-enhanced repair can improve repair strength, and motivate a search for optimal adhesives. STATEMENT OF SIGNIFICANCE Current surgical techniques for tendon-to-bone repair have unacceptably high failure rates, indicating that the initial repair strength is insufficient to prevent gapping or rupture. In the rotator cuff, repair techniques apply compression over the repair interface to achieve contact healing between tendon and bone, but transfer almost all force in shear across only a few points where sutures puncture the tendon. Therefore, we evaluated the ability of an adhesive film, implanted between tendon and bone, to enhance repair strength and minimize the likelihood of rupture. Mechanical models demonstrated that optimally designed adhesives would improve repair strength by over 10-fold. Experiments using idealized and clinically-relevant repairs validated these models. This work demonstrates an opportunity to dramatically improve tendon-to-bone repair strength using adhesive films with appropriate material properties.
Collapse
|
9
|
Galvez MG, Comer GC, Chattopadhyay A, Long C, Behn AW, Chang J. Gliding Resistance After Epitendinous-First Repair of Flexor Digitorum Profundus in Zone II. J Hand Surg Am 2017; 42:662.e1-662.e9. [PMID: 28501340 DOI: 10.1016/j.jhsa.2017.04.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 01/27/2017] [Accepted: 04/19/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE The importance of flexor tendon repair with both core and epitendinous suture placement has been well established. The objective of this study was to determine whether suture placement order affects gliding resistance and bunching in flexor digitorum profundus tendons in a human ex vivo model. METHODS The flexor digitorum profundus tendons of the index, middle, ring, and little fingers of paired cadaver forearms were tested intact for excursion and mean gliding resistance in flexion and extension across the A2 pulley. Tendons were subsequently transected and repaired with either an epitendinous-first (n = 12) or a control (n = 12) repair. Gliding resistance of pair-matched tendons were analyzed at cycle 1 and during the steady state of tendon motion. The tendon repair breaking strength was also measured. RESULTS The mean steady state gliding resistance was less for the epitendinous-first repair than for the control repair in flexion (0.61 N vs 0.72 N) and significantly less in extension (0.68 N vs 0.85 N). Similar results were seen for cycle 1. None of the repairs demonstrated gap formation; however, control repairs exhibited increased bunching. Load to failure was similar for both groups. CONCLUSIONS The order of suture placement for flexor tendon repair is important. Epitendinous-first repair significantly decreased mean gliding resistance, allowed for easier placement of core sutures, and resulted in decreased bunching. CLINICAL RELEVANCE Epitendinous-first flexor tendon repairs may contribute to improved clinical outcomes compared with control repairs by decreasing gliding resistance and bunching.
Collapse
Affiliation(s)
- Michael G Galvez
- Stanford University School of Medicine, Stanford, CA; Division of Plastic & Reconstructive Surgery, Stanford University, Stanford, CA; Division of Plastic & Reconstructive Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Garet C Comer
- Stanford University School of Medicine, Stanford, CA; Division of Plastic & Reconstructive Surgery, Stanford University, Stanford, CA; Division of Plastic & Reconstructive Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Department of Orthopedic Surgery, Stanford University, Stanford, CA
| | | | - Chao Long
- Stanford University School of Medicine, Stanford, CA
| | - Anthony W Behn
- Stanford University School of Medicine, Stanford, CA; Department of Orthopedic Surgery, Stanford University, Stanford, CA
| | - James Chang
- Stanford University School of Medicine, Stanford, CA; Division of Plastic & Reconstructive Surgery, Stanford University, Stanford, CA; Division of Plastic & Reconstructive Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Department of Orthopedic Surgery, Stanford University, Stanford, CA.
| |
Collapse
|
10
|
Berschback JC, Amadio PC, Zhao C, Zobitz ME, An KN. Providing Quantitative Feedback When Teaching Tendon Repair: A New Tool. ACTA ACUST UNITED AC 2016; 30:626-32. [PMID: 16131467 DOI: 10.1016/j.jhsb.2005.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2004] [Accepted: 06/21/2005] [Indexed: 11/28/2022]
Abstract
Flexor tendon repair remains one of the more difficult technical tasks facing the hand surgeon. A good repair must be both strong and able to glide smoothly through the tendon sheath. The purpose of this study is to present a model that allows surgeons to improve their technique of flexor tendon repair by receiving feedback on these important biomechanical parameters. The set-up requires testing equipment found in most biomechanical laboratories and should be available in many academic medical centres. Preliminary data suggest that receiving feedback about the strength and smoothness of a flexor tendon repair may be a very useful tool in helping surgeons improve the overall quality of their tendon repair technique.
Collapse
Affiliation(s)
- J C Berschback
- Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
| | | | | | | | | |
Collapse
|
11
|
Rappaport PO, Thoreson AR, Yang TH, Reisdorf RL, Rappaport SM, An KN, Amadio PC. Effect of wrist and interphalangeal thumb movement on zone T2 flexor pollicis longus tendon tension in a human cadaver model. J Hand Ther 2016. [PMID: 26209161 DOI: 10.1016/j.jht.2015.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Therapy after flexor pollicis longus (FPL) repair typically mimics finger flexor management, but this ignores anatomic and biomechanical features unique to the FPL. PURPOSE OF THE STUDY We measured FPL tendon tension in zone T2 to identify biomechanically appropriate exercises for mobilizing the FPL. METHODS Eight human cadaver hands were studied to identify motions that generated enough force to achieve FPL movement without exceeding hypothetical suture strength. RESULTS With the carpometacarpal and metacarpophalangeal joints blocked, appropriate forces were produced for both passive interphalangeal (IP) motion with 30° wrist extension and simulated active IP flexion from 0° to 35° with the wrist in the neutral position. DISCUSSION This work provides a biomechanical basis for safely and effectively mobilizing the zone T2 FPL tendon. CONCLUSION Our cadaver study suggests that it is safe and effective to perform early passive and active exercise to an isolated IP joint. LEVEL OF EVIDENCE NA.
Collapse
Affiliation(s)
- Patricia O Rappaport
- Tendon and Soft Tissue Biology Laboratory and the Biomechanics Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Andrew R Thoreson
- Tendon and Soft Tissue Biology Laboratory and the Biomechanics Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Tai-Hua Yang
- Tendon and Soft Tissue Biology Laboratory and the Biomechanics Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Ramona L Reisdorf
- Tendon and Soft Tissue Biology Laboratory and the Biomechanics Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Stephen M Rappaport
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Kai-Nan An
- Tendon and Soft Tissue Biology Laboratory and the Biomechanics Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Peter C Amadio
- Tendon and Soft Tissue Biology Laboratory and the Biomechanics Laboratory, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
12
|
Flexor tendon injuries in children: Rehabilitative options and confounding factors. J Hand Ther 2016; 28:195-9; quiz 200. [PMID: 25840491 DOI: 10.1016/j.jht.2014.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 11/11/2014] [Accepted: 12/03/2014] [Indexed: 02/03/2023]
Abstract
Research pertaining to the rehabilitation of children with flexor tendon injuries is less prevalent than that in the adult population, and most authors agree that immobilization protocols comprise a safe and efficacious choice. This article presents suggested protocols and correlated literature regarding the outcomes of immobilization, early passive motion, and early active motion in the pediatric population. Confounding factors which influence rehabilitative choices, both personal and environmental, are also presented.
Collapse
|
13
|
Asmus A, Kim S, Millrose M, Jodkowski J, Ekkernkamp A, Eisenschenk A. Rehabilitation nach Beugesehnenverletzungen an der Hand. DER ORTHOPADE 2015; 44:786-802. [DOI: 10.1007/s00132-015-3160-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|
14
|
Linderman SW, Kormpakis I, Gelberman RH, Birman V, Wegst UGK, Genin GM, Thomopoulos S. Shear lag sutures: Improved suture repair through the use of adhesives. Acta Biomater 2015; 23:229-239. [PMID: 26022966 PMCID: PMC4522236 DOI: 10.1016/j.actbio.2015.05.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 03/27/2015] [Accepted: 05/07/2015] [Indexed: 10/23/2022]
Abstract
Suture materials and surgical knot tying techniques have improved dramatically since their first use over five millennia ago. However, the approach remains limited by the ability of the suture to transfer load to tissue at suture anchor points. Here, we predict that adhesive-coated sutures can improve mechanical load transfer beyond the range of performance of existing suture methods, thereby strengthening repairs and decreasing the risk of failure. The mechanical properties of suitable adhesives were identified using a shear lag model. Examination of the design space for an optimal adhesive demonstrated requirements for strong adhesion and low stiffness to maximize the strength of the adhesive-coated suture repair construct. To experimentally assess the model, we evaluated single strands of sutures coated with highly flexible cyanoacrylates (Loctite 4903 and 4902), cyanoacrylate (Loctite QuickTite Instant Adhesive Gel), rubber cement, rubber/gasket adhesive (1300 Scotch-Weld Neoprene High Performance Rubber & Gasket Adhesive), an albumin-glutaraldehyde adhesive (BioGlue), or poly(dopamine). As a clinically relevant proof-of-concept, cyanoacrylate-coated sutures were then used to perform a clinically relevant flexor digitorum tendon repair in cadaver tissue. The repair performed with adhesive-coated suture had significantly higher strength compared to the standard repair without adhesive. Notably, cyanoacrylate provides strong adhesion with high stiffness and brittle behavior, and is therefore not an ideal adhesive for enhancing suture repair. Nevertheless, the improvement in repair properties in a clinically relevant setting, even using a non-ideal adhesive, demonstrates the potential for the proposed approach to improve outcomes for treatments requiring suture fixation. Further study is necessary to develop a strongly adherent, compliant adhesive within the optimal design space described by the model.
