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Imbergamo CM, Sequeira SB, Miles MR, Means KR. A Meta-Analysis of Biomechanical Studies for Suture Button Pullout Versus Suture Anchor Repair of Flexor Digitorum Profundus Avulsions. Hand (N Y) 2024; 19:671-678. [PMID: 36196928 PMCID: PMC11141426 DOI: 10.1177/15589447221126760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND There is no current consensus on which of the two most common flexor digitorum profundus (FDP) avulsion repair constructs, via suture button pullout (SBP) or suture anchor (SA), is biomechanically superior. Our purpose was to compare these repair methods via systematic review and meta-analysis of available literature. METHODS We performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-guided systematic review of PubMed, the Cochrane library, and Embase. We only included studies with direct comparison data for both techniques. We performed a meta-analysis comparing the reported biomechanical results using pooled data for initial repair stiffness (N/mm), gap formation (mm), and ultimate load to failure (N). RESULTS Seven studies met inclusion criteria, including a total of 201 cadaveric specimens. Four studies reported initial construct stiffness, with pooled analysis showing superiority for SA repairs (P < .05). Four studies evaluated gap formation, with pooled analysis demonstrating less gapping with SA repair (P < .05). Mean gap formation was 2.4 (±1.4) mm and 3.9 (±2.0) mm for the SA and SBP groups, respectively. All 7 studies assessed load to failure, with pooled analysis revealing no significant difference between groups (P > .05). We lacked statistical power to determine equivalence between techniques for load to failure. Both groups had failure values significantly lower than the native FDP. CONCLUSIONS Via meta-analysis, there was increased initial construct stiffness and less gap formation for SA compared to SBP for FDP reinsertion, with no significant differences for ultimate failure load.
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2
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Daniels SP, Kirby D, De Tolla J. Diagnosis and treatment of flexor tendon injuries of the hand: what the radiologist needs to know. Skeletal Radiol 2024; 53:597-608. [PMID: 37828095 DOI: 10.1007/s00256-023-04460-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 09/20/2023] [Accepted: 09/20/2023] [Indexed: 10/14/2023]
Abstract
This article reviews the diagnosis and treatment of flexor tendon injuries of the hand highlighting flexor tendon anatomy, important pre-operative imaging findings, surgical options, and post-operative complications. Imaging plays a key role in guiding treatment of these difficult to manage injuries. Thus, it is important for radiologists to have a sound understanding of factors important in treatment decision-making. In the pre-operative setting, accurately identifying the location of the torn proximal tendon stump in subacute and chronic injuries helps dictate whether the patient is a candidate for a primary flexor tendon repair or may require a tendon reconstruction to restore function. In the post-operative setting, the status of the repair and presence of surrounding adhesions help dictate if and when the patient will require subsequent surgery and whether that surgery will be a tenolysis, revision repair, reconstruction, or fusion.
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Affiliation(s)
- Steven P Daniels
- Department of Radiology, New York University Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA.
| | - David Kirby
- Department of Orthopedic Surgery, New York University Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA
| | - Jadie De Tolla
- Department of Orthopedic Surgery, New York University Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA
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3
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Li W, Hammert WC. Complications and Clinical Outcomes Following Zone I Flexor Tendon Repair Using All-Inside Suture Fixation. J Hand Surg Am 2024; 49:383.e1-383.e6. [PMID: 36202675 DOI: 10.1016/j.jhsa.2022.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 06/29/2022] [Accepted: 08/05/2022] [Indexed: 11/07/2022]
Abstract
PURPOSE The purpose of this study was to evaluate complications and outcomes of an all-inside repair technique for flexor digitorum profundus (FDP) avulsions. METHODS A retrospective review of a single institution database identified all FDP avulsions that were repaired using an all-inside technique by a single surgeon. In this method, 2 Keith needles are drilled from the volar to dorsal aspect, exiting proximal to the nail matrix and within the extensor tendon. Nonabsorbable sutures were placed in the flexor tendon and passed through the bone tunnels, tying dorsally over the distal phalanx. The demographics characteristics, injury characteristics, the surgical procedure, postoperative complications, and outcomes were reviewed. RESULTS Seventeen patients were included in the study. The average age was 40 years (range, 21-68 years), and 2 patients were women. Seventeen fingers were included: 14 ring fingers, 1 index finger, and 2 little fingers. Six patients had an associated distal phalanx fracture and one had an associated distal interphalangeal joint dislocation. The average time between injury and surgery was 9 days (range, 2-18 days). Four patients had complications: 3 with erythema related to infection, which appeared to be a reaction to the suture prompting removal, and 1 with a subungual mass related to the suture at removal. One patient had persistent pain. Postoperative range of motion, assessed using the Strickland criteria, was excellent or good in 5 (33%) of 15 patients, but this was predominantly due to motion at the proximal joints as overall DIP motion was limited. Patients had a mean distal interphalangeal joint range of motion of 24° (range, 0° to 55°). CONCLUSIONS In our series, repair of FDP avulsions via all-inside suture fixation is associated with limited distal interphalangeal joint motion and an incidence of infection (24%) at final follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic V.
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Affiliation(s)
- Wei Li
- University of Rochester School of Medicine, Rochester, NY
| | - Warren C Hammert
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC.
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4
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Belyea CM, Abbasi P, Sanghavi KK, Giladi AM, Means KR. All-Suture Anchor Repair of the Flexor Digitorum Profundus Insertion: A Biomechanical Comparison of 2 Suturing Techniques. J Hand Surg Am 2023; 48:1276.e1-1276.e7. [PMID: 35778231 DOI: 10.1016/j.jhsa.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 03/22/2022] [Accepted: 05/11/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE We compared 2 suturing techniques for reattachment of the flexor digitorum profundus (FDP) via all-suture anchor. METHODS We used fresh, matched-pair, cadaveric hands. We disarticulated the fingers at the proximal interphalangeal joints, preserving the proximal FDP. We released the FDPs at their distal insertion and placed an all-suture, 1.0-mm anchor at the center of each FDP footprint. Each anchor's sutures were used to reattach each FDP using 1 of 2 techniques: group H (n = 14) via horizontal mattress; group H + K (n = 12) via horizontal mattress with knots thrown and, with each suture tail, 3 proximal, running-locking, Krackow-type passes on the radial and ulnar FDP sides with the suture ends tied together. We excluded 2 specimens from the H + K group because of improper anchor placement. All other fingers in both groups were individually mounted in an MTS machine for FDP loading in the following sequence for 500 cycles each: (1) to 15 N to simulate passive motion forces; (2) to 19 N for short-arc active motion forces; and (3) to 28 N for full active motion forces. Specimens that had not failed during cyclic testing were then loaded to failure. We measured FDP-to-bone gapping via a digital transducer. We defined failure as >3-mm gapping. RESULTS The H + K group had significantly less gapping during cyclic loading up to 19 N and significantly higher load to failure. The H + K group failed exclusively at the anchor-bone level; the H group failed mostly by suture-tendon pullout. CONCLUSIONS The H + K group performed significantly better regarding cyclic and load-to-failure testing after FDP reattachment. CLINICAL RELEVANCE The H + K technique combines the benefits of horizontal-mattress tendon-to-bone apposition and Krackow-tendon locking. It converts the point of failure to the bone level rather than the suture-tendon level.
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Affiliation(s)
- Christopher M Belyea
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD; Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Pooyan Abbasi
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - Kavya K Sanghavi
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - Aviram M Giladi
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - Kenneth R Means
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD.
