The Washington Regimen: rehabilitation of the hand following flexor tendon injuries

This article describes the use of the "Washington Regimen" of early controlled motion in the rehabilitation of flexor tendon injuries of the hand. This regimen is derived from a combination of Kleinert's controlled active extension with rubber-hand passive flexion, Duran's controlled passive techniques, and the modification of the Kleinert orthosis that uses a palmar pulley system. Based on results of clinical investigations, this regimen of early controlled motion appears effective in inhibiting peritendinous scarring, joint contractures, and other complications that commonly occur secondary to flexor tendon repairs. A six-week staged regimen of postoperative rehabilitation is presented. Splint design, exercise regimen, and rationale for treatment are reviewed.     

鸡肌腱的玻璃化冷冻保存

目的：筛选出适合于肌腱玻璃化冷冻保存的溶液及保存程序，并通过细胞培养来进一步检测玻璃化肌腱的活性。方法：实验于2003-11／2005—02在解放军总医院骨科研究所完成。实验包括（1）筛选与检测：取来亨鸡30只，切取屈趾深肌腱，按随机数字法分为2组，新鲜鸡肌腱组，玻璃化组。运用正交设计和肌腱活性快速检测技术，筛选出适合鸡屈趾肌腱玻璃化保存程序，再从6种玻璃化溶液中（二甲基亚砜＋乙酰胺＋丙二醇＋聚乙二醇；乙二醇＋二甲基亚砜＋蔗糖；乙二醇＋二甲基亚砜＋丁二醇；丙二醇＋二甲基亚砜＋蔗糖；二甲基亚砜＋乙酰胺＋丙二醇；二甲基亚砜＋丙二醇）筛选出适于肌腱玻璃化保存的配比方案。②细胞培养：将玻璃化法保存鸡屈趾深肌腱进行细胞培养，观察培养后细胞的存活情况，以了解玻璃化法保存肌腱的细胞活性。结果：①通过统计学分析，肌腱玻璃化保存的最佳程序为平衡处理选择4℃3个浓度梯度、平衡时间选择4℃30min、洗脱处理选择4℃3个浓度梯度、洗脱时间选择4℃20min。玻璃化溶液二甲基亚砜＋丙二醇为的最佳配比方案。②应用酶消法测得新鲜肌腱活性为89．26％，玻璃化法优化组合所保存肌腱的活性为78．49％。（3）将玻璃化组肌腱进行细胞培养，细胞第8天自组织块周边长出，第21天后传代，培养3代后出现明显的退化现象，玻璃化组肌腱细胞的生物学特性与新鲜肌腱组相似。④将两组肌腱所培养的细胞分别进行免疫组织化学染色，经鉴定均为肌腱细胞。结论：玻璃化法冷冻保存的肌腱具有良好的细胞活性，经细胞培养获得成功，其生物学特性无明显变异。     

鸡肌腱的玻璃化冷冻保存

目的:筛选出适合于肌腱玻璃化冷冻保存的溶液及保存程序,并通过细胞培养来进一步检测玻璃化肌腱的活性。方法:实验于2003-11/2005-02在解放军总医院骨科研究所完成。实验包括①筛选与检测:取来亨鸡30只,切取屈趾深肌腱,按随机数字法分为2组,新鲜鸡肌腱组,玻璃化组。运用正交设计和肌腱活性快速检测技术,筛选出适合鸡屈趾肌腱玻璃化保存程序,再从6种玻璃化溶液中(二甲基亚砜 乙酰胺 丙二醇 聚乙二醇;乙二醇 二甲基亚砜 蔗糖;乙二醇 二甲基亚砜 丁二醇;丙二醇 二甲基亚砜 蔗糖;二甲基亚砜 乙酰胺 丙二醇;二甲基亚砜 丙二醇)筛选出适于肌腱玻璃化保存的配比方案。②细胞培养:将玻璃化法保存鸡屈趾深肌腱进行细胞培养,观察培养后细胞的存活情况,以了解玻璃化法保存肌腱的细胞活性。结果:①通过统计学分析,肌腱玻璃化保存的最佳程序为平衡处理选择4℃3个浓度梯度、平衡时间选择4℃30min、洗脱处理选择4℃3个浓度梯度、洗脱时间选择4℃20min。玻璃化溶液二甲基亚砜 丙二醇为的最佳配比方案。②应用酶消法测得新鲜肌腱活性为89.26%,玻璃化法优化组合所保存肌腱的活性为78.49%。③将玻璃化组肌腱进行细胞培养,细胞第8天自组织块周边长出,第21天后传代,培养3代后出现明显的退化现象,玻璃化组肌腱细胞的生物学特性与新鲜肌腱组相似。④将两组肌腱所培养的细胞分别进行免疫组织化学染色,经鉴定均为肌腱细胞。结论:玻璃化法冷冻保存的肌腱具有良好的细胞活性,经细胞培养获得成功,其生物学特性无明显变异。     