Collapse
Affiliation(s)
- Stephen W Linderman
- Department of Orthopaedic Surgery, Washington University, St Louis, MO 63110, United States; Department of Biomedical Engineering, Washington University, St Louis, MO 63130, United States
| | - Ioannis Kormpakis
- Department of Orthopaedic Surgery, Washington University, St Louis, MO 63110, United States
| | - Richard H Gelberman
- Department of Orthopaedic Surgery, Washington University, St Louis, MO 63110, United States
| | - Victor Birman
- Engineering Education Center, Missouri University of Science and Technology, St Louis, MO 63131, United States
| | - Ulrike G K Wegst
- Thayer School of Engineering, Dartmouth College, Hanover, NH 03755, United States
| | - Guy M Genin
- Department of Mechanical Engineering and Materials Science, Washington University, St Louis, MO 63130, United States.
| | - Stavros Thomopoulos
- Department of Orthopaedic Surgery, Washington University, St Louis, MO 63110, United States; Department of Biomedical Engineering, Washington University, St Louis, MO 63130, United States; Department of Mechanical Engineering and Materials Science, Washington University, St Louis, MO 63130, United States.
| |
Collapse
|
15
|
Edsfeldt S, Rempel D, Kursa K, Diao E, Lattanza L. In vivo flexor tendon forces generated during different rehabilitation exercises. J Hand Surg Eur Vol 2015; 40:705-10. [PMID: 26115682 DOI: 10.1177/1753193415591491] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 04/27/2015] [Indexed: 02/03/2023]
Abstract
UNLABELLED We measured in vivo forces in the flexor digitorum profundus and the flexor digitorum superficialis tendons during commonly used rehabilitation manoeuvres after flexor tendon repair by placing a buckle force transducer on the tendons of the index finger in the carpal canal during open carpal tunnel release of 12 patients. We compared peak forces for each manoeuvre with the reported strength of a flexor tendon repair. Median flexor digitorum profundus force (24 N) during isolated flexor digitorum profundus flexion and median flexor digitorum superficialis force (13 N) during isolated flexor digitorum superficialis flexion were significantly higher than during the other manoeuvres. Significantly higher median forces were observed in the flexor digitorum superficialis with the wrist at 30° flexion (6 N) compared with the neutral wrist position (5 N). Median flexor digitorum profundus forces were significantly higher during active finger flexion (6 N) compared with place and hold (3 N). Place and hold and active finger flexion with the wrist in the neutral position or tenodesis generated the lowest forces; isolated flexion of these tendons generated higher forces along the flexor tendons. LEVEL OF EVIDENCE III (controlled trial without randomization).
Collapse
Affiliation(s)
- S Edsfeldt
- Department of Surgery, University of California at San Francisco, San Francisco CA, USA
| | - D Rempel
- Department of Surgery, University of California at San Francisco, San Francisco CA, USA
| | - K Kursa
- Department of Surgery, University of California at San Francisco, San Francisco CA, USA
| | - E Diao
- Department of Surgery, University of California at San Francisco, San Francisco CA, USA
| | - L Lattanza
- Department of Surgery, University of California at San Francisco, San Francisco CA, USA
| |
Collapse
|
16
|
Novak CB, von der Heyde RL. Rehabilitation of the upper extremity following nerve and tendon reconstruction: when and how. Semin Plast Surg 2015; 29:73-80. [PMID: 25685106 PMCID: PMC4317280 DOI: 10.1055/s-0035-1544172] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Following upper extremity nerve and tendon reconstruction, rehabilitation is necessary to achieve optimal function and outcome. In this review, the authors present current evidence and literature regarding the strategies and techniques of rehabilitation following peripheral nerve and tendon reconstruction.
Collapse
Affiliation(s)
- Christine B. Novak
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Toronto Rehab and Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | | |
Collapse
|
17
|
Burger MC, De Wet H, Collins M. The BGN and ACAN genes and carpal tunnel syndrome. Gene 2014; 551:160-6. [PMID: 25173489 DOI: 10.1016/j.gene.2014.08.051] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 08/01/2014] [Accepted: 08/25/2014] [Indexed: 11/30/2022]
Abstract
The causes of idiopathic carpal tunnel syndrome (CTS) remain unknown and the involvement of the tendons within the carpal tunnel structure in the aetiology of CTS cannot be excluded. Variants within the COL5A1 gene, an important regulator of fibril assembly in tendons, have previously been associated with modulating the risk of CTS. Furthermore, proteoglycans are also important structural components of tendons and variants within the aggrecan gene are associated with musculoskeletal soft tissue injuries. The aim of this study was to determine whether ACAN and BGN variants are associated with CTS. Self-reported Coloured participants (n=99), with a history of CTS release surgery (CTS), and 136 control participants, with no history of CTS symptoms (CON), were genotyped for ACAN rs1516797(G/T) and BGN rs1126499(C/T) variants. The BGN CC genotype was significantly over-represented (p=0.0498; OR=0.545, 95% CI=0.30-0.99) in the CON group (71.8%) versus the CTS (58.1%) group. When the previously reported associated COL5A1 genotypes were included in the analysis, COL5A1 and BGN gene-gene interactions were also shown to significantly modulate the risk of CTS in females. In conclusion this is the first study to report that variants within the BGN gene, independently and by interacting with COL5A1 variants, are associated with CTS. Further studies are required to replicate these findings.
Collapse
Affiliation(s)
- Marilize C Burger
- UCT/MRC Research Unit for Exercise Science and Sports Medicine, Department of Human Biology, University of Cape Town, Cape Town, South Africa
| | - Hanli De Wet
- Life Occupational Health, Western Cape, South Africa
| | - Malcolm Collins
- UCT/MRC Research Unit for Exercise Science and Sports Medicine, Department of Human Biology, University of Cape Town, Cape Town, South Africa.
| |
Collapse
|
18
|
Peck FH, Roe AE, Ng CY, Duff C, McGrouther DA, Lees VC. The Manchester short splint: A change to splinting practice in the rehabilitation of zone II flexor tendon repairs. HAND THERAPY 2014. [DOI: 10.1177/1758998314533306] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction The results of patients with primary zone II flexor tendon repairs rehabilitated using a traditional forearm-based splint were audited and compared with those who were managed in the Manchester short splint. Method The short splint was fabricated to permit maximal wrist flexion and up to 45° of wrist extension with a block to 30° of metacarpophalangeal joint extension. A rehabilitation regimen consisting of early combined passive flexion exercises and active motion was employed. In 2011, 62 patients (76 digits) with a mean age of 34 years (range 14–58) were rehabilitated using the forearm-based splint (group A). In 2012, 40 patients (45 digits) with a mean age of 31 years (range 15–71) were rehabilitated using the Manchester short splint (group B). Results Group B had significantly less flexion contracture at their proximal interphalangeal joints than group A at 6 weeks (median 15° versus 28°; p = 0.003) and 12 weeks (median 6° versus 18°; p = 0.024) postoperatively. At the final review, group B had a significantly greater arc of flexion at their distal interphalangeal joints (median 59° versus 30°; p < 0.001) and a greater proportion of patients with excellent/good Strickland’s grades. There were three (3.9%) ruptures in group A and two (4.4%) ruptures in group B (p > 0.999). Conclusion The use of a shorter splint would appear to enhance the outcomes whilst preserving repair integrity.
Collapse
Affiliation(s)
- FH Peck
- The Plastic Surgery Unit, Wythenshawe Hospital, University Hospital of South Manchester, UK
| | - AE Roe
- The Plastic Surgery Unit, Wythenshawe Hospital, University Hospital of South Manchester, UK
| | - CY Ng
- The Plastic Surgery Unit, Wythenshawe Hospital, University Hospital of South Manchester, UK
| | - C Duff
- The Plastic Surgery Unit, Wythenshawe Hospital, University Hospital of South Manchester, UK
| | - DA McGrouther
- The Plastic Surgery Unit, Wythenshawe Hospital, University Hospital of South Manchester, UK
| | - VC Lees
- The Plastic Surgery Unit, Wythenshawe Hospital, University Hospital of South Manchester, UK
| |
Collapse
|
19
|
Killian ML, Cavinatto L, Shah SA, Sato EJ, Ward SR, Havlioglu N, Galatz LM, Thomopoulos S. The effects of chronic unloading and gap formation on tendon-to-bone healing in a rat model of massive rotator cuff tears. J Orthop Res 2014; 32:439-47. [PMID: 24243733 PMCID: PMC3900302 DOI: 10.1002/jor.22519] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 10/21/2013] [Indexed: 02/04/2023]
Abstract
The objective of this study was to understand the effect of pre-repair rotator cuff chronicity on post-repair healing outcomes using a chronic and acute multi-tendon rat rotator cuff injury model. Full-thickness dual tendon injuries (supra- and infraspinatus) were created unilaterally in adult male Sprague Dawley rats, and left chronically detached for 8 or 16 weeks. After chronic detachment, tears were repaired and acute dual tendon injuries were created and immediately repaired on contralateral shoulders. Tissue level outcomes for bone, tendon, and muscle were assessed 4 or 8 weeks after repair using histology, microcomputed tomography, biomechanical testing, and biochemical assays. Substantial gap formation was seen in 35% of acute repairs and 44% of chronic repairs. Gap formation negatively correlated with mechanical and structural outcomes for both healing time points regardless of injury duration. Bone and histomorphometry, as well as biomechanics, were similar between acute and chronic injury and repair regardless of chronicity and duration of healing. This study was the first to implement a multi-tendon rotator cuff injury with surgical repair following both chronic and acute injuries. Massive tear in a rodent model resulted in gap formation regardless of injury duration which had detrimental effects on repair outcomes.