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Harenberg PS, Grünert JG, Christen SM. The Transosseous Internal Four Strand Technique: A New All-Inside Technique for Zone 1 Flexor Tendon Repairs. Hand (N Y) 2023; 18:628-634. [PMID: 34963321 PMCID: PMC10233645 DOI: 10.1177/15589447211060430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Multiple techniques for the repair of flexor tendon injuries in zone 1 have been proposed over time. While pull-out suture techniques and bone anchor seem to be stronger than internal suture techniques, they are associated with a higher complication rate. We therefore developed an alternative internal suture repair with similar biomechanical stability to those of pull-out sutures and bone anchors. METHODS Twenty porcine distal phalanges and deep flexor tendons were randomized to 2 groups of 10 each. The tendons were transsected at the level of the distal interphalangeal joint. In group 1, repairs were performed with a well-established intraosseous suture repair and in group 2 with our new multistrand technique. The repairs were biomechanically tested with linear distraction until failure. RESULTS We recorded a significantly higher 2-mm gap force (2GF)-and thus higher stability-of the repairs in group 1 in comparison to group 2. With a 2GF of more than 50 N, our suture technique allows for a modern early active motion rehabilitation protocol. Breakage of the suture construct occurred at random places in the repair in both groups. No pull-outs were noted. CONCLUSIONS This study presents a strong transosseous multistrand repair technique for flexor tendon repair in zone 1 that is simple and fast to perform and should have enough strength to withstand early active motion rehabilitation.
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Affiliation(s)
- Patrick S. Harenberg
- BG University Hospital Bergmannsheil
Bochum, Germany
- Kantonsspital St. Gallen,
Switzerland
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6
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Aletto C, Aicale R, Oliva F, Maffulli N. Hand Flexor Tendon Repair: From Biology to Surgery and Rehabilitation. Hand Clin 2023; 39:215-225. [PMID: 37080653 DOI: 10.1016/j.hcl.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
Tendon biology and anatomy are crucial to manage hand flexor tendon injuries, not only for surgical treatment but also for rehabilitation; surgeon and physical therapist have to choose zone by zone the best way to manage and restore the normal function of hand flexor tendons.
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Affiliation(s)
- Cristian Aletto
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Baronissi 84084, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, Salerno 84131, Italy.
| | - Rocco Aicale
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Baronissi 84084, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, Salerno 84131, Italy
| | - Francesco Oliva
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Baronissi 84084, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, Salerno 84131, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Baronissi 84084, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, Salerno 84131, Italy; Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London E1 4DG, England; Keele University, Faculty of Medicine, School of Pharmacy and Bioengineering, Guy Hilton Research Centre, Thornburrow Drive, Hartshill, Stoke-on-Trent ST4 7QB, UK
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7
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Hesse N, Reidler P, Schmitt R. [Sports-related injuries of the thumb and fingers]. RADIOLOGIE (HEIDELBERG, GERMANY) 2023; 63:284-292. [PMID: 36917239 DOI: 10.1007/s00117-023-01127-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 02/01/2023] [Indexed: 03/16/2023]
Abstract
Finger and thumb injuries are common in established and trend sports. Imaging plays an important role in acute trauma care, further therapy planning, and ultimately for a rapid return to play. Sound knowledge of the complex anatomy of the fingers and thumb is indispensable for accurate diagnosis. This article presents the ligament anatomy of the metacarpophalangeal and interphalangeal joints of the finger and the thumb, the extensor and flexor tendon apparatus, and the diagnosis of typical sports injuries using x‑rays and magnetic resonance imaging. Furthermore, imaging findings of typical sports-associated injuries are illustrated.
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Affiliation(s)
- N Hesse
- Klinik und Poliklinik für Radiologie, Ludwig-Maximilians-Universität (LMU) München, Ziemssenstr. 5, 81377, München, Deutschland.
| | - P Reidler
- Klinik und Poliklinik für Radiologie, Ludwig-Maximilians-Universität (LMU) München, Ziemssenstr. 5, 81377, München, Deutschland
| | - R Schmitt
- Klinik und Poliklinik für Radiologie, Ludwig-Maximilians-Universität (LMU) München, Ziemssenstr. 5, 81377, München, Deutschland.,Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Würzburg, Würzburg, Deutschland
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8
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Carroll TJ, O'Donnell M. Isolated Avulsion Fracture of the Extensor Carpi Ulnaris: A Case Report and Review of Literature. Cureus 2023; 15:e36504. [PMID: 37090358 PMCID: PMC10119743 DOI: 10.7759/cureus.36504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 04/25/2023] Open
Abstract
Avulsion fractures of the extensor carpi ulnaris (ECU) insertion are rare injuries that are poorly described in the literature. Several case reports detail closed ECU ruptures, however, only one previous case report describes an ECU avulsion fracture from the insertion on the fifth metacarpal base in the setting of multiple wrist and hand injuries. To our knowledge, we present the only case report of an isolated ECU avulsion fracture. In our case, a 35-year-old female presented with ulnar-sided wrist pain after forcefully impacting a steering wheel while radially deviating her wrist. She was diagnosed with an ECU avulsion fracture and elected to undergo open repair with a suture button technique. The patient recovered to nearly full strength and range of motion compared to her contralateral side by her eight-week visit. She returned back to work without restrictions after completing hand therapy.
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Affiliation(s)
| | - Marc O'Donnell
- Orthopedic Surgery, University of Rochester, Rochester, USA
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9
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Fathy Sadek A, Azmy MM, Nady Saleh Elsaid A, Zein AMN, Yehya Hasan M. Repair of flexor digitorum profundus avulsions including the palmar plate: a retrospective comparative study of 56 cases. J Hand Surg Eur Vol 2022; 47:633-638. [PMID: 35107344 DOI: 10.1177/17531934221074514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We retrospectively reviewed 56 fingers with a type 1 flexor digitorum profundus avulsion (jersey finger) injury. Nineteen fingers were treated with a four-strand pull-out suture technique that did not include the distal palmar plate, and 37 were treated with a six-strand pull-out suture technique that included the distal palmar plate. An early active mobilization regimen was used. At follow-up (mean 13 and 14 months, respectively), total active interphalangeal joint motion was significantly better in the six-strand/palmar plate group, as were the results assessed with the Strickland-Glogovac grading system and patient satisfaction according to the Stark criteria. No repair ruptures occurred in this group versus two ruptures in the four-strand/no-palmar-plate group. We consider that the better results can be attributed to a stronger repair, which facilitated early active mobilization.Level of evidence: III.