屈指肌腱Ⅱ区与V区修复术后早期主动运动方案的疗效对比

目的：观察Ⅱ区与V区屈肌腱修复术后早期康复治疗的疗效。方法：将38例屈肌腱修复术后患者依损伤部位分Ⅱ区组20例（46指）和V区组18例（44指）。2组患者术后均采用背侧石膏托固定、物理因子疗法、运动疗法等治疗。术后12周时进行总主动活动范围测量法（TAM ）和上肢功能指数（UEFI）评定。结果：治疗12周后,V区组TAM优良率及UEFI评分均明显高于Ⅱ区组（P＜0．05）。V区组指间关节伸直缺失明显低于Ⅱ区组（P＜0．01）。结论：屈肌腱修复术后早期采用主动运动方案安全有效,而且V区损伤后手指活动度和日常生活能力的恢复均优于Ⅱ区。     

Psychometric characteristics of Duruoz Hand Index in patients with traumatic hand flexor tendon injuries

Introduction.?The aim of the study was to assess reliability, validity and responsiveness of Duruoz Hand Index (DHI), which has been developed for evaluation of activity limitation in rheumatoid arthritis in patients with traumatic hand flexor tendon injuries.

Material and method.?Sixty-five patients older than 16 years who underwent surgical intervention after flexor tendon injuries were enrolled. Reliability was assessed by internal consistency (with Cronbach's-α) and test-retest intraclass correlation coefficient (ICC). Construct validity was estimated correlating the scale with the DASH and VAS-hd. Also responsiveness was estimated using standardised response mean (SRM) and effect size (ES).

Result.?Mean age of the patients was 30.25 ± 11.07 years and totally 140 fingers were evaluated. Cronbach's-α and ICC values of DHI were found to be 0.87 and 0.99, respectively. In validation study, highly significant correlation was detected between DHI with DASH and VAS-hd (r == 0.86, r == 0.54, p < 0.0001, respectively). SRM values and ES values (excepting workplaces subgroup score) were higher than 0.80 for total and all subgroup scores.

Conclusion.?DHI is a reliable, valid questionnaire to assess hand-related activity limitation in patients with traumatic hand flexor tendon injuries. Also, due to its high level responsiveness DHI can be used for assessing the clinical course of the traumatic hand flexor tendon injured patient.     

Rehabilitation of fingers after flexor tendon lesions qualified for secondary reconstruction, using Kleinert's dynamic splinting method

Background. Primary reconstruction of flexor tendons lesions resulting from serious hand mutilations is not always possible. This causes problems in the rehabilitation of finger joints that are unable to perform active flexion. There is no generally accepted approach to such cases. The authors used a dynamic splinting regimen to treat fingers with unrepaired flexor tendons qualified for secondary reconstruction. Material and methods. Our research involved 39 patients treated in the Department Limb Replantation at St. Jadwiga's Hospital in Trzebnica, Poland, who had been referred for flexor tendon repair (from 1 to 3) in secondary reconstruction. The time from the primary operation ranged from 10 to 14 weeks. There were 27 men and 12 women, ranging in age from 19 to 60 years (ave. 39.5), divided into two groups. 24 patients (group I) had their fingers mobilized by dynamic splinting method, while in 14 patients (group II) no specific regimen of rehabilitation applied: the patients mobilized their fingers with their unimpaired hand. Results. The loss of total passive motion of finger joints was up to 75.65 degrees (~29%) greater in group II. Conclusions. The method applied is very effective in maintaining a wide range of passive motion in finger joints, which is essential for secondary flexor tendon reconstruction.     