Collapse
Affiliation(s)
- Megan L. Killian
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO 63110
| | - Leonardo Cavinatto
- Department of Orthopaedics and Traumatology, University of Sao Paulo, Brazil
| | - Shivam A. Shah
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO 63110
| | - Eugene J. Sato
- Departments of Radiology, Orthopaedic Surgery, and Bioengineering, University of California San Diego, La Jolla, CA 92093
| | - Samuel R. Ward
- Departments of Radiology, Orthopaedic Surgery, and Bioengineering, University of California San Diego, La Jolla, CA 92093
| | - Necat Havlioglu
- John Cochran Veterans Affairs Medical Center, St. Louis, MO 63106
| | - Leesa M. Galatz
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO 63110,Corresponding Authors: Stavros Thomopoulos, Ph.D., Washington University, Department of Orthopaedic Surgery, 660 South Euclid, Campus Box 8233, St. Louis, MO 63110, , Phone: 314-362-8605, Fax: 314-362-0334. Leesa M. Galatz, M.D., Washington University, Department of Orthopaedic Surgery, 660 South Euclid, Campus Box 8233, St. Louis, MO 63110,
| | - Stavros Thomopoulos
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO 63110,Corresponding Authors: Stavros Thomopoulos, Ph.D., Washington University, Department of Orthopaedic Surgery, 660 South Euclid, Campus Box 8233, St. Louis, MO 63110, , Phone: 314-362-8605, Fax: 314-362-0334. Leesa M. Galatz, M.D., Washington University, Department of Orthopaedic Surgery, 660 South Euclid, Campus Box 8233, St. Louis, MO 63110,
| |
Collapse
|
20
|
Thomopoulos S, Kim HM, Silva MJ, Ntouvali E, Manning CN, Potter R, Seeherman H, Gelberman RH. Effect of bone morphogenetic protein 2 on tendon-to-bone healing in a canine flexor tendon model. J Orthop Res 2012; 30:1702-9. [PMID: 22618762 PMCID: PMC3427722 DOI: 10.1002/jor.22151] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2011] [Accepted: 04/30/2012] [Indexed: 02/04/2023]
Abstract
Tendon-to-bone healing is typically poor, with a high rate of repair-site rupture. Bone loss after tendon-to-bone repair may contribute to poor outcomes. Therefore, we hypothesized that the local application of the osteogenic growth factor bone morphogenetic protein 2 (BMP-2) would promote bone formation, leading to improved repair-site mechanical properties. Intrasynovial canine flexor tendons were injured in Zone 1 and repaired into bone tunnels in the distal phalanx. BMP-2 was delivered to the repair site using either a calcium phosphate matrix (CPM) or a collagen sponge (COL) carrier. Each animal also received carrier alone in an adjacent repair to serve as an internal control. Repairs were evaluated at 21 days using biomechanical, radiographic, and histologic assays. Although an increase in osteoid formation was noted histologically, no significant increases in bone mineral density occurred. When excluding functional failures (i.e., ruptured and gapped repairs), mechanical properties were not different when comparing BMP-2/CPM groups with carrier controls. A significantly higher percentage of BMP-2 treated specimens had a maximum force <20 N compared to carrier controls. While tendon-to-bone healing can be enhanced by addressing the bone loss that typically occurs after surgical repair, the delivery of BMP-2 using the concentrations and methods of the current study did not improve mechanical properties over carrier alone. The anticipated anabolic effect of BMP-2 was insufficient in the short time frame of this study to counter the post-repair loss of bone.
Collapse
Affiliation(s)
- Stavros Thomopoulos
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO 63110, USA.
| | | | | | | | | | | | | | | |
Collapse
|
21
|
Nelson GN, Potter R, Ntouvali E, Silva MJ, Boyer MI, Gelberman RH, Thomopoulos S. Intrasynovial flexor tendon repair: a biomechanical study of variations in suture application in human cadavera. J Orthop Res 2012; 30:1652-9. [PMID: 22457145 PMCID: PMC3621034 DOI: 10.1002/jor.22108] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Accepted: 02/23/2012] [Indexed: 02/04/2023]
Abstract
To improve the functional outcomes of intrasynovial tendon suture, prior experiments evaluated individual technical modifications used in the repair process. Few studies, however, have assessed the combinatorial effects of those suture modifications in an integrated biomechanical manner, including a sample size sufficient to make definitive observations on repair technique. Two hundred fifty-six flexor tendon repairs were performed in human cadavera, and biomechanical properties were determined. The effects of five factors for flexor tendon repair were tested: core suture caliber (4-0 or 3-0), number of sutures crossing the repair site (four- or eight-strand), core suture purchase (0.75 or 1.2 cm), peripheral suture caliber (6-0 or 5-0), and peripheral suture purchase (superficial or 2 mm). Significant factors affecting the properties of the repair were the number of core suture strands and the peripheral suture purchase. The least significant factors were core suture purchase and peripheral suture caliber. The choice of core suture caliber affected the properties of repair marginally. Based on these results, we recommend that surgeons continue to focus on multi-strand repair methods, as the properties of eight-strand repairs were far better than those of four-strand repairs. To resist gap formation and enhance repair strength, a peripheral suture with 2 mm purchase is also recommended. Finally, since core suture caliber affected some biomechanical properties, including the failure mode, a 3-0 suture could be considered, provided that future in vivo studies can confirm that gliding properties are not adversely influenced.
Collapse
Affiliation(s)
| | | | | | | | | | - RH Gelberman
- Corresponding Authors: Biomechanics, Stavros Thomopoulos, Ph.D., Washington University, Department of Orthopaedic Surgery, 660 South Euclid, Campus Box 8233, St. Louis, MO 63110, Phone: 314-362-8605, ; Clinical Relevance, Richard H. Gelberman, Washington University, Department of Orthopaedic Surgery, 660 South Euclid, Campus Box 8233, St. Louis, MO 63110, Phone: 314-747-2531,
| | - S Thomopoulos
- Corresponding Authors: Biomechanics, Stavros Thomopoulos, Ph.D., Washington University, Department of Orthopaedic Surgery, 660 South Euclid, Campus Box 8233, St. Louis, MO 63110, Phone: 314-362-8605, ; Clinical Relevance, Richard H. Gelberman, Washington University, Department of Orthopaedic Surgery, 660 South Euclid, Campus Box 8233, St. Louis, MO 63110, Phone: 314-747-2531,
| |
Collapse
|
22
|
Moriya T, Thoreson AR, Zhao C, An KN, Amadio PC. The effects of oblique or transverse partial excision of the A2 pulley on gliding resistance during cyclic motion following zone II flexor digitorum profundus repair in a cadaveric model. J Hand Surg Am 2012; 37:1634-8. [PMID: 22763054 PMCID: PMC3898674 DOI: 10.1016/j.jhsa.2012.05.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 05/08/2012] [Accepted: 05/09/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the gliding resistance of flexor tendons after oblique versus transverse partial excision of the A2 pulley in a human cadaveric model, to determine the effect of the angle of pulley trimming. METHODS We obtained 36 human flexor digitorum profundus tendons from the index through the little finger and repaired them with a modified Massachusetts General Hospital suture using 4-0 FiberWire. We repaired all tendons with a similar epitendinous stitch. We randomly assigned the tendons to 1 of 3 groups: intact pulley, transverse partial excision, or oblique partial excision. We measured peak and normalized peak gliding resistance between the repairs and the A2 pulley during 1,000 cycles of simulated motion. RESULTS There was no significant difference in the peak or normalized peak gliding resistance at any cycle among the 3 groups. CONCLUSIONS Both transverse and oblique trimming of the A2 pulley had similar effects on the peak and normalized gliding resistance after flexor tendon repair. CLINICAL RELEVANCE When partial pulley resection is needed after flexor tendon repair, the transverse or oblique trimming of pulley edge does not affect repaired tendon gliding resistance.
Collapse
|
23
|
Oishi M, Ogihara N, Endo H, Une Y, Ichihara N, Asari M, Amasaki H. Muscle dimensions of the foot in the orangutan and the chimpanzee. J Anat 2012; 221:311-7. [PMID: 22803586 DOI: 10.1111/j.1469-7580.2012.01545.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2012] [Indexed: 11/28/2022] Open
Abstract
The hindlimbs of two orangutans and four chimpanzees were dissected, and muscle parameters (mass, fascicle length, and physiological cross-sectional area: PCSA) were determined to explore possible interspecies variation in muscle dimensions. Muscle mass and PCSA were divided by the total mass and total PCSA of the entire foot muscles for normalization. The results indicate that the pedal interosseous and the intrinsic pedal digital extensor muscles in the orangutans probably have higher capacity for force production due to their relatively larger PCSAs than in chimpanzees. Moreover, the medial components of the intrinsic muscles exhibited relatively larger mass and PCSA ratios in orangutans. The mass and PCSA ratios of the hallucal muscles were larger in chimpanzees. These differences in foot muscle dimensions of the two species suggest that the orangutan is more specialized for hook-like digital gripping without involvement of the rudimentary hallux, while the chimpanzee is adapted to hallux-assisted power gripping in arboreal locomotion.