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Affiliation(s)
- Ahmed Fathy Sadek
- Orthopaedic Surgery Department, Faculty of Medicine, Minia University, Minia, Egypt
| | - Mohamed M Azmy
- Orthopaedic Surgery Department, Faculty of Medicine, Minia University, Minia, Egypt
| | | | - Asem M N Zein
- Orthopaedic Surgery Department, Faculty of Medicine, Minia University, Minia, Egypt
| | - Mohamed Yehya Hasan
- Orthopaedic Surgery Department, Faculty of Medicine, Minia University, Minia, Egypt
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10
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Compton J, Wall LB, Romans S, Goldfarb CA. Outcomes of Acute Repair Versus Nonrepair of Zone I Flexor Digitorum Profundus Tendon Injuries. J Hand Surg Am 2022:S0363-5023(22)00120-4. [PMID: 35414448 DOI: 10.1016/j.jhsa.2022.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 12/14/2021] [Accepted: 02/02/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this study was to determine whether the clinical results of zone I flexor digitorum profundus (FDP) tendon injuries managed with acute surgical repair are comparable to the clinical results of those managed without repair (eg, primary FDP excision or observation). METHODS Patients aged ≥18 years presenting to a level 1 trauma center between 2015 and 2020 with zone I FDP tendon injury were identified with retrospective chart review. We assessed the following data: age, sex, physical therapy visits, surgical intervention, surgical complications (including infection, repeat surgery after the primary intervention, and rupture of repair), and patient-reported outcomes measurement information system scores. RESULTS Twenty-six patients met the inclusion criteria. Group 1 (N = 15 patients, 23 fingers) patients were treated with acute surgical repair. Group 2 (N = 11 patients, 11 fingers) patients were managed without surgical repair, including FDP excision (N = 7) or observation alone (N = 4). In group 1, the average distance from the distal palmar crease to fingertip at the final follow-up was 1.6 cm (range, 0-4 cm). Fourteen of the 15 patients participated in >3 therapy visits. The following complications occurred: 4 fingers with rerupture (2 patients), 4 fingers with surgical wound dehiscence (2 patients), 3 infections (2 patients), and 4 repeat surgeries for these complications. In group 2, the average distance from the distal palmar crease to fingertip at the final follow-up was 1.1 cm (range, 0.5-3 cm). There were no infections, episodes of wound dehiscence, or repeat surgeries. At the final follow-up, both groups showed clinically meaningful improvement on Patient Reported Outcomes Measurement Information System (PROMIS) upper extremity, pain interference, and physical function scores, with similar PROMIS domain scores between groups. CONCLUSIONS Patients treated without FDP tendon repair had similar outcomes to, and fewer complications than, patients treated with acute tendon repair. Our data suggest that the notable commitment of health care costs, time, and adherence to protocols/restrictions after surgical repair may not confer functional benefit. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Jocelyn Compton
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Lindley B Wall
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Sarah Romans
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Charles A Goldfarb
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO.
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11
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Mortimer JW, Alsaykhan H, Vadibeler S, Rust PA, Paxton JZ. Anatomy and histomorphology of the flexor digitorum profundus enthesis: functional implications for tissue engineering and surgery. BMC Musculoskelet Disord 2021; 22:1032. [PMID: 34893040 PMCID: PMC8665545 DOI: 10.1186/s12891-021-04922-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/12/2021] [Indexed: 11/28/2022] Open
Abstract
Background The enthesis possesses morphological adaptations across the soft-hard tissue junction which are not fully restored during surgical avulsion repairs. This loss of anatomical structure, highly related to function, contributes to poor clinical outcomes. Investigating the native macro- and micro-structure of a specific enthesis can provide functional and biomechanical insights to develop specialised, novel tissue-engineered therapeutic options and potentially improve current surgical treatments for avulsion injuries. Methods This study examines the anatomy and histomorphology of the flexor digitorum profundus (FDP) enthesis in 96 fresh-frozen human cadaveric fingers, quantitatively and qualitatively analyzing the shape, size, angle of tendon fibres and histological architecture, and explores differences in sex, finger and distance along the enthesis using linear mixed effects models. Results Macroscopically, results showed a consistent trapezoidal insertion shape of 29.29 ± 2.35 mm2 mean surface area, but with significant morphometric size differences influenced primarily by the smaller dimensions of the little finger. Microscopically, a fibrocartilaginous enthesis was apparent with a 30.05 ± 0.72o mean angle of inserting tendon fibres, although regional variation in fibrocartilage and the angle change of tendon fibres before insertion existed. Conclusions The implication of these findings on native and specific FDP enthesis function is discussed whilst providing recommendations for optimal FDP enthesis recreation for interfacial tissue engineers and hand surgeons. The study emphasizes the importance of region-specific knowledge whilst also describing methods applicable to assessing any soft tissue insertion. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04922-1.
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Affiliation(s)
- Jeremy W Mortimer
- Anatomy@Edinburgh, Deanery of Biomedical Sciences, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, EH8 9AG, UK
| | - Hamad Alsaykhan
- Anatomy@Edinburgh, Deanery of Biomedical Sciences, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, EH8 9AG, UK
| | - Subashan Vadibeler
- Anatomy@Edinburgh, Deanery of Biomedical Sciences, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, EH8 9AG, UK
| | - Philippa A Rust
- Anatomy@Edinburgh, Deanery of Biomedical Sciences, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, EH8 9AG, UK.,Hooper Hand Unit, St John's Hospital, Livingston, Edinburgh, UK
| | - Jennifer Z Paxton
- Anatomy@Edinburgh, Deanery of Biomedical Sciences, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, EH8 9AG, UK.
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12
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Kong AC, Kitto A, Pineda DE, Miki RA, Alfonso DT, Alfonso I. Four Anchor Repair of Jersey Finger. THE IOWA ORTHOPAEDIC JOURNAL 2021; 41:95-100. [PMID: 34924876 PMCID: PMC8662931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Various surgical techniques for treating avulsions of the flexor digitorum profundus tendon at the distal phalanx have been published but no ideal technique has emerged. We introduce a new all-internal 4-anchor flexor tendon repair technique and evaluate outcomes in three clinical cases. METHODS In this retrospective case series, we reviewed three patients that sustained an avulsion of the flexor digitorum profundus tendon at the distal phalanx. All patients were surgically treated with the four-anchor repair technique. Two titanium anchors were inserted into the distal phalanx and two all-suture anchors were inserted distal to the first set of anchors. The tendon was then attached to these four anchors using a Krackow stitch pattern and the anchors were sown to each other. Active flexion and extension of the proximal and distal interphalangeal joint were measured at 3-month, 12-month, and 5-year follow-up. Postoperative complications were documented. RESULTS All patients achieved excellent clinical outcomes according to assessment criteria. At 3-month follow-up, all patients regained full flexion; two patients had full extension, while one patient was 3 degrees short of full extension. At 12-month follow-up, all patients had full flexion and extension. Five-year follow-up demonstrated the same results with no loss of function, sensation or grip strength. The repairs healed without rupture, and no complications were reported. CONCLUSION The 4-anchor flexor tendon repair is a viable surgical technique for zone 1 flexor digitorum profundus tendon repair or reconstruction. Further studies are needed to replicate these promising results and biomechanically validate this technique.Level of Evidence: IV.
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Affiliation(s)
- Adrian C. Kong
- Department of Orthopedics, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Alex Kitto
- Department of Orthopedics and Physical Rehabilitation, University of Massachusetts Medical School, Worcester, MA, USA
| | | | - Roberto A. Miki
- Department of Orthopedics, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
- Miki & Alfonso Hand & Upper Extremity Center, Miami, FL, USA
| | | | - Israel Alfonso
- Department of Neurology, Khalifa University College of Medicine and Health Sciences, Abu Dhabi, United Arab Emirates
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13
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Rosskopf AB, Martinoli C, Sconfienza LM, Gitto S, Taljanovic MS, Picasso R, Klauser A. Sonography of tendon pathology in the hand and wrist. J Ultrason 2021; 21:e306-e317. [PMID: 34970442 PMCID: PMC8678645 DOI: 10.15557/jou.2021.0052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/15/2021] [Indexed: 11/28/2022] Open
Abstract
Traumatic and non-traumatic tendon lesions are common at the wrist and hand. For the diagnosis, therapy management, and long-term prognosis of tendon lesions, a detailed understanding of the complex anatomy and knowledge of typical injury patterns is crucial for both radiologists and clinicians. Improvements in high-resolution ultrasound are producing high-quality images of the superficial tendinous and peritendinous structures. Thus, ultrasound is a valuable first-choice tool for visualizing traumatic, inflammatory, and degenerative conditions of the extensor and flexor tendons, particularly with the advantage of possible dynamic examination. The additional use of duplex-Doppler and power Doppler ultrasound imaging is recommended for detection of tenosynovitis in overuse injury, inflammatory disease, infection, and after traumatic conditions. In traumatic tendon injuries, knowing the precise injury zone is important for treatment decision-making. In cases of tendon rupture, the radiologist should report the tear type (i.e., complete or partial-thickness) and assess the degree of tendon retraction and associated avulsion injury, including the degree of fragment displacement. The function of intact flexor tendons may be impaired by thickening, strain, or rupture of corresponding annular pulleys. This review describes in detail the typical ultrasound imaging features of common pathologies of hand and wrist tendons, including annular pulley lesions.