屈肌腱损伤术后早期运动方案与影响手功能恢复的相关因素

目的:探讨手部肌腱损伤术后实施康复训练时间、受伤手指数及年龄等相关因素与手功能恢复的关系。方法:肌腱损伤患者77例,根据其开始康复训练距离手术的时间选择合适的矫形器进行处理,指导患者进行主动伸指,被动屈指的活动。分别于手术后6,12周用“CARROLL手功能评估表”和总主动活动度(TAM)对手功能进行评估,用SPSS10.0对所得数据及年龄、开始康复的术后天数、受伤手指数等进行多重线性回归分析筛选对手功能康复有统计学意义的变量。用ONEWAYANOVA分析开始接受康复的手术周数对术后6周和12周患者手功能和TAM的影响。结果:经逐步回顾筛选,对术后6周的手功能有统计学意义的变量为开始康复的术后天数X1和受伤手指数X2,偏回归系数b1为-2.761(P<0.0005),b2为-4.773(P<0.0005);对术后6周TAM有意义的变量同上,偏回归系数b1为-5.314(P<0.0005),b2=-6.241(P=0.006)。对术后12周手功能和TAM有影响的变量为开始康复的术后天数X1,偏回归系数b1分别为-1.942(P<0.0005),-6.029(P<0.0005)。开始接受康复距离手术的周数和对应术后6周和12周手功能和ATM均数的二维图显示手功能和TAM第1周与第2周的差异最具显著性意义。结论:早期活动是影响肌腱损伤患者长期预后的关键因素。     

正中神经松解术联合屈肌腱滑膜切除治疗腕管综合征的疗效

目的 探讨正中神经松解术联合屈肌腱滑膜切除治疗腕管综合征(CTS)的疗效.方法 选择2017年1月至2018年12月上海德济医院诊治的CTS患者117例为研究对象,按照手术方式不同分为观察组(74例,接受正中神经松解术联合屈肌腱滑膜切除治疗)和对照组(43例,接受正中神经松解术治疗).比较两组疗效,手术前后握力、捏力、上肢功能评定量表(DASH)评分、上肢功能指数量表(UEFI)评分、Levine CTS问卷调查表结果,以及拇短展肌肌肉复合动作电位(CMAP)、中环指感觉神经动作电位(SNAP)的潜伏期和波幅.结果 观察组的疗效优良率为95.95％,高于对照组的81.40％,差异有统计学意义(P<0.05).治疗后两组握力、捏力、UEFI评分、拇短展肌CMAP波幅、中环指SNAP潜伏期和波幅较治疗前明显升高,DASH评分、症状评分、功能评分、钝痛评分、夜间症状评分、拇短展肌CMAP潜伏期较治疗前明显降低,差异有统计学意义(P<0.05).治疗后观察组握力、捏力、UEFI评分,以及拇短展肌CMAP波幅、中环指SNAP潜伏期和波幅高于对照组,DASH评分、症状评分、功能评分、钝痛评分、夜间症状评分,以及拇短展肌CMAP潜伏期低于对照组,差异有统计学意义(P<0.05).结论 正中神经松解术联合屈肌腱滑膜切除治疗CTS疗效显著,能够促进腕关节功能恢复,改善患者症状.     

Rehabilitation following repair of a torn latissimus dorsi tendon

BACKGROUND AND PURPOSE: This report describes the rehabilitation of a patient following surgical repair of a torn latissimus dorsi tendon. The scientific rationale for the treatment progression is discussed. CASE DESCRIPTION: A 35-year-old man with a ruptured latissimus dorsi tendon 6 weeks following surgical repair was referred for physical therapy to recover range of motion and strength sufficient for return to work as a police officer on the SWAT team. A review of tendon healing in animal studies is presented and related to the development of the plan of care for this patient. OUTCOMES: Latissimus dorsi muscle isometric force generation on the injured side was 92% of that of the uninjured side. The patient returned to work as a SWAT team member. DISCUSSION: No detailed reports of postoperative latissimus dorsi tendon rehabilitation are available. The program for this patient was based on research demonstrating the timeline for recovery of tensile strength in healing tendons. This approach can direct rehabilitation following repair of other tendons, especially in uncommon injuries where specific guidelines have not been developed.     

满足手屈肌腱断裂修复后早期功能锻炼的修复方法探讨

目的 探索满足肌腱早期活动的缝合方法。方法 采用 3种缝合方法并进行强度和疲劳试验,术后进行早期功能训练。结果 最大强度 (N)：改良 Kessler法 29.7± 6.3, Tsuge法 45.9± 4.8,本文方法 58.4± 5.4。疲劳试验 (次 )：改良 Kessler法 19± 7, Tsuge法 36± 7,本文方法 53± 9。操作时间 (min)：改良 Kessler法 5.2± 0.4, Tsuge法 4.3± 0.6,本文方法 10.6± 2.8。未发生肌腱二次断裂, TAM平均 (247± 13),为健侧的 92％。结论 本文方法是强度最大的缝合方法 ,有利于早期功能训练,防止肌腱粘连。     