Collapse
Affiliation(s)
- Motoharu Oishi
- Department of Veterinary Anatomy, School of Veterinary Medicine, Nippon Veterinary and Life Science University, Tokyo, Japan.
| | | | | | | | | | | | | |
Collapse
|
24
|
Moriya T, Larson MC, Zhao C, An KN, Amadio PC. The effect of core suture flexor tendon repair techniques on gliding resistance during static cycle motion and load to failure: a human cadaver study. J Hand Surg Eur Vol 2012; 37:316-22. [PMID: 21987278 PMCID: PMC3337341 DOI: 10.1177/1753193411422793] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to describe a modification of the Massachusetts General Hospital (MMGH) tendon repair and to compare it with three other suture techniques. Twenty human flexor digitorum profundus (FDP) tendons were randomly assigned to the modified Pennington (MP) suture and the MMGH suture. These were compared to the modified Kessler (MK) and Massachusetts General Hospital (MGH) sutures, using data from a previous study. All tendons were repaired with a similar epitendinous stitch and core sutures of 4-0 FiberWire. There was no significant difference in the normalized gliding resistance within the two-strand or four-strand core repair groups. The MP suture had significantly higher 2 mm gap force and ultimate load to failure than the MK suture. The MMGH suture had significantly higher 2 mm gap force and maximum failure ultimate load than the MGH suture. All repairs failed by knot unravelling.
Collapse
Affiliation(s)
| | | | - C. Zhao
- Mayo Clinic, Rochester, MN, USA
| | | | | |
Collapse
|
25
|
The role of mechanobiology in tendon healing. J Shoulder Elbow Surg 2012; 21:228-37. [PMID: 22244066 PMCID: PMC3259533 DOI: 10.1016/j.jse.2011.11.002] [Citation(s) in RCA: 157] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 11/11/2011] [Accepted: 11/12/2011] [Indexed: 02/01/2023]
Abstract
Mechanical cues affect tendon healing, homeostasis, and development in a variety of settings. Alterations in the mechanical environment are known to result in changes in the expression of extracellular matrix proteins, growth factors, transcription factors, and cytokines that can alter tendon structure and cell viability. Loss of muscle force in utero or in the immediate postnatal period delays tendon and enthesis development. The response of healing tendons to mechanical load varies depending on anatomic location. Flexor tendons require motion to prevent adhesion formation, yet excessive force results in gap formation and subsequent weakening of the repair. Excessive motion in the setting of anterior cruciate ligament reconstruction causes accumulation of macrophages, which are detrimental to tendon graft healing. Complete removal of load is detrimental to rotator cuff healing; yet, large forces are also harmful. Controlled loading can enhance healing in most settings; however, a fine balance must be reached between loads that are too low (leading to a catabolic state) and too high (leading to microdamage). This review will summarize existing knowledge of the mechanobiology of tendon development, homeostasis, and healing.
Collapse
|
26
|
Moriya T, Zhao C, Yamashita T, An KN, Amadio PC. Effect of core suture technique and type on the gliding resistance during cyclic motion following flexor tendon repair: a cadaveric study. J Orthop Res 2010; 28:1475-81. [PMID: 20872584 PMCID: PMC3906802 DOI: 10.1002/jor.21177] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We investigated the effects of two suture techniques using three suture types in a human model in vitro. We obtained 60 flexor digitorum profundus (FDP) tendons from cadavers and measured the gliding resistance during 1,000 cycles of simulated flexion-extension motion and load to failure of six groups: the modified Kessler (MK) repair using 3-0 coated, braided polyester (Ethibond, Ethicon, Somerville, NJ), 3-0 coated, braided polyester/monofilament polyethylene composite (FiberWire®; Arthrex, Naples, FL), or 4-0 FiberWire; and the Massachusetts General Hospital (MGH) repair using 3-0 Ethibond, 3-0 FiberWire, or 4-0 FiberWire. The 3-0 Ethibond MGH suture had significantly higher ultimate load to failure than the 3-0 or 4-0 FiberWire MK suture. The 3-0 and 4-0 FiberWire MGH sutures had significantly higher load to failure than the three MK groups. The gliding resistances of the three MGH groups were significantly higher than that of the three corresponding MK groups. The MGH repair had more gliding resistance than an MK repair, even when comparing large diameter suture in the MK repair with smaller diameter suture in the MGH repair. In this study, suture technique was more important in predicting repair load to failure and gliding resistance than the nature or caliber of the suture material that was used.
Collapse
Affiliation(s)
- Tamami Moriya
- Orthopedic Biomechanics Laboratory, Division of Orthopaedic Research, Mayo Clinic, 200 1st Street Southwest, Rochester, Minnesota
| | - Chunfeng Zhao
- Orthopedic Biomechanics Laboratory, Division of Orthopaedic Research, Mayo Clinic, 200 1st Street Southwest, Rochester, Minnesota
| | - Toshihiko Yamashita
- Department of Orthopaedic Surgery, Sapporo Medical University of Medicine, Sapporo, Japan
| | - Kai-Nan An
- Orthopedic Biomechanics Laboratory, Division of Orthopaedic Research, Mayo Clinic, 200 1st Street Southwest, Rochester, Minnesota
| | - Peter C. Amadio
- Orthopedic Biomechanics Laboratory, Division of Orthopaedic Research, Mayo Clinic, 200 1st Street Southwest, Rochester, Minnesota
| |
Collapse
|
27
|
Mechanical feasibility of immediate mobilization of the brachioradialis muscle after tendon transfer. J Hand Surg Am 2010; 35:1473-8. [PMID: 20709465 PMCID: PMC2947370 DOI: 10.1016/j.jhsa.2010.06.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2010] [Revised: 05/26/2010] [Accepted: 06/01/2010] [Indexed: 02/02/2023]
Abstract
PURPOSE Tendon transfer is often used to restore key pinch after cervical spinal cord injury. Current postoperative recommendations include elbow immobilization in a flexed position to protect the brachioradialis-flexor pollicis longus (BR-FPL) repair. The purpose of this study was to measure the BR-FPL tendon tension across a range of wrist and elbow joint angles to determine whether joint motion could cause repair rupture. METHODS We performed BR-to-FPL tendon transfers on fresh-frozen cadaveric arms (n = 8) and instrumented the BR-FPL tendon with a buckle transducer. Arms were ranged at 4 wrist angles from 45 degrees of flexion to 45 degrees of extension and 8 elbow angles from 90 degrees of flexion to full extension, measuring tension across the BR-FPL repair at each angle. Subsequently, the BR-FPL tendon constructs were removed and elongated to failure. RESULTS Over a wide wrist and elbow range of motion, BR-FPL tendon tension was under 20 N. Two-way analysis of variance with repeated measures revealed a significant effect of wrist joint angle (p<.001) and elbow joint angle (p<.001) with significant interaction between elbow and joint angles (p<.001). Because the failure load of the repair site was 203 +/- 19 N, over 10 times the loads that would be expected to occur at the repair site, our results demonstrate that the repair has a safety factor of at least 10. CONCLUSIONS Our tendon force measurements support the assertion that the elbow joint need not be immobilized when the BR is used as a donor muscle in tendon transfer to the FPL. This is based on the fact that maximum passive tendon tension was only about 20 N in our cadaveric model and the failure strength of this specific repair was over 200 N. We suggest that it is possible to consider performing multiple tendon transfers in a single stage, avoiding immobilization, which may adversely affect functional recovery. These results must be qualified by the fact that issues unique to living tissues such as postoperative edema and tendon gliding cannot be accounted for by this cadaveric model.
Collapse
|
28
|
The effect of epitendinous suture technique on gliding resistance during cyclic motion after flexor tendon repair: a cadaveric study. J Hand Surg Am 2010; 35:552-8. [PMID: 20189323 PMCID: PMC3591492 DOI: 10.1016/j.jhsa.2009.12.025] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2009] [Revised: 12/14/2009] [Accepted: 12/17/2009] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate the effects of motion following repair with a modified Kessler core suture and 5 different epitendinous suture designs on the gliding resistance, breaking strength, 2-mm gap force, and stiffness of flexor digitorum profundus tendons in a human in vitro model. METHODS The flexor digitorum profundus tendons of the index, middle, ring, and little fingers of 50 human cadavers were transected and repaired with a 2-strand modified Kessler suture and assigned to 5 groups based on type of epitendinous suture design. The 5 epitendinous designs tested were a simple, running epitendinous suture whose knot was outside the repair (simple running KO); a simple, running epitendinous suture whose knot was inside the repair (simple running KI); a cross-stitch epitendinous suture; an interlocking, horizontal mattress (IHM) epitendinous suture; and a running-locking epitendinous suture. The tendon repair strength and 2-mm gap force were measured after 1,000 cycles of tendon motion. The resistance to gap formation, a measure of repair stiffness, was obtained from the force versus gap data. RESULTS None of the repairs showed any gap formation after 1,000 cycles of tendon motion. The cross-stitch epitendinous suture, IHM epitendinous suture, and running-locking epitendinous suture all had significantly lower gliding resistance than the simple running KO epitendinous suture after 1 cycle. The simple running KI epitendinous suture had significantly lower gliding resistance than the simple running KO epitendinous suture after 100 cycles and 1,000 cycles. The differences for gap force at 2 mm and stiffness of the repaired tendon evaluation were not statistically significant. The cross-stitch epitendinous suture, IHM epitendinous suture, and running-locking epitendinous suture all had significantly higher maximal failure strength after 1,000 cycles than the simple running KI epitendinous suture. CONCLUSIONS The cross-stitch, IHM, and running-locking epitendinous sutures had the best combination of higher strength and lower gliding resistance in this study. Although these findings suggest a potential for these suture types to be preferred as epitendinous sutures, these repairs should first be investigated in vivo to address their effect on tendon healing and adhesion formation.