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Affiliation(s)
- Andrea B Rosskopf
- Radiology, Balgrist University Hospital, University of Zurich, Switzerland.,Radiology, ARISTRA, Switzerland
| | - Carlo Martinoli
- Department of Health Science (DISSAL), Università di Genova, Italy.,IRCCS, Ospedale Policlinico San Martino, Italy
| | - Luca M Sconfienza
- IRCCS, Istituto Ortopedico Galeazzi, Italy.,Department of Biomedical Sciences for Health, University of Milano, Italy
| | - Salvatore Gitto
- Department of Biomedical Sciences for Health, University of Milano, Italy
| | - Mihra S Taljanovic
- Department of Radiology, University of New Mexico, United States.,Departments of Medical Imaging and Orthopaedic Surgery, University of Arizona, United States
| | | | - Andrea Klauser
- Department of Radiology, Division of Rheumatology and Sports Imaging, Medical University Innsbruck, Austria
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Lane O'Neill B, Beecher SM, Cahill KC. Flexor digitorum profundus avulsion repair with a syringe button construct. J Hand Surg Eur Vol 2021; 46:899-900. [PMID: 34013790 DOI: 10.1177/17531934211016669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Billy Lane O'Neill
- Department of Plastic & Reconstructive Surgery, St James's Hospital, Dublin, Ireland
| | - Suzanne M Beecher
- Department of Plastic & Reconstructive Surgery, St James's Hospital, Dublin, Ireland
| | - Kevin C Cahill
- Department of Plastic & Reconstructive Surgery, St James's Hospital, Dublin, Ireland
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15
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Riedel BB, Miller RE, Chen YH, Wongworawat D. Intramedullary Suture Anchor Fixation of a Type Vb Flexor Digitorum Profundus Avulsion: A Case Report. JBJS Case Connect 2021; 11:01709767-202109000-00031. [PMID: 34264876 DOI: 10.2106/jbjs.cc.21.00044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE Flexor digitorum profundus avulsions are common injuries that manifest as tendinous or bony avulsions from the distal phalanx. Rarely, additional fractures can occur in the distal phalanx. For such injuries, repair of the avulsion and fracture is recommended but difficult because of limited bone stock for fixation. CONCLUSION We present a case of a 28-year-old man with a combined flexor digitorum profundus bony avulsion and bony mallet finger, and describe a strategic fixation technique using an intramedullary suture anchor and dorsal button that provided stable fixation and resulted in excellent motion and function, with return to sport at 12 weeks.
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Affiliation(s)
- Barth B Riedel
- Loma Linda University Medical Center, Loma Linda, California
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16
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Rosskopf AB, Taljanovic MS, Sconfienza LM, Gitto S, Martinoli C, Picasso R, Klauser A. Pulley, Flexor, and Extensor Tendon Injuries of the Hand. Semin Musculoskelet Radiol 2021; 25:203-215. [PMID: 34082447 DOI: 10.1055/s-0041-1727196] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Tendon injuries represent the second most common injury of the hand (after fractures) and are a common scanning indication in radiology. Pulley injuries are very frequent in rock climbers with the A2 pulley the most commonly affected. Tendon and pulley injuries can be reliably evaluated using ultrasound (US) and magnetic resonance imaging (MRI). US can be postulated as a first-line imaging modality, allowing dynamic examination. MRI is essential for cases with ongoing diagnostic doubt post-US and also for preoperative pulley reconstruction assessment.
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Affiliation(s)
- Andrea B Rosskopf
- Department of Radiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.,Department of Radiology, ARISTRA, Zurich, Switzerland
| | - Mihra S Taljanovic
- Department of Medical Imaging, University of Arizona, Business, SimonMed Imaging, Scottsdale, Arizona
| | - Luca M Sconfienza
- IRCCS Istituto Ortopedico Galeazzi, Milano, Italy.,Department of Biomedical Sciences for Health, University of Milano, Milano, Italy
| | - Salvatore Gitto
- Department of Biomedical Sciences for Health, University of Milano, Milano, Italy
| | - Carlo Martinoli
- Cattedra di Radiologia-DISC, Università di Genova, Genova, Italy
| | - Riccardo Picasso
- Cattedra di Radiologia-DISC, Università di Genova, Genova, Italy
| | - Andrea Klauser
- Department of Radiology, Division of Rheumatology and Sports Imaging, Medical University Innsbruck, Innsbruck, Austria
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17
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Christen SM, Gruenert JG, Harenberg PS. Transosseous Sutures in Tendon-to-Bone Repairs: the Role of the Epitendinous Suture. J INVEST SURG 2021; 35:584-590. [PMID: 33784920 DOI: 10.1080/08941939.2021.1904464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Numerous transosseous fixation techniques for flexor tendon injuries in Zone 1 of the hand have been described in the literature. While relatively high maximal loads to failure are documented in different biomechanical experiments, several tests revealed a low 2 mm gapping resistance of the tendon-to-bone repairs. We therefore aimed to investigate the effect on gap formation adding a peripheral suture to an established transosseous fixation technique. In addition, we analyzed the influence of different suture materials (braided vs. non-braided) on the stability of the core suture. METHOD A total of 30 porcine flexor digitorum profundus tendons were divided into 3 groups (n = 10 each) and repaired using the transverse intraosseous loop technique (TILT). In group 1 and group 2 the repairs were performed using PDS 3-0 or Ethibond 3-0, respectively. In group 3, a peripheral suture was added to the core suture (PDS 3-0) consisting of two figure-of-eight stitches with PDS 5-0. The biomechanical performance of the repaired tendons was analyzed using a standardized protocol. RESULTS The suture material and peripheral suture showed no effect on the ultimate failure load in our testing. However, the addition of a peripheral suture led to a statistically significantly higher 2 mm gap force when compared with the repair with a core suture only. CONCLUSION In conclusion, addition of a palmar epitendinous suture to the transosseous core suture significantly increases the load to 2 mm gap formation in Zone 1 flexor tendon repairs and thus allows an immediate controlled mobilization.