鸡趾屈肌腱鞘内损伤修复后的愈合和bFGF的表达

目的：了解鸡趾屈肌腱鞘内损伤修复后碱性成纤维细胞生长因子（bFGF）的表达及其与肌腱愈合的关系。方法：将36只来亨鸡的右足第3趾趾屈长肌腱切断后缝合并重新覆以腱鞘，于术后不同时间点切取标本（每个时间点6只），另取6只未行手术处理鸡的肌腱标本作为对照。将标本行组织学检查，并用RT—PCR和免疫组化方法测定肌腱bFGF的表达。结果：肌腱修复后断端先出现炎细胞浸润。接着成纤维细胞聚集并分泌胶原，最后胶原纤维重新塑形。这些细胞活动在腱实质比腱鞘、腱外膜出现迟且弱。bFGF在对照组肌腱仅出现低水平表达．而在实验组肌腱各个时间点均明显上调；腱鞘、腱外膜的表达明显高于腱实质。结论：bFGF参与了鸡趾屈肌腱损伤修复的愈合过程。     

脱细胞羊膜预防生物衍生肌腱修复鸡屈趾肌腱Ⅱ区缺损修复后的粘连

背景：羊膜有预防肌腱修复后粘连的作用,但存在一定的免疫排斥反应。目的：探讨脱细胞羊膜对生物衍生肌腱修复鸡屈趾深肌腱Ⅱ区缺损修复后肌腱粘连的预防作用。方法：分别以罗曼鸡右爪的第2,3,4趾将实验分成生物衍生肌腱组,生物衍生肌腱＋脱细胞羊膜组以及自体肌腱组,建立屈趾深肌腱Ⅱ区1cm缺损模型。以生物衍生肌腱桥接第2,3趾缺损,以自体肌腱桥接第4趾的肌腱缺损,在第3趾的生物衍生肌腱和上下吻合口周围包裹完整的脱细胞羊膜。结果与结论：生物衍生肌腱组与自体肌腱组移植物为外源性愈合,生物衍生肌腱＋脱细胞羊膜组羊膜有效地防止了成纤维细胞向修复区域内浸润,形成内源性愈合。肌腱粘连程度生物衍生肌腱＋脱细胞羊膜组优于生物衍生肌腱组和自体肌腱组,生物衍生肌腱组和自体肌腱组相似,移植物周围的炎症反应生物衍生肌腱＋脱细胞羊膜组〉生物衍生肌腱组〉自体肌腱组。证实脱细胞羊膜能通过机械性阻挡周围肉芽组织向修复区域内生长而防止外源性愈合造成的肌腱粘连。     

脱细胞羊膜预防生物衍生肌腱修复鸡屈趾肌腱Ⅱ区缺损修复后的粘连

背景:羊膜有预防肌腱修复后粘连的作用,但存在一定的免疫排斥反应。目的:探讨脱细胞羊膜对生物衍生肌腱修复鸡屈趾深肌腱Ⅱ区缺损修复后肌腱粘连的预防作用。方法:分别以罗曼鸡右爪的第2,3,4趾将实验分成生物衍生肌腱组,生物衍生肌腱+脱细胞羊膜组以及自体肌腱组,建立屈趾深肌腱Ⅱ区1cm缺损模型。以生物衍生肌腱桥接第2,3趾缺损,以自体肌腱桥接第4趾的肌腱缺损,在第3趾的生物衍生肌腱和上下吻合口周围包裹完整的脱细胞羊膜。结果与结论:生物衍生肌腱组与自体肌腱组移植物为外源性愈合,生物衍生肌腱+脱细胞羊膜组羊膜有效地防止了成纤维细胞向修复区域内浸润,形成内源性愈合。肌腱粘连程度生物衍生肌腱+脱细胞羊膜组优于生物衍生肌腱组和自体肌腱组,生物衍生肌腱组和自体肌腱组相似,移植物周围的炎症反应生物衍生肌腱+脱细胞羊膜组>生物衍生肌腱组>自体肌腱组。证实脱细胞羊膜能通过机械性阻挡周围肉芽组织向修复区域内生长而防止外源性愈合造成的肌腱粘连。     

Gene therapy strategies to improve strength and quality of flexor tendon healing

ABSTRACT

Introduction: Rupture of the repair and adhesion around a tendon are two major problems after tendon surgery. Novel biological therapies which enhance healing and reduce adhesions are goals of many investigations. Gene therapy offers a new and promising approach to tackle these difficult problems. In the past decade, we sought to develop methods to augment tendon healing and reduce tendon adhesion through gene therapy.

Areas covered: This review discusses the methods and results of adeno-associated viral (AAV) type 2 vector gene therapy to increase tendon healing strength and reduce adhesions in a chicken model. Micro-RNA related gene therapy is also discussed. We also developed a controlled release system, which incorporates nanoparticles to deliver micro-RNAs to regulate tendon healing.