Collapse
|
29
|
Thomopoulos S, Das R, Silva MJ, Sakiyama-Elbert S, Harwood FL, Zampiakis E, Kim HM, Amiel D, Gelberman RH. Enhanced flexor tendon healing through controlled delivery of PDGF-BB. J Orthop Res 2009; 27:1209-15. [PMID: 19322789 PMCID: PMC2916020 DOI: 10.1002/jor.20875] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
A fibrin/heparin-based delivery system was used to provide controlled delivery of platelet derived growth factor BB (PDGF-BB) in an animal model of intrasynovial flexor tendon repair. We hypothesized that PDGF-BB, administered in this manner, would stimulate cell proliferation and matrix remodeling, leading to improvements in the sutured tendon's functional and structural properties. Fifty-six flexor digitorum profundus tendons were injured and repaired in 28 dogs. Three groups were compared: (1) controlled delivery of PDGF-BB using a fibrin/heparin-based delivery system; (2) delivery system carrier control; and (3) repair- only control. The operated forelimbs were treated with controlled passive motion rehabilitation. The animals were euthanized at 7, 14, and 42 days, at which time the tendons were assessed using histologic (hyaluronic acid content, cellularity, and inflammation), biochemical (total DNA and reducible collagen crosslink levels), and biomechanical (gliding and tensile properties) assays. We found that cell activity (as determined by total DNA, collagen crosslink analyses, and hyaluronic acid content) was accelerated due to PDGF-BB at 14 days. Proximal interphalangeal joint rotation and tendon excursion (i.e., tendon gliding properties) were significantly higher for the PDGF-BB-treated tendons compared to the repair-alone tendons at 42 days. Improvements in tensile properties were not achieved, possibly due to suboptimal release kinetics or other factors. In conclusion, PDGF-BB treatment consistently improved the functional but not the structural properties of sutured intrasynovial tendons through 42 days following repair.
Collapse
Affiliation(s)
- S Thomopoulos
- Washington University, Department of Orthopaedic Surgery, St Louis, MO
| | - R Das
- Washington University, Department of Orthopaedic Surgery, St Louis, MO
| | - MJ Silva
- Washington University, Department of Orthopaedic Surgery, St Louis, MO
| | - S Sakiyama-Elbert
- Washington University, Department of Biomedical Engineering, St Louis, MO
| | - FL Harwood
- University of California San Diego, Department of Orthopaedic Surgery, San Diego, CA
| | - E Zampiakis
- Washington University, Department of Orthopaedic Surgery, St Louis, MO
| | - HM Kim
- Washington University, Department of Orthopaedic Surgery, St Louis, MO
| | - D Amiel
- University of California San Diego, Department of Orthopaedic Surgery, San Diego, CA
| | - RH Gelberman
- Washington University, Department of Orthopaedic Surgery, St Louis, MO
| |
Collapse
|
30
|
Boisgontier M, Vuillerme N, Thomas D, Pinsault N, Emprin M, Caillat-Miousse JL. Effects of neuromuscular electrical stimulation on the range of motion recovery in hand proximal interphalangeal sprain. Sci Sports 2009. [DOI: 10.1016/j.scispo.2008.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
31
|
Silva JM, Zhao C, An KN, Zobitz ME, Amadio PC. Gliding resistance and strength of composite sutures in human flexor digitorum profundus tendon repair: an in vitro biomechanical study. J Hand Surg Am 2009; 34:87-92. [PMID: 19121735 PMCID: PMC2796445 DOI: 10.1016/j.jhsa.2008.09.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2008] [Revised: 09/12/2008] [Accepted: 09/17/2008] [Indexed: 02/02/2023]
Abstract
PURPOSE Although the strength of a tendon repair is clearly important, the friction of the repair is also a relevant consideration. The purpose of this study was to characterize the frictional coefficient, gliding resistance, and breaking strength of suture materials and a suture construct commonly used for flexor tendon repair. METHODS We measured the friction coefficients of 3-0 braided nylon enclosed in a smooth nylon outer shell (Supramid, S. Jackson, Alexandria, VA), 3-0 braided polyester coated with polybutilate (Ethibond, Ethicon, Somerville, NJ), and 3-0 braided polyester/monofilament polyethylene composite (FiberWire, Arthrex, Naples, FL) sutures. We also measured the gliding resistance, linear breaking strength, and resistance to gapping of zone 2 modified Pennington tendon repairs with the 2 lowest-friction sutures in 20 human cadaveric flexor digitorum profundus tendons. RESULTS The braided polyester/monofilament polyethylene composite had a significantly lower friction coefficient (0.054) than either the coated polyester (0.076) or nylon (0.130) sutures. The gliding resistances of the repaired tendons with braided/monofilament polyethylene composite suture and those of coated, braided polyester were similar. The strength of the 2 repairs (force to produce a 2 mm gap) and resistance to gap formation were also not significantly different. CONCLUSIONS Braided polyester composite is a low-friction suture material. However, when this suture was used for tendon repair with a locking suture technique, it did not show a significant effect on the gliding resistance and repair strength compared with the same repair using a coated polyester suture.
Collapse
Affiliation(s)
- Jose M Silva
- Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
| | | | | | | | | |
Collapse
|
32
|
Sakiyama-Elbert SE, Das R, Gelberman RH, Harwood F, Amiel D, Thomopoulos S. Controlled-release kinetics and biologic activity of platelet-derived growth factor-BB for use in flexor tendon repair. J Hand Surg Am 2008; 33:1548-57. [PMID: 18984337 PMCID: PMC2586996 DOI: 10.1016/j.jhsa.2008.05.030] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2008] [Revised: 05/22/2008] [Accepted: 05/27/2008] [Indexed: 02/02/2023]
Abstract
PURPOSE Surgically repaired intrasynovial tendons are at greatest risk of failure in the first 3 weeks after surgery. Attempts to improve the strength of repair by modifying rehabilitation parameters have not always been successful. Manipulation of the biological environment of the sutured tendon holds great promise for accelerating the repair process. The goals of this study were to examine (1) the range of conditions (eg, dosage, delivery system formulation, presence of cells) over which delivery of platelet-derived growth factor-BB (PDGF-BB) can be sustained from fibrin matrices using a heparin-binding delivery system (HBDS) and (2) the biological activity of the PDGF-BB released from this system on canine tendon fibroblasts in vitro. METHODS We examined in vitro release kinetics from cellular and acellular fibrin matrices using enzyme-linked immunosorbent assays. We examined the biologic activity of the PDGF-BB in vitro by measuring cell proliferation (ie, total DNA) and collagen synthesis (ie, proline incorporation). RESULTS The acellular release kinetics of PDGF-BB was modulated by varying the ratio of PDGF-BB to heparin (PDGF-binding sites) or the dose of PDGF-BB in the presence of the delivery system. In the presence of canine tendon fibroblasts, the delivery system prolonged the duration of PDGF-BB release from fibrin matrices, thus demonstrating that cells are able to liberate PDGF-BB retained by the HBDS. Sustained delivery of PDGF-BB promoted increased cell proliferation at doses of 0.125 microg/mL and 1.25 microg/mL compared to fibrin without delivery system. Collagen synthesis was enhanced by PDGF-BB at doses of 0.125 microg/mL and 1.25 microg/mL; however, there was an enhancement over fibrin without the delivery system only at the lower dose. CONCLUSIONS These results demonstrate that the PDGF-BB released from fibrin matrices containing an HBDS is biologically active and can modulate both cell proliferation and extracellular matrix synthesis, both of which are key factors in the process of tendon repair.
Collapse
Affiliation(s)
- Shelly E. Sakiyama-Elbert
- Department of Biomedical Engineering, Washington University in St. Louis, Center for Materials Innovation, Washington University in St. Louis
| | - Rosalina Das
- Department of Orthopaedic Surgery, Washington University in St. Louis
| | | | - Fredrick Harwood
- Department of Orthopaedic Surgery, University of California San Diego
| | - David Amiel
- Department of Orthopaedic Surgery, University of California San Diego
| | - Stavros Thomopoulos
- Department of Biomedical Engineering, Washington University in St. Louis, Center for Materials Innovation, Washington University in St. Louis, Department of Orthopaedic Surgery, Washington University in St. Louis
| |
Collapse
|
33
|
Thomopoulos S, Zaegel M, Das R, Harwood FL, Silva MJ, Amiel D, Sakiyama-Elbert S, Gelberman RH. PDGF-BB released in tendon repair using a novel delivery system promotes cell proliferation and collagen remodeling. J Orthop Res 2007; 25:1358-68. [PMID: 17551975 DOI: 10.1002/jor.20444] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The purpose of this study was to promote fibroblast proliferation and collagen remodeling in flexor tendon repair through sustained delivery of platelet derived growth factor (PDGF-BB). The release kinetics of PDGF-BB from a novel fibrin matrix delivery system was initially evaluated in vitro. After the in vivo degradation rate of the fibrin matrix was determined using fluorescently tagged fibrin, PDGF-BB was delivered to the site of flexor tendon repair in vivo in a canine model. The effect of PDGF-BB on intrasynovial tendon healing was studied using histology-based assays (cell density, proliferation, and type I collagen expression) and by measuring total DNA levels and reducible collagen crosslink levels. The fibrin matrix delivery system provided sustained release of PDGF-BB in vitro at a rate modulated by the ratio of heparin to growth factor. In vivo, the fibrin matrix remained at the repair site for more than 10 days. Delivery of PDGF-BB led to a qualitative increase in cell density, cell proliferation, and type I collagen mRNA expression. PDGF-BB also led to statistically significant increases in total DNA (20% increase at 7 days, 18% increase at 14 days) and reducible collagen crosslinks (30% increase at 7 days). Sustained delivery of growth factors may be achieved using a novel fibrin-based delivery system. PDGF-BB delivery increased cell proliferation and matrix remodeling and thus may accelerate flexor tendon healing.