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Affiliation(s)
- Samuel M Christen
- Department of Hand, Plastic and Reconstructive Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Jörg G Gruenert
- Department of Hand, Plastic and Reconstructive Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Patrick S Harenberg
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
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18
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Geary MB, Li KK, Chadderdon RC, Gaston RG. Complications Following Transosseous Repair of Zone I Flexor Tendon Injuries. J Hand Surg Am 2020; 45:1183.e1-1183.e7. [PMID: 32723570 DOI: 10.1016/j.jhsa.2020.05.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 04/16/2020] [Accepted: 05/25/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE Multiple techniques are described for repair of zone I flexor tendon injuries, many of which are fraught with complications. This study evaluated the clinical complications after a transosseous repair technique. METHODS A retrospective review of a single institutional database identified all zone I flexor digitorum profundus (FDP) injuries repaired using a transosseous technique. In this technique, 2 nonabsorbable sutures were passed from volar to dorsal through transosseous tunnels and tied dorsally over the distal phalanx proximal to the germinal matrix. Demographics, injury characteristics, operative details, and complications were reviewed. RESULTS Eight patients met the inclusion criteria. Average age was 31 years (range, 15-66 years) and all patients were male. Eight fingers were included: ring (4), small (3), and middle (1). Seven injuries were closed and one was open. Average time between injury and surgery was 13 days (range, 4-34 days). Five patients experienced complications, including osteomyelitis, chronic draining granuloma, and abnormal nail growth. Three patients required an additional operative procedure for management of complications. CONCLUSIONS Transosseous repair of zone I flexor digitorum profundus injuries with a buried dorsal suture is associated with a high rate of clinical complications. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic V.
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Affiliation(s)
- Michael B Geary
- Department of Orthopaedics, Atrium Health/Carolinas Medical Center, Charlotte, NC
| | - Katherine K Li
- Department of Orthopaedics, Atrium Health/Carolinas Medical Center, Charlotte, NC
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19
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Abstract
This article describes a novel technique for flexor digitorum profundus (FDP) avulsion injuries, useful for Leddy Packer type 3, 4, and 5 injuries. Multidirectional stability is achieved with combination pull-out suture, which neutralizes the deforming force of FDP, and cerclage wire, which holds the bone fragment in an anatomic position and provides interfragmentary compression. Traditional techniques such as interosseous wires, Kirschner wires, or plating risk fragment comminution and loss of reduction due to proximal pull of FDP as demonstrated in this case report of failed Kirschner-wire fixation. The technique presented here eliminates the risk of avulsion fragment comminution and provides stable fixation that allows for early mobilization.
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20
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Bond S, Rust P, Boland M. The Accommodation of Bone Anchors Within the Distal Phalanx for Repair of Flexor Digitorum Profundus Avulsions. J Hand Surg Am 2019; 44:986.e1-986.e6. [PMID: 30777399 DOI: 10.1016/j.jhsa.2018.12.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 10/19/2018] [Accepted: 12/11/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE Avulsion injury of the flexor digitorum profundus (FDP) tendon has been traditionally repaired with a pull-out suture over the nail plate. Complication rates with this method and improvements in anchor design have led to the increased use of bone anchors to give a rigid all-inside repair. However, the dimensions of the distal phalanx may limit their use. The primary hypothesis was that 2 micro bone anchors could fit in either perpendicular or 45° proximally angled positions within each distal phalanx. A further hypothesis was that 1 mini bone anchor could fit in similar positions in the distal phalanx. METHODS Thirty-two fresh frozen fingers were dissected, and the FDP tendon was removed from the distal phalanx footprint. Two bone anchor types were used, mini and micro sizes, and inserted at 2 angles, perpendicular and 45° proximally angled. Observations of dorsal cortex and joint space penetration were recorded. Distal phalanx dimensions were measured for each finger. RESULTS The micro anchors penetrated the dorsal cortex in perpendicular tests in little fingers only. The micro anchor did not penetrate the joint in any angled tests. The mini bone anchor penetrated the dorsal cortex in 100% of perpendicular tests and the joint in 63% of angled tests, although none of these included the middle finger. CONCLUSIONS Two micro bone anchors fit within the distal phalanx in all fingers tested, except the little finger, when placed in the perpendicular position. At a 45° angle, the distal phalanx of the little finger can also accommodate micro bone anchors without any evidence of complication when placed 4 mm from the joint. The mini anchors were too large to fit in a perpendicular position within the distal phalanx. In the 45° angled position, the joint was not penetrated by the mini anchor in only middle fingers. CLINICAL RELEVANCE The study provides anatomical evidence of the accommodation of micro bone anchors within the distal phalanx in perpendicular or 45° angled positions for the repair of FDP tendon avulsion injury.
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Affiliation(s)
- Sarah Bond
- Anatomy, University of Edinburgh, Edinburgh
| | - Philippa Rust
- Hooper Hand Surgery Unit, St. John's Hospital, Livingston, Scotland.
| | - Maria Boland
- Hooper Hand Surgery Unit, St. John's Hospital, Livingston, Scotland
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21
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Putnam JG, Adamany D. Biomechanical Comparison of Flexor Digitorum Profundus Avulsion Repair. J Wrist Surg 2019; 8:312-316. [PMID: 31402995 PMCID: PMC6685782 DOI: 10.1055/s-0039-1685470] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 03/04/2019] [Indexed: 01/28/2023]
Abstract
Purpose Multiple repair techniques have been investigated for flexor digitorum profundus (FDP) tendon avulsions. The purpose of this study is to compare the biomechanical characteristics of a new fully threaded titanium suture anchor with previously examined fixation techniques. Methods Repair of FDP tendon avulsions was performed in 18 fresh-frozen cadavers using one of three implants: Nano Corkscrew FT 1.7 mm suture anchor (Group 1; Arthrex, Inc., Naples, FL; n = 6), Mitek Micro 1.3 mm suture anchor (Group 2; Mitek Surgical Products, Westwood, MA; n = 6), or pullout suture button fixation (Group 3; n = 6). Constructs were preloaded before testing load to failure. For each trial, elongation at 20 N and maximum load, mean load to failure, stiffness, and failure mechanism were recorded. Results Load to failure occurred in all trials. Mean load to failure was significantly greater for Group 1 (61.6 ± 18.9 N) compared to Group 2 (42.5 ± 4.2 N; p < 0.05) and Group 3 (41.6 N ± 8.0 N; p < 0.05). Stiffness was significantly greater in Groups 1 and 2 compared to Group 3 (6.9 ± 2.2 N/mm vs. 6.1 ± 0.8 N/mm vs. 3.1 N/mm ± 0.5 N/mm, respectively, p < 0.01). Mechanism of failure differed between the groups: Group 1 broke at the anchor in two trials and tore through the tendon in three trials, Group 2's suture universally broke at the anchor, and Group 3's trials mainly failed at the button. Conclusions The Nano Corkscrew anchor (Group 1) has a significantly higher load to failure when compared with the other techniques. The higher load to failure of the corkscrew anchor provides a secure method for flexor tendon repair in zone I. Clinical Relevance A fully threaded titanium suture anchor used for FDP tendon avulsion injuries is likely to withstand early active range of motion protocols.
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Affiliation(s)
- Jill G. Putnam
- Department of Orthopaedic Surgery, University of Arizona College of Medicine—Phoenix, Phoenix, Arizona
| | - Damon Adamany
- The Center for Orthopaedic Research and Education, Phoenix, Arizona
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22
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Polfer EM, Sabino JM, Katz RD. Zone I Flexor Digitorum Profundus Repair: A Surgical Technique. J Hand Surg Am 2019; 44:164.e1-164.e5. [PMID: 30309664 DOI: 10.1016/j.jhsa.2018.08.015] [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: 05/10/2018] [Revised: 08/13/2018] [Accepted: 08/24/2018] [Indexed: 02/02/2023]
Abstract
We present an all-inside technique for zone I flexor tendon repair that combines suture anchor fixation with buried back-up fixation. The back-up fixation uses transosseous tunnels and a dorsal counterincision to allow a suture tied dorsal to the distal phalanx and buried. This technique is strong and permits early active range of motion. The dorsal tie-over does not require a suture button and, therefore, does not imperil the nail matrix. The surgical technique is herein described including the proposed anesthesia (wide awake), the incisions (midlateral), the exposures, and the repair itself.