Expert opinion: We obtained promising results of enhancement of tendon healing strength in a chicken model using AAV2-mediated gene transfer. AAV2-mediated micro-RNA transfer also limited adhesions around the tendon. Controlled release systems incorporating nanoparticles have ideally delivered genes to the healing tendons and resulted in a moderate (but incomplete) reduction of adhesions. It remains to be determined what the best doses are and what other factors are in play in adhesion formation. These are two targets in our future investigations.     

个体化、量化康复训练队屈指肌腱吻合术后功能恢复的影响

目的探讨个体化、量化康复训练对屈指肌腱吻合术后功能恢复的影响。 方法将180例屈指肌腱吻合术患者随机分为量化组及对照组。量化组患者在术中测量所吻合肌腱的最大抗张强度(Fmax),术中安装训练支具,测量吻合术后肌腱两断端分离达到2 mm间隙时的橡皮筋长度及载荷,并加装保护装置,术后给予个体化、量化康复训练。对照组患者术中未进行肌腱最大抗张强度测定,术后康复训练时亦无特殊保护装置,由患者自行训练手指活动功能。为进一步研究康复训练频率对疗效的影响,将量化组及对照组分别细分为A,B两亚组,分别给予每天3次（A组）、每天6次（B组）康复训练。 结果经3个月训练后,发现量化组术后无肌腱断离者,对照组有6例患者发生肌腱再断离,量化组优良率达91.1%,对照组优良率为80.0%,组间差异具有统计学意义（P<0.05）;进一步分析发现,量化B组患者康复疗效明显优于其它亚组,组间差异均有统计学意义（P<0.05）。 结论个体化、量化康复训练能有效防止肌腱吻合术后患者肌腱再断离,且每天训练6次可能是较佳康复治疗频率。     

Value of transducer positions in the measurement of finger flexor tendon thickness by sonography.

OBJECTIVE: To assess the value of 2 transducer positions for measurement of finger flexor tendon thickness by sonography. METHODS: Flexor tendon thickness of the third finger was measured sonographically by 2 independent investigators in 20 healthy volunteers (n = 40 fingers) and in 4 cadaveric specimens (n = 4 fingers). Flexor tendon thickness was measured at histologic examination in the cadaveric specimens. We defined the area of the A1 annular pulley as position I and the area of the A2 annular pulley as position II. Sonographic measurements were performed in transverse (dorsovolar and radioulnar) and longitudinal planes. Interobserver and intraobserver variabilities were evaluated by each investigator performing 3 measurements at each position. RESULTS: In position I, volunteers had flexor tendon thickness of 2.7 to 4.0 mm (mean +/- SD, 3.28 +/- 0.26 mm) longitudinally; transversally the thickness was 2.5 to 4.0 mm (mean, 3.34 +/- 0.29 mm) dorsovolar and 5.5 to 8.9 mm (mean, 7.34 +/- 0.71) radioulnar in position I. Position II revealed thickness of 3.2 to 4.2 mm (mean, 3.6 +/- 0.23 mm) longitudinally; transversally the thickness was 2.7 to 4.1 mm (mean, 3.4 +/- 0.27) dorsovolar and 4.3 to 6.8 mm (mean, 5.27 +/- 0.65) radioulnar. Interobserver and intraobserver variability for position I was better than for position II (P < .01 versus P < .05). Sonographic findings correlated excellently with histologic findings (r2 = 0.94). CONCLUSIONS: Standardized transducer positions for sonographic measurements of finger flexor tendon thickness showed good interobserver and intraobserver variability. Position I was found to be more reliable than position II.     

Rehabilitation of traumatic injuries: use of the delphi method to identify topics for evidence-based review

Evidence-based reviews of research literature are useful in determining the efficacy of specific clinical practices, but the review process is frequently time-consuming and costly. The purpose of this study was to identify important research questions in rehabilitation that are appropriate for evidence-based reviews. The focus of this study was rehabilitation after traumatic injuries. Topics were identified using the Delphi method, which utilized a panel of 24 researchers and clinicians with expertise in rehabilitation of traumatic injuries. The experts identified 71 topics, predominantly in the areas of spinal cord injury and traumatic brain injury rehabilitation. The most commonly suggested intervention topics involved assessment of pharmacologic agents, the timing or intensity of interventions, or specific nonpharmacologic therapies and exercises. Topics were ranked by mean importance score. Ten of 24 questions in the top tertile were considered to have some or a substantial amount of available research and thus may be appropriate for structured evidence-based reviews. Similar methods could be used to identify appropriate topics in other areas of rehabilitation.