Collapse
Affiliation(s)
- Stavros Thomopoulos
- Department of Orthopaedics, Washington University, St. Louis, Missouri 63110, USA.
| | | | | | | | | | | | | | | |
Collapse
|
34
|
Taguchi M, Zhao C, Zobitz ME, An KN, Amadio PC. Effect of finger ulnar deviation on gliding resistance of the flexor digitorum profundus tendon within the A1 and A2 pulley complex. J Hand Surg Am 2006; 31:113-7. [PMID: 16443115 DOI: 10.1016/j.jhsa.2005.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2005] [Revised: 09/13/2005] [Accepted: 09/13/2005] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the effect of ulnar deviation of the finger on gliding resistance of the flexor digitorum profundus tendon within the A1 and A2 pulley complex. METHODS Thirty-two human cadaveric fingers (index through small fingers) were used. The gliding resistance was measured at 5 different angles of ulnar deviation (0 degrees, 15 degrees, 30 degrees, 45 degrees, 60 degrees). RESULTS There was a significant increase in gliding resistance with increased ulnar deviation. The gliding resistances at 0 degrees, 15 degrees, 30 degrees, 45 degrees, and 60 degrees of ulnar deviation were 0.40+/-0.13 N, 0.44+/-0.13 N, 0.55+/-0.17 N, 0.74+/-0.21 N, and 1.02+/-0.30 N, respectively. The gliding resistance at 60 degrees was significantly greater than at all other angles; 45 degrees ulnar deviation had significantly higher gliding resistance than 0 degrees, 15 degrees, and 30 degrees; and 30 degrees ulnar deviation had significantly higher gliding resistance than 0 degrees. CONCLUSIONS A greater angle of ulnar deviation causes higher gliding resistance during motion of the flexor digitorum profundus tendon within the A1 and A2 pulley complex. The gliding resistance increases significantly at angles greater than 30 degrees of ulnar deviation. The increased tendon loading needed to overcome increased gliding resistance caused by ulnar deviation could result in a vicious cycle of progressive ulnar deviation. Although mild degrees of ulnar deviation may be well tolerated mechanically a reasonable therapeutic guideline might be to prevent deviation from exceeding 30 degrees.
Collapse
Affiliation(s)
- Manabu Taguchi
- Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
| | | | | | | | | |
Collapse
|
35
|
Abstract
In vivo tendon forces provide a view inside the musculoskeletal system revealing muscle function and potential injury etiologies. The studies presented here measured the in vivo tendon force of the flexor digitorum superficialis of the long finger during open carpal tunnel release surgery in ten adult patients. Forces were measured during passive movement of the finger, isometric pinch, and dynamic tapping of the finger. The tendon forces during passive movement of the finger were the largest with the finger fully extended. During isometric pinch, tendon force was linearly related to fingertip force, and was on average 3.3 times larger than the fingertip force. During dynamic activities, however, the relationship between tip and tendon force was nonlinear and often remained elevated when the finger was moving but with no applied force. Tendon forces were the highest with the isometric finger pinch. In conclusion, tendon force is a completed function of both fingertip load and motion of the joints that the tendons cross. A comparison of these results with others published in the literature indicated that rehabilitation processes need to incorporate a systems approach rather than rely on one specific physiologic relationship to minimize finger flexor tendon forces.
Collapse
Affiliation(s)
- Jack Tigh Dennerlein
- Department of Environmental Health, Harvard School of Public Health, Boston, Massachusetts 02115, USA
| |
Collapse
|
36
|
Abstract
The most important difference between the various approaches to postoperative digital flexor tendon rehabilitation is how the repaired tendon is treated during the first three to six weeks, in the earliest stages of healing. Early mobilization is the most commonly reported method of managing the healing flexor tendon. There are many different protocols and abundant research to support published approaches to tendon management. With so many choices, today's hand therapist must understand not only what those choices are, but also why and when to use them. There is no one correct way to manage a repaired flexor tendon; the specialist who does not understand how current techniques evolved is ill-equipped to design the appropriate treatment for a given patient. This article presents an overview of management options and how they have been developed over time, with special attention to changes in splint and exercise design in the crucial first few weeks after repair.
Collapse
Affiliation(s)
- Karen M Pettengill
- NovaCare Hand and Upper Extremity Rehabilitation, Springfield, Massachusetts, USA.
| |
Collapse
|
37
|
Tanaka T, Amadio PC, Zhao C, Zobitz ME, Kutsumi K, An KN. Effect of elbow position on canine flexor digitorum profundus tendon tension. J Orthop Res 2005; 23:249-53. [PMID: 15734233 DOI: 10.1016/j.orthres.2004.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/05/2004] [Indexed: 02/04/2023]
Abstract
Tendon injury in the finger remains a clinical challenge to hand surgeons. A canine model is commonly used to study biological effects of tendon injuries and their treatment. There is an important anatomical difference between human and canine anatomy that may be overlooked, however, namely that most of the flexor digitorum profundus (FDP) muscle in dogs takes its origin from the medial epicondyle of the humerus, whereas in humans this muscle arises purely from the forearm. Therefore, elbow position can affect the tension of this muscle in dogs, while having no effect in humans. The purpose of this study was to measure the effect of elbow position on tendon tension in the canine digit in vitro. Elbow position had a significant effect on tendon tension. Digit motion with the elbow fully flexed resulted in significantly higher tendon tension compared to digit motion with the elbow flexed 90 degrees or fully extended, regardless of digit or wrist position (p<0.05). The tension with the elbow flexed 90 degrees was also significantly higher than with the elbow fully extended (p<0.05). The maximum tendon tension with the elbow fully flexed was more than eight times larger than that of the fully extended elbow (p<0.05). We conclude that, in the canine model, elbow position is an important parameter that affects the passive tension applied to the flexor digitorum profundus, and, by implication, to any repair of that tendon. Dog flexor tendon rehabilitation protocols should therefore specify elbow position, in addition to wrist and digit position.
Collapse
Affiliation(s)
- Tatsuro Tanaka
- Division of Orthopedic Research, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | | | | | | | | | | |
Collapse
|
38
|
Tanaka T, Amadio PC, Zhao C, Zobitz ME, An KN. Flexor digitorum profundus tendon tension during finger manipulation. J Hand Ther 2005; 18:330-8; quiz 338. [PMID: 16059854 PMCID: PMC1307525 DOI: 10.1197/j.jht.2005.04.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Abstract The purpose of this study was to measure the tension in the flexor digitorum profundus (FDP) tendon in zone II and the digit angle during joint manipulations that replicate rehabilitation protocols. Eight FDP tendons from eight human cadavers were used in this study. The dynamic tension in zone II of the tendon and metacarpophalangeal (MCP) joint angle were measured in various wrist and digit positions. Tension in the FDP tendon increased with MCP joint extension. There was no tension with the finger fully flexed and wrist extended (synergistic motion), but the tendon force reached 1.77 +/- 0.43 N with the MCP joint hyperextended 45 degrees with the distal interphalangeal and proximal interphalangeal joints flexed. The combination of wrist extension and MCP joint hyperextension with the distal interphalangeal and proximal interphalangeal joints fully flexed, what the authors term "modified synergistic motion," produced a modest tendon tension and may be a useful alternative configuration to normal synergistic motion in tendon rehabilitation.
Collapse
Affiliation(s)
| | - Peter C. Amadio
- Correspondence and reprint requests to Dr. Amadio, Division of Orthopedic Research, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905; e-mail: <>
| | | | | | | |
Collapse
|
39
|
Zhao C, Amadio PC, Tanaka T, Yang C, Ettema AM, Zobitz ME, An KN. Short-term assessment of optimal timing for postoperative rehabilitation after flexor digitorum profundus tendon repair in a canine model. J Hand Ther 2005; 18:322-9; quiz 329. [PMID: 16059853 PMCID: PMC1351120 DOI: 10.1197/j.jht.2005.04.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Abstract The purpose of this study was to compare the short-term outcome following flexor tendon repair for postoperative rehabilitation commencing on day 1 (a common clinical choice) versus day 5 (the day on which, with postoperative immobilization, the initial gliding resistance is least in this model) in an in vivo canine model. Work of flexion (WOF) and tendon strength were evaluated following tendon laceration and repair in 24 dogs sacrificed 10 days postoperatively. Starting postoperative mobilization at day 5 resulted in no tendon ruptures compared with tendon ruptures in four of the dogs (33%) in the group subjected to mobilization starting at day 1. While there was no statistically significant difference in WOF between groups at day 10, there was a trend toward lower resistance favoring the day 5 start group, and the statistical power to detect a difference in WOF was diminished by the ruptures in the day 1 group. We conclude that starting rehabilitation on day 5, when initial gliding resistance is lower, may have an advantage over earlier starting times, when surgical edema and other factors increase the initial force requirements to initiate tendon gliding. We plan further studies to evaluate the longer-term benefits of this rehabilitation program.