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Affiliation(s)
- Elizabeth M Polfer
- Walter Reed National Military Medical Center, MedStar Union Memorial Hospital, Bethesda, MD; Curtis National Hand Center, Baltimore, MD
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23
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Bai RJ, Zhang HB, Zhan HL, Qian ZH, Wang NL, Liu Y, Li WT, Yin YM. Sports Injury-Related Fingers and Thumb Deformity Due to Tendon or Ligament Rupture. Chin Med J (Engl) 2018; 131:1051-1058. [PMID: 29692376 PMCID: PMC5937313 DOI: 10.4103/0366-6999.230721] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background: Hand injuries are very common in sports, such as skiing and ball sports. One of the major reasons causing hand and finger deformity is due to ligament and tendon injury. The aim of this study was to investigate if the high-resolution 3T magnetic resonance imaging (MRI) can demonstrate the complex anatomy of the fingers and thumb, especially the tendons and ligaments, and provide the accurate diagnosis of clinically important fingers and thumbs deformity due to ligamentous and tendinous injuries during sport activities. Methods: Sixteen fresh un-embalmed cadaveric hands were harvested from eight cadavers. A total of 20 healthy volunteers' hands and 44 patients with fingers or thumb deformity due to sports-related injuries were included in this study. All subjects had MR examination with T1-weighted images and proton density-weighted imaging with fat suppression (PD FS) in axial, coronal, and sagittal plane, respectively. Subsequently, all 16 cadaveric hands were sliced into 2-mm thick slab with a band saw (six in coronal plane, six in sagittal plane, and four in axial plane). The correlation of anatomic sections and the MRI characteristics of tendons of fingers and the ulnar collateral ligament (UCL) at the metacarpal phalangeal joint (MCPJ) of thumb between 20 healthy volunteers and 44 patients (confirmed by surgery) were analyzed. Results: The normal ligaments and tendons in 16 cadaveric hands and 20 volunteers' hands showed uniform low-signal intensity on all the sequences of the MRI. Among 44 patients with tendinous and ligamentous injuries in the fingers or thumb, 12 cases with UCL injury at MCPJ of the thumb (Stener lesion = 8 and non-Stener lesion = 4), 6 cases with the central slip injury, 12 cases with terminal tendon injury, and 14 cases with flexor digitorum profundus injury. The ligaments and tendons disruption manifested as increased signal intensity and poor definition, discontinuity, and heterogeneous signal intensity of the involved ligaments and tendons. Conclusions: Sports injury-related fingers and thumb deformity are relatively common. MRI is an accurate method for evaluation of the anatomy and pathologic conditions of the fingers and thumb. It is a useful tool for accurate diagnosis of the sports-related ligaments and tendons injuries in hand.
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Affiliation(s)
- Rong-Jie Bai
- Department of Radiology, Beijing Jishuitan Hospital, Beijing Institute of Traumatology and Orthopedics, Beijing 100035, China
| | - Hui-Bo Zhang
- Department of Radiology, Beijing Chaoyang Hospital of Capital Medical University, Beijing 100020, China
| | - Hui-Li Zhan
- Department of Radiology, Beijing Jishuitan Hospital, Beijing Institute of Traumatology and Orthopedics, Beijing 100035, China
| | - Zhan-Hua Qian
- Department of Radiology, Beijing Jishuitan Hospital, Beijing Institute of Traumatology and Orthopedics, Beijing 100035, China
| | - Nai-Li Wang
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing 100005, China
| | - Yue Liu
- Department of Radiology, Beijing Jishuitan Hospital, Beijing Institute of Traumatology and Orthopedics, Beijing 100035, China
| | - Wen-Ting Li
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing 100005, China
| | - Yu-Ming Yin
- Radiology Associates, LLP, 1814 South Alameda Street, Corpus Christi, TX 78404, USA
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24
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Abstract
Flexor tendon injuries of the hand are uncommon, and they are among the most challenging orthopaedic injuries to manage. Proper management is essential to ensure optimal outcomes. Consistent, successful management of flexor tendon injuries relies on understanding the anatomy, characteristics and repair of tendons in the different zones, potential complications, rehabilitation protocols, recent advances in treatment, and future directions, including tissue engineering and biologic modification of the repair site.
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25
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Tempelaere C, Brun M, Doursounian L, Feron JM. Traumatic avulsion of the flexor digitorum profundus tendon. Jersey finger, a 29 cases report. HAND SURGERY & REHABILITATION 2017; 36:368-372. [PMID: 28694076 DOI: 10.1016/j.hansur.2017.06.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 12/21/2016] [Accepted: 06/19/2017] [Indexed: 11/30/2022]
Abstract
Traumatic avulsion of flexor digitorum profundus (jersey finger) is an uncommon injury. Our study aimed to describe functional outcomes of jersey fingers after surgical treatment. From January 2004 to 2014, we performed surgery on 32 patients who had jersey finger. Twenty-six of these patients were male and 6 were female with a mean age of 37.2years (range 16-68). Of the 32 cases, 11 were sports injuries, 16 presented on the ring finger and 13 on the little finger. Using the Leddy and Packer and Smith classifications, 16 of the injuries were type I, 4 were type II, 5 were type III, 7 were type IV. The mean time between injury and surgery was 6.8days (range: 0-32). The surgical techniques used were anchor, pull-out, or an association of both these techniques. Prior to the patient discharge, functional outcomes were evaluated. Twenty-nine patients were evaluated in total and three patients were lost. Of the 29, the average time between surgery and discharge was 36.6months ranging from 4.5 to 118months. According to the Buck-Gramcko classification, six patients had an excellent result, six had a good result, seven had a satisfactory result and ten a poor result. The mean Quick DASH score immediately to prior discharge was 5.66 (range: 0-56.82). Twelve complications were reported on nine patients. No infections were reported. Rapid diagnosis and rapid surgical treatment led to restoration of full range motion.
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Affiliation(s)
- C Tempelaere
- Service de chirurgie orthopédique, CHU Saint Antoine, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France.
| | - M Brun
- Service de chirurgie orthopédique, CHU Saint Antoine, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France; Clinique du Mont-Louis, 8-10, rue de la Folie-Regnault, 75011 Paris, France
| | - L Doursounian
- Service de chirurgie orthopédique, CHU Saint Antoine, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - J-M Feron
- Service de chirurgie orthopédique, CHU Saint Antoine, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
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26
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Azeem MA, Marwan Y, Morshidy AE, Esmaeel A, Zakaria Y. A New Classification Scheme for Closed Avulsion Injuries of the Flexor Digitorum Profundus Tendon. J Hand Surg Asian Pac Vol 2017; 22:46-52. [PMID: 28205464 DOI: 10.1142/s0218810417500083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Closed avulsion injury of the flexor digitorum profundus (FDP) tendon is a relatively common condition of the hand. Its present classification system seems to be deficient in including all possible patterns of injury, leading to improper selection of the best treatment method for the injury. We aim to provide a new classification scheme for this injury. METHODS We developed a new classification scheme based on the possible pattern of FDP tendon injury. It consisted of three main types, and 10 sub-types. This was used to classify the injury of 34 patients, and help in choosing the best management approach. All patients underwent surgical treatment of their injury. The distal interphalangeal (DIP) joint extension deficit and total active motion (TAM) of the proximal interphalangeal (PIP) and DIP joints were considered as the main outcomes. Five orthopaedic surgeons used the new classification system for our cases, and the inter-rater reproducibility was tested with Fleiss' kappa. RESULTS The multi-rater kappa for the classification was excellent. At the final follow-up visit 24 months following surgery, the mean loss of extension of the DIP joint was 13.76° ± 13.53° (range 0° to 45°), while the mean TAM was 148.88° ± 22.64° (range 94° to 172°). Based on the TAM score, 21 (61.76%), 8 (23.53%) and 5 (14.71%) patients had excellent, good and fair results, respectively. None of our patients had poor results. CONCLUSIONS Our new classification scheme of FDP tendon avulsion appeared to be comprehensive and useful in guiding the surgeon for the best treatment option. Nevertheless, this should be confirmed by using it for larger number of patients with different patterns of injury.
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Affiliation(s)
- Mokhtar Abdul Azeem
- * Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Al-Razi Orthopaedic Hospital, Kuwait City, Kuwait.,† Division of Hand and Microsurgery, Department of Orthopaedic Surgery, Al-Razi Orthopaedic Hospital, Kuwait City, Kuwait.,‡ Department of Orthopaedic Surgery, Al-Azhar University Hospitals, Cairo, Egypt
| | - Yousef Marwan
- * Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Al-Razi Orthopaedic Hospital, Kuwait City, Kuwait.,§ Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Ahmed El Morshidy
- § Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Ali Esmaeel
- * Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Al-Razi Orthopaedic Hospital, Kuwait City, Kuwait.,∥ Division of Orthopaedic Surgery, Department of Surgery, Faculty of Medicine, Health Sciences Center, Kuwait University, Kuwait City, Kuwait
| | - Yehia Zakaria
- * Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Al-Razi Orthopaedic Hospital, Kuwait City, Kuwait.,¶ Department of Plastic Surgery, Al-Babtain Hospital, Kuwait City, Kuwait.,** Department of Plastic Surgery, Zagazig University, Zagazig, Egypt
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27
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Diagnosis, Treatment, and Return to Play for Four Common Sports Injuries of the Hand and Wrist. J Am Acad Orthop Surg 2016; 24:853-862. [PMID: 27792055 DOI: 10.5435/jaaos-d-15-00388] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Hand and wrist injuries in the high-level athlete are challenging because they may be underestimated by the patient, family, and team, and return to play may be longer than desired. The needs of the player and the team must be balanced with the long-term functional ramifications of the injury. Four common soft-tissue sports injuries are flexor digitorum profundus avulsion, flexor pulley rupture, extensor carpi ulnaris dislocation, and thumb metacarpophalangeal joint ulnar collateral ligament injury. For each of these injuries, the assessment, treatment, and considerations for return to play should be individualized on the basis of the patient, the sport, and the timing of the injury.
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28
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Fletcher DR, McClinton MA. Single-Stage Flexor Tendon Grafting: Refining the Steps. J Hand Surg Am 2015; 40:1452-60. [PMID: 26026357 DOI: 10.1016/j.jhsa.2015.04.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 04/15/2015] [Indexed: 02/02/2023]
Abstract
Single-stage tendon grafting for reconstruction of zone I and II flexor tendon injuries is a challenging procedure in hand surgery. Careful patient selection, strict indications, and adherence to sound surgical principles are mandatory for return of digital motion.
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Affiliation(s)
- Derek R Fletcher
- Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - Michael A McClinton
- Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD.
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29
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Abdul Azeem M, Marwan Y, Esmaeel A. Avulsion Injuries of the Flexor Digitorum Profundus Tendon: An Unclassified Pattern of Injury. HAND SURGERY : AN INTERNATIONAL JOURNAL DEVOTED TO HAND AND UPPER LIMB SURGERY AND RELATED RESEARCH : JOURNAL OF THE ASIA-PACIFIC FEDERATION OF SOCIETIES FOR SURGERY OF THE HAND 2015; 20:319-21. [PMID: 26051779 DOI: 10.1142/s0218810415720144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Closed avulsion of the flexor digitorum profundus (FDP) tendon is classified based on the impact of injury on the management plan. In this report, we present a case with unclassified pattern of FDP tendon avulsion. The injury involves an intra-articular fracture of the volar part of distal phalanx of the little finger resulting into two bony fragments, one attached to the retracted avulsed tendon and another separated and incarcerated at A4 pulley, and an intact dorsal cortex of the phalanx. Based on that, we recommend the development of a new classification scheme for this condition.
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Affiliation(s)
- Mokhtar Abdul Azeem
- * Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Al-Razi Orthopaedic Hospital, Kuwait.,† Division of Hand and Microsurgery, Department of Orthopaedic Surgery, Al-Razi Orthopaedic Hospital, Kuwait City, Kuwait.,‡ Department of Orthopaedic Surgery, Al-Azhar University Hospitals, Cairo, Egypt
| | - Yousef Marwan
- * Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Al-Razi Orthopaedic Hospital, Kuwait
| | - Ali Esmaeel
- * Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Al-Razi Orthopaedic Hospital, Kuwait.,‡ Division of Orthopaedic Surgery, Department of Surgery, Faculty of Medicine, Health Sciences Center, Kuwait University, Kuwait City, Kuwait
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Brar R, Owen JR, Melikian R, Gaston RG, Wayne JS, Isaacs JE. Reattachment of flexor digitorum profundus avulsion: biomechanical performance of 3 techniques. J Hand Surg Am 2014; 39:2214-9. [PMID: 25227598 DOI: 10.1016/j.jhsa.2014.07.054] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 07/10/2014] [Accepted: 07/12/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate whether inclusion of the volar plate in repair of flexor digitorum profundus avulsions increases the strength of the repair and resists gapping. METHODS Cadaveric fingers (n = 18) were divided into 3 equal groups. The first technique involved 2 micro-suture anchors only (A). The second used only volar plate repair (VP). The third group was a hybrid, combining a micro-suture anchor with volar plate augmentation (AVP). Specimens were loaded cyclically to simulate passive motion rehabilitation before being loaded to failure. Clinical failure was defined as 3 mm of gapping, and physical failure as the highest load associated with hardware failure, suture breakage, anchor pullout, or volar plate avulsion. RESULTS Gapping throughout cycling was significantly greater for the A group than VP and AVP with no difference detected between VP and AVP groups. Gapping exceeded 3 mm during cycling of 3 A specimens, but in none of the VP or AVP specimens. Load at clinical and physical failure for A was significantly lower than for VP and AVP, whereas no difference was detected between VP and AVP. CONCLUSIONS In this cadaveric model, incorporating the volar plate conferred a significant advantage in strength, increasing the mean load to physical failure by approximately 100 N. CLINICAL RELEVANCE According to previous biomechanical studies, current reconstructive strategies for flexor digitorum profundus zone I avulsions are not strong enough to withstand active motion rehabilitation. We demonstrated the potential use of volar plate augmentation and the prospective advantageous increase in strength in this cadaveric model. In vivo performance and effects on digital motion are not known.