Collapse
Affiliation(s)
| | - Peter C. Amadio
- Correspondence and reprint requests to Peter C. Amadio, MD, Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic College of Medicine, Rochester, MN 55905; e-mail: <>
| | | | | | | | | | | |
Collapse
|
40
|
Zhao C, Amadio PC, Tanaka T, Kutsumi K, Tsubone T, Zobitz ME, An KN. Effect of gap size on gliding resistance after flexor tendon repair. J Bone Joint Surg Am 2004; 86:2482-8. [PMID: 15523022 DOI: 10.2106/00004623-200411000-00019] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Gap formation is a common complication after flexor tendon repair and is associated with adhesion formation, tendon rupture, and decreased strength. The purpose of this study was to investigate the effect of gap formation on tendon gliding resistance after flexor tendon repair in a human cadaver model. METHODS Twelve index, middle, and ring fingers from four adult human cadaveric hands were used. Gliding resistance versus excursion between the flexor digitorum profundus tendon and the A2 pulley was first measured in intact tendons. After full laceration, each tendon was repaired with the Pennington suture technique and the gliding resistance was measured again. Then, the repaired tendon (a 0-mm gap) was stretched to form a 1-mm gap, and gliding resistance was remeasured. A magnified video image was used to monitor gap size. This process was repeated to evaluate gap sizes of 2, 3, and 4 mm at the repair site. Peak gliding resistance was determined, and the peak gliding resistance was compared among the groups. RESULTS No significant difference in peak gliding resistance was detected between repaired tendons without a gap and tendons with a 1-mm gap. Repaired tendons with a 2-mm gap could pass through the A2 pulley; however, peak gliding resistance was significantly higher than that for tendons with a 0 or a 1-mm gap (p < 0.05). When the gap reached > or =3 mm, all tendons caught at the A2 pulley edge, causing a dramatically increased peak gliding resistance. CONCLUSIONS The presence of a 2-mm gap after flexor tendon repair significantly increased tendon peak gliding resistance (p < 0.05), while a gap of > or =3 mm further increased peak gliding resistance because of catching at the pulley edge.
Collapse
Affiliation(s)
- Chunfeng Zhao
- Orthopedic Biomechanics Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA
| | | | | | | | | | | | | |
Collapse
|
41
|
Abstract
Postoperative rehabilitation for patients who have sustained a laceration to their flexor tendon apparatus is an important factor in maximizing functional outcome. Quality rehabilitation is characterized by the development of a tailored exercise regimen. There is currently no model available to tailor an exercise regimen for a person with an atypical physiologic response pattern. If rehabilitation protocols were classified according to the criteria of forces applied across a tendon juncture and/or excursion, and a clinical method were available to assist in the identification of optimal tendon loading and/or excursion application, then those individuals with atypical response patterns could be treated more efficiently and effectively. The author conducted a literature review and case study. A model for systematic application of progressive loading exercises to the intrasynovial flexor tendon injury and repair is conceptually developed. The model consists of a pyramidal series of eight specific rehabilitation exercises in the following sequence: passive protected extension, place and hold, active composite fist, hook and straight fist, isolated joint motion, resistive composite fist, resistive hook and straight fist, and resistive isolated joint motion. Concepts are developed to implement a three-point clinical adhesion-grading system. Clinical application of the system is highlighted. An excellent outcome was considered 112% total active motion. A model for systematic application of progressive loading exercises has been conceptually developed in concert with a method for determination of optimal tendon loading. Further substantiation is necessary to validate the proposed theory.
Collapse
Affiliation(s)
- Gail N Groth
- Department of Industry and Manufacturing Engineering, College of Engineering and Applied Science, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA.
| |
Collapse
|
42
|
Zarucco L, Swanstrom MD, Driessen B, Hawkins D, Hubbard M, Steffey EP, Stover SM. An in vivo equine forelimb model for short-term recording of peak isometric force in the superficial and deep digital flexor muscles. Vet Surg 2004; 32:439-50. [PMID: 14569572 DOI: 10.1053/jvet.2003.50058] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To develop and test an experimental model for in vivo short-term recording of peak isometric forces of the digital flexor muscles in the forelimb of adult horses. STUDY DESIGN In vivo experimental study. SAMPLE POPULATION Four healthy, anesthetized, adult Thoroughbred horses (3 to 7 years old; 527 +/- 87 kg) METHODS In dorsal recumbency, ulnar and median nerves were exposed and instrumented with insulated bipolar cuff stimulation electrodes for later connection to an electrical stimulator. In left lateral recumbency, a biplanar fixator was applied to the right humerus and a custom-made, rigid, aluminum frame connected to it, to allow loading of muscles distal to the fixator. Threaded transfixation pins through the radial and metacarpal condyles were clamped to the rigid frame so that the humerus, radius, ulna, and metacarpus were fixed in position. Each digital flexor muscle insertion tendon was transected just above the metacarpophalangeal joint, extracted from the carpal canal, and secured in a metal clamp positioned at the distal myotendinous (MT) junction. Distally, the clamp was connected in series to a load cell and a pneumatic actuator to record force and to maintain muscle length during nerve stimulation. A linear potentiometer was connected in parallel to the actuator to record MT junction position. Initial trials were conducted to identify median and ulnar nerve stimulation variables to achieve maximal muscle contraction. Isometric contractions were performed at different muscle lengths and peak forces registered during 3 seconds of supramaximal dual (ulnar and median) nerve stimulation. RESULTS A stimulation voltage of 2.5 to 5.0 V at 50 Hz usually produced maximal force for both the superficial digital flexor (SDF) and deep digital flexor (DDF) muscles. Single ulnar and median nerve stimulation elicited force development not only in the DDF muscle but also in the SDF muscle. At voltages higher than 1 V, normalized force was greatest with combined median and ulnar nerve stimulation for both the DDF and SDF muscles; however, normalized force was greater for median nerve stimulation than ulnar nerve stimulation in the DDF muscle, and the opposite relationship was observed for the SDF muscle. Final recording of dual supramaximal nerve stimulation of SDF and DDF muscles resulted in peak isometric forces of 716 +/- 192 N and 1,577 +/- 203 N, respectively. CONCLUSIONS The instrumentation technique and experimental protocol enabled recording of peak isometric forces in the SDF and DDF muscles of anesthetized adult horses. CLINICAL RELEVANCE Studies using this model will improve knowledge of SDF and DDF muscle mechanics with insight to functional implications of the complex architecture of these muscles. Knowledge of the dynamic performance of the SDF and DDF muscles would also be useful for the development of new treatment strategies for flexor deformities and tendon injuries in horses.
Collapse
Affiliation(s)
- Laura Zarucco
- Veterinary Medical Teaching Hospital, Biomedical Engineering Graduate Group, the Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, CA, USA
| | | | | | | | | | | | | |
Collapse
|
43
|
Zhao C, Amadio PC, Paillard P, Tanaka T, Zobitz ME, Larson DR, An KN. Digital resistance and tendon strength during the first week after flexor digitorum profundus tendon repair in a canine model in vivo. J Bone Joint Surg Am 2004; 86:320-7. [PMID: 14960677 DOI: 10.2106/00004623-200402000-00015] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND After flexor tendon repair, the strength of the repair and the resistance to digital motion are important considerations in deciding when to initiate postoperative rehabilitation. Our objective was to assess these factors in a short-term in vivo canine model of flexor tendon repair. METHODS Forty-eight dogs were randomly allocated to four groups based on the duration of postoperative follow-up (one, three, five, or seven days). In each group, two flexor digitorum profundus tendons of one forepaw were exposed. One tendon (the repair tendon) was sharply transected and repaired with a modified Kessler suture, and the other one (the sham tendon) was simply exposed without laceration. The involved paw was immobilized until the animal was killed on the designated day. Three tendons from each dog, including the repair tendon, the sham tendon, and a control tendon from a corresponding normal digit on the contralateral side, were tested. RESULTS The mean peak total digital resistance force in the repair group was lowest at five days (p < 0.01 compared with seven days; p > 0.05 compared with one and three days). The mean peak force needed to overcome the internal gliding resistance between the repaired tendon and sheath was significantly higher than that in both the sham and control groups at all time-points (p < 0.001); however, this value was also smallest at five days. There was no significant difference in suture strength at any time-point (p > 0.05). CONCLUSIONS When we evaluated tendon-gliding and suture strength after flexor tendon repair, the least favorable ratio of repair strength to force needed to overcome the resistance to digital motion was noted on Day 7, whereas the best combination of tendon strength and low peak resistance force was noted on Day 5.
Collapse
Affiliation(s)
- Chunfeng Zhao
- Orthopedic Biomechanics Laboratory, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA
| | | | | | | | | | | | | |
Collapse
|
44
|
Tanaka T, Amadio PC, Zhao C, Zobitz ME, Yang C, An KN. Gliding characteristics and gap formation for locking and grasping tendon repairs: a biomechanical study in a human cadaver model. J Hand Surg Am 2004; 29:6-14. [PMID: 14751096 DOI: 10.1016/j.jhsa.2003.09.017] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to compare the frictional characteristics and mechanical properties of various locking and grasping suture techniques in a human in vitro model of flexor tendon repair. METHODS Forty-five cadaveric human flexor digitorum profundus tendons were transected in zone II and repaired using 1 of 5 core suture methods (n = 9 per group): either grasping (modified grasping Kessler, modified Lee) or locking (Pennington, modified Pennington, locking Lee) loop suture techniques. All repairs used 4-0 Supramid looped core suture and an epitenon running suture of 6-0 nylon. Gliding resistance at the tendon-pulley interface was measured along with failure strength and gap formation. The force to produce 0.5-, 1.0-, 1.5-, and 2.0-mm gaps were measured. RESULTS One of the locking repairs, the locking Lee, had a gliding resistance significantly higher than that of one of the grasping repairs (modified grasping Kessler) and the other 2 locking repairs (Pennington, modified Pennington) (p <.05). There was no significant difference between the other grasping (modified Kessler, modified Lee) and locking (Pennington, modified Pennington) suture configurations (p =.21). The maximum force of one of the locking repairs, the modified Pennington repair (48.0 N; standard deviation, 3.9) was significantly higher than the other locking and grasping repairs (p <.05). The force required to produce more than 1.5 mm of gap for the modified Pennington repair was also significantly higher than that for some of the other grasping (modified Kessler, modified Lee) and locking (Pennington) repairs (p <.05). CONCLUSIONS The lack of significant difference in gliding resistance among the similarly designed modified grasping Kessler, Pennington, and modified Pennington repairs (overall mean, 0.87 N; standard deviation, 0.16) suggests that the locking loop configuration itself does not adversely affect tendon gliding resistance. The modified Pennington repair increased not only ultimate strength but also resistance to gap formation more than 1.5 mm.
Collapse
Affiliation(s)
- Tatsuro Tanaka
- Biomechanics Laboratory, Department of Orthopedics, Mayo Clinic Rochester, 200 First St SW, Rochester, MN 55905, USA
| | | | | | | | | | | |
Collapse
|
45
|
Boyer MI, Harwood F, Ditsios K, Amiel D, Gelberman RH, Silva MJ. Two-portal repair of canine flexor tendon insertion site injuries: histologic and immunohistochemical characterization of healing during the early postoperative period. J Hand Surg Am 2003; 28:469-74. [PMID: 12772107 DOI: 10.1053/jhsu.2003.50091] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE In vivo animal studies have indicated that the complex structure of the tendon-bone interface may not be restored after repair even under optimal conditions. Controversy exists about the histologic findings in the early postoperative period after tendon reattachment to bone; this may have impact on biomechanical properties. The objective was to study the histologic structure and immunohistochemical staining of the tendon-bone interface in a large model of digital flexor tendon-bone repair. The hypothesis was that the tendon-bone interface matures and assumes a progressively more anatomic histologic and immunohistochemical appearance during the first 6 weeks after repair. METHODS Twenty-four canine flexor digitorum profundus tendons were released from their insertion by sharp dissection and repaired to bone. The forelimb was immobilized after surgery and 10 minutes of daily passive motion rehabilitation was performed. Dogs were killed at 10, 21, and 42 days after surgery. Hematoxylin-eosin and immunohistochemical staining for types I, II, and II collagen were performed. RESULTS Although at both 10 and 21 days after surgery substantial inflammation was seen at the tendon-bone repair site, this had decreased markedly by 42 days. Although direct apposition of tendon to bone was seen at 42 days, the mature tendon-bone insertion site was not recreated by this time. Staining for types I and III collagen was diffuse throughout the tendon-bone insertion throughout the interval examined. CONCLUSION These findings suggest that at 6 weeks after surgery the intact tendon-bone repair site shows minimal histologic and molecular similarity when compared with unoperated specimens.
Collapse
Affiliation(s)
- Martin I Boyer
- Department of Orthopaedic Surgery, Barnes-Jewish Hospital at Washington University School of Medicine, St. Louis, MO 63130, USA
| | | | | | | | | | | |
Collapse
|
46
|
Abstract
Although advances in the treatment of flexor tendon injuries have led to improved clinical outcomes during the past several decades, a subset of patients continue to experience a loss of function. Using a canine model of sharp transection of the flexor digitorum profundus tendon followed by repair and rehabilitation using clinically relevant techniques, we have examined the influence of multistrand suture and postoperative rehabilitation variables on digital function and tendon strength. Our findings highlight the critical role of repair technique in providing a stiff and strong repair and indicate that continued refinement of suture techniques is warranted in order to minimize repair-site elongation (gap). Gap formation continues to occur at a high frequency, and the formation of gaps greater than 3 mm delays the accrual of repair-site strength that occurs with time. Furthermore, our results indicate that passive-motion rehabilitation that produces a moderate amount of tendon excursion (2 mm) at low levels of tendon force (5 N) is sufficient to inhibit adhesion formation and to promote healing. Increases in excursion or force beyond these levels do not accelerate the healing process. These findings suggest that we are approaching the limit of the extent to which we can modulate healing by manipulating rehabilitation variables such as tendon excursion and force. Future advances will probably require manipulation of the biological factors that promote healing.
Collapse
Affiliation(s)
- Matthew J Silva
- Department of Orthopaedic Surgery, Barnes-Jewish Hospital at Washington University School of Medicine, One Barnes-Jewish Hospital Plaza, Suite 11300 West Pavilion, St. Louis, MO 63110, USA
| | | | | |
Collapse
|
47
|
Boyer MI, Ditsios K, Gelberman RH, Leversedge F, Silva M. Repair of flexor digitorum profundus tendon avulsions from bone: an ex vivo biomechanical analysis. J Hand Surg Am 2002; 27:594-8. [PMID: 12132082 DOI: 10.1053/jhsu.2002.33708] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Avulsions or distal transections of the flexor digitorum profundus tendon are typically repaired by direct suture of the tendon stump to the distal phalanx. The optimal repair technique to withstand in vivo rehabilitation forces is unknown. Our objective was to determine the time-zero tensile mechanical properties of 4-strand tendon-bone repair site constructs performed with 3-0 and 4-0 sutures and with modified Kessler and modified Becker grasping techniques. We hypothesized that the 3-0 modified Becker grasping suture technique not described previously for the reattachment of tendon to bone would show improved biomechanical properties compared with the 4-0 or modified Kessler techniques. All modified Kessler repairs failed by suture pullout from the tendon, whereas all modified Becker repairs failed by rupture of the suture at the tendon-bone junction. Although the 3-0 modified Becker repair group showed greater ultimate force then the other groups (p <.01), tendon-bone gap observed did not differ markedly between Becker or Kessler groups. Neither suture caliber nor repair technique had a notable effect on strain at 20-N force, suggesting that early gap formation at the tendon-bone repair site may occur regardless of technique.
Collapse
Affiliation(s)
- Martin I Boyer
- Department of Orthopaedic Surgery, Barnes Jewish Hospital at Washington University, One Barnes Jewish Hospital, Suite 11300 West Pavilion, St. Louis, MO 63110, USA
| | | | | | | | | |
Collapse
|
48
|
Zhao C, Amadio PC, Zobitz ME, Momose T, Couvreur P, An KN. Effect of synergistic motion on flexor digitorum profundus tendon excursion. Clin Orthop Relat Res 2002:223-30. [PMID: 11859247 DOI: 10.1097/00003086-200203000-00033] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Clinical and experimental studies have shown that postoperative rehabilitation is an important factor that improves digital function after flexor tendon repair. In the current study, the effect of synergistic wrist and finger motion therapy and fixed flexed wrist motion therapy on the in vivo gliding excursion was evaluated after repair of partial laceration of the canine flexor digitorum profundus tendon. The gliding excursion of the repaired tendons treated with synergistic wrist and finger motion therapy was significantly greater than that of tendons rehabilitated with the wrist fixation therapy, suggesting that wrist extension generates force that can pull the repair site through the pulley, thereby increasing passive excursion of the tendon. As a result of increased tendon excursion, synergistic therapy may improve the clinical outcome after repair of partial tendon lacerations.
Collapse
Affiliation(s)
- Chunfeng Zhao
- Orthopedic Biomechanics Laboratory, Mayo Clinic/Mayo Foundation, Rochester, MN 55905, USA
| | | | | | | | | | | |
Collapse
|
49
|
Graf V, Papaloïzos M, Borisch N, Della Santa D. [Interest in early active controlled mobilization and flexion following flexor tendon repair in zone 2]. CHIRURGIE DE LA MAIN 2001; 20:458-65. [PMID: 11778333 DOI: 10.1016/s1297-3203(01)00072-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Primary repair of flexor tendons in zone II of the hand and early post-operative rehabilitation is no longer challenged. However, early rehabilitation methods vary from one unit to another. Although currents techniques such as of Kleinert's and Duran's have brought considerable improvements in functional outcomes, they do not allow early active motion of repaired flexor tendons. METHODS A promising method of active controlled mobilization has been proposed by the Bordeaux Hand Unit and adopted by our rehabilitation unity since 1995. The aims of this method are: to avoid of proprioceptive inhibition linked to passive methods and prevention of adhesions. This method has been assessed by a prospective study of 22 consecutive patients with average follow-up of 11.8 months. RESULTS Our rating was based on the Strickland scoring technique. 81% of good and excellent results were observed. Our score rates confirm the results published by others authors who have applied the same active protocols. The results observed in our series tend to confirm the advantages of early controlled active mobilization techniques and lead us to pursue their application in the future.
Collapse
Affiliation(s)
- V Graf
- Unité de chirurgie de la main, département de chirurgie, hôpital universitaire de Genève, Suisse
| | | | | | | |
Collapse
|
50
|
Zhao C, Amadio PC, Momose T, Couvreur P, Zobitz ME, An KN. The effect of suture technique on adhesion formation after flexor tendon repair for partial lacerations in a canine model. THE JOURNAL OF TRAUMA 2001; 51:917-21. [PMID: 11706340 DOI: 10.1097/00005373-200111000-00015] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Adhesion formation is a serious problem after flexor tendon repair. Many repair techniques have been developed to increase the suture strength after tendon repair surgery. The purpose of this study was to assess adhesion formation with different suture techniques in an in vivo canine model. METHODS Sixty flexor digitorum profundus tendons were partially lacerated (80%) and repaired with either a modified Kessler (MK) or Becker (MGH) suture technique and supplemented with a simple running suture. The dogs were sacrificed at 1 week, 3 weeks, or 6 weeks after surgery and the repaired tendons were evaluated for adhesion breaking strength. RESULTS At 1 week there was no significant difference between the two repair groups (p > 0.05). At 3 and 6 weeks, the adhesion breaking strength in the MK suture group was significantly less than that of the MGH suture group (p < 0.05). CONCLUSION High friction suture techniques may cause more adhesion formation than the lower friction suture techniques under passive postoperative therapy.
Collapse
Affiliation(s)
- C Zhao
- Orthopedic Biomechanics Laboratory, Mayo Clinic/Mayo Foundation, Rochester, Minnesota 55905, USA
| | | | | | | | | | | |
Collapse
|