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Affiliation(s)
- Ravinder Brar
- Orthopaedic Research Laboratory, Departments of Orthopaedic Surgery and Biomedical Engineering, Virginia Commonwealth University, Richmond, VA; OrthoCarolina Hand Center, Charlotte, NC
| | - John R Owen
- Orthopaedic Research Laboratory, Departments of Orthopaedic Surgery and Biomedical Engineering, Virginia Commonwealth University, Richmond, VA; OrthoCarolina Hand Center, Charlotte, NC
| | - Raymond Melikian
- Orthopaedic Research Laboratory, Departments of Orthopaedic Surgery and Biomedical Engineering, Virginia Commonwealth University, Richmond, VA; OrthoCarolina Hand Center, Charlotte, NC
| | - R Glenn Gaston
- Orthopaedic Research Laboratory, Departments of Orthopaedic Surgery and Biomedical Engineering, Virginia Commonwealth University, Richmond, VA; OrthoCarolina Hand Center, Charlotte, NC
| | - Jennifer S Wayne
- Orthopaedic Research Laboratory, Departments of Orthopaedic Surgery and Biomedical Engineering, Virginia Commonwealth University, Richmond, VA; OrthoCarolina Hand Center, Charlotte, NC
| | - Jonathan E Isaacs
- Orthopaedic Research Laboratory, Departments of Orthopaedic Surgery and Biomedical Engineering, Virginia Commonwealth University, Richmond, VA; OrthoCarolina Hand Center, Charlotte, NC.
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Yavuz H, Ata AM, Özçakar L. Ultrasound imaging of a partial flexor digitorum profundus tear due to a bony spur. PM R 2014; 7:334-5. [PMID: 25459657 DOI: 10.1016/j.pmrj.2014.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 10/23/2014] [Accepted: 10/25/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Hülya Yavuz
- Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey(∗).
| | - Ayşe Merve Ata
- Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey(†)
| | - Levent Özçakar
- Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey(‡)
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Abstract
Fractures of the hand are common injuries and in particular, fractures involving the articular surfaces can present difficulties to the orthopedic surgeon in practice. Although the treatment of these fractures needs to be individualized based on fracture pattern and location, the goals for these fractures are to restore the alignment, stability, and congruity and to allow for early motion to prevent stiffness and traumatic arthritis. This article classifies the various types of intra-articular hand fractures as well as the workup and management of these injuries.
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Affiliation(s)
- Nikhil Oak
- Department of Orthopaedic Surgery, University of Michigan, 1500 East Medical Center Drive, 2912 Taubman Center, Ann Arbor, MI 48109, USA
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Huq S, George S, Boyce DE. The outcomes of zone 1 flexor tendon injuries treated using micro bone suture anchors. J Hand Surg Eur Vol 2013; 38:973-8. [PMID: 23390152 DOI: 10.1177/1753193413475748] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This article evaluates the outcome of 42 consecutive zone 1 flexor tendon injuries treated by using micro bone anchors during the period 2003-2008. Patients were rehabilitated using the modified Belfast Regime. The range of motion at the distal interphalangeal joint was assessed using Moiemen's classification. A total of 56% of patients achieved excellent or good results for range of motion at the distal interphalangeal joint and 23% had a poor outcome. The mean distal interphalangeal joint and proximal interphalangeal joint range of motion were 48° and 96°, respectively. A total of 94% of patients returned back to work by 12 weeks. One patient sustained a tendon rupture and one developed osteomyelitis. The mean QuickDASH score was 13.5 and 81% of patients were satisfied with their outcomes. This is the largest clinical study on the use of bone anchors for zone 1 tendon injuries. Our study demonstrated a low rate of complications and outcomes that compare favourably with other published techniques.
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Affiliation(s)
- S Huq
- Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, UK
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Huq S, George S, Boyce D. Zone 1 flexor tendon injuries: A review of the current treatment options for acute injuries. J Plast Reconstr Aesthet Surg 2013; 66:1023-31. [DOI: 10.1016/j.bjps.2013.04.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 04/04/2013] [Accepted: 04/06/2013] [Indexed: 11/24/2022]
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Chu JY, Chen T, Awad HA, Elfar J, Hammert WC. Comparison of an all-inside suture technique with traditional pull-out suture and suture anchor repair techniques for flexor digitorum profundus attachment to bone. J Hand Surg Am 2013; 38:1084-90. [PMID: 23578439 PMCID: PMC4426886 DOI: 10.1016/j.jhsa.2013.02.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Revised: 01/25/2013] [Accepted: 02/01/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE One goal in repairing zone 1 flexor digitorum profundus (FDP) injuries is to create a tendon-bone construct strong enough to allow early rehabilitation while minimizing morbidity. This study compares an all-inside suture repair technique biomechanically with pull-out suture and double-suture anchor repairs. METHODS Repairs were performed on 30 cadaver fingers. In all-inside suture repairs (n = 8), the FDP tendon was attached to bone with two 3-0 Ethibond sutures and tied over the dorsal aspect of distal phalanx. Pull-out suture repairs (n = 8) were performed with 2-0 Prolene suture and tied over a dorsal button. There were 2 suture anchor repair groups: Arthrex Micro Corkscrew anchors preloaded with 2-0 FiberWire suture (n = 7) and Depuy Micro Mitek anchors preloaded with 3-0 Orthocord suture (n = 7). Repair constructs were tested using a servohydraulic materials testing system and loaded until the repair lost 75% of its strength. RESULTS There were no statistically significant differences in tensile stiffness, ultimate load, or work to failure between the repairs. Failure mode was suture stretch and gap formation greater than 2 mm at the repair site for all pull-out suture repairs and for 7 of 8 all-inside suture repairs. Two of the Arthrex Micro Corkscrew repairs and 5 of the Depuy Micro Mitek repairs failed by anchor pull-out. CONCLUSIONS This cadaveric biomechanical study showed no difference in tensile stiffness, ultimate load, and work to failures between an all-inside suture repair technique for zone 1 FDP repairs and previously described pull-out suture and suture anchor repair techniques. The all-inside suture technique also has the advantages of avoiding an external button and the cost of anchors. Therefore, it should be considered as an alternative to other techniques. CLINICAL RELEVANCE This study introduces a new FDP reattachment technique that avoids some of the shortcomings of current techniques.
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Affiliation(s)
- Jennifer Y Chu
- University of Rochester Medical Center Department of Orthopaedic Surgery and Rehabilitation Rochester, NY
| | - Tony Chen
- University of Rochester Medical Center Center for Musculoskeletal Research Rochester, NY, University of Rochester Medical Center Department of Biomedical Engineering Rochester, NY
| | - Hani A. Awad
- University of Rochester Medical Center Center for Musculoskeletal Research Rochester, NY, University of Rochester Medical Center Department of Biomedical Engineering Rochester, NY
| | - John Elfar
- University of Rochester Medical Center Department of Orthopaedic Surgery and Rehabilitation Rochester, NY
| | - Warren C. Hammert
- University of Rochester Medical Center Department of Orthopaedic Surgery and Rehabilitation Rochester, NY
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Abstract
This article summarizes select multinational early motion protocols. Included are flexor and extensor protocols for digital tendon repair in many forms. Custom orthosis design, exercise regimens, and advanced techniques are examples of what to expect. The goal of the article is to expose the reader to new ideas, educate regarding advanced techniques in tendon rehabilitation, and stimulate independent study to further the reader's skill set.
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Pulp tissue anchor repair for the zone I flexor tendon injury: introduction of a new and cost-effective technique. EUROPEAN JOURNAL OF PLASTIC SURGERY 2013. [DOI: 10.1007/s00238-012-0713-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Suture anchors are an important tool in the orthopedist's armamentarium. Their use is prevalent in surgery of the entire upper limb. Suture anchors have mostly obviated the need for multiple drill holes when striving for secure fixation of soft tissue to bone. As with most other orthopedic products, the designs of these anchors and the materials used to fabricate them have evolved as their use increased and their applications became more widespread. It is ultimately the surgeon's responsibility to be familiar with these rapidly evolving technologies and to use the most appropriate anchor for any given surgery.
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Affiliation(s)
- Min Jung Park
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, 2501 Christian Street 103, Philadelphia, PA 19146, USA
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