Traumatische und degenerative Läsionen der Sehnen an der Hand

Tendon lesions are the second most common injury in the hand and therefore an important factor in orthopedic patients. Most injuries are open injuries to the flexor or extensor tendons; nevertheless, also less frequent injuries such as damage to the functional system of tendon sheath and pulley or dull avulsions need to be considered. Besides the clinical examination, ultrasound and MRI have proven to be important diagnostic tools. In the postoperative course of flexor tendon injuries, the principle of early passive movement is important to trigger "intrinsic" tendon healing to guarantee a good outcome.     

Tendon transfers for radial, median, and ulnar nerve injuries: current surgical techniques

Tendon transfers are performed predominantly to restore hand function or balance due to injuries of the radial, median, and ulnar nerves. Current surgical techniques for the most common tendon transfers for reconstruction of radial, median, and ulnar nerve palsies are demonstrated. These techniques can also be applied to restore flexion and extension of the fingers and thumb after injuries to the extrinsic flexor and extensor muscles and tendons of the forearm or intrinsic muscles of the hand.     

Principles of tendon repair

Tendon injuries in the hand are common; they are usually open injuries requiring surgical intervention. In this article we discuss tendon injuries in terms of approach to repair beginning at the time of diagnosis through to the rehabilitation programmes and outcome measures commonly used in the UK. In general tendon injuries should be considered using Verdan's zones for both extensor and flexor injuries. Flexor tendons require a high strength repair and usually warrant a core suture with epitendinous reinforcement bearing in mind the importance of not disrupting glide with unnecessary suture bulk. Extensor tendons more proximally can be treated in the same way but distally require only a running suture in the flattened tendon ends. All tendon injuries require a period of protected mobilization with splinting aiming to protect the repair but reduce stiffness in other joints.     

Pulley rupture and reconstruction in rock climbers

Hand-grip techniques in modern rock climbing generate climbing-related injuries, especially at the flexor tendon sheath level. The most frequent injury is A2 pulley rupture. The clinical diagnosis is based on bowstringing of the flexor tendon and confirmed by computed tomograph scan or magnetic resonance imaging. The surgical procedure is based on an extensor retinaculum graft to reconstruct the ruptured pulley. It is the only efficient treatment regardless of the time between accident and surgery. Thanks to this surgical procedure, patients recover or improve their former climbing performance. Some precautions before climbing may prevent this injury, and these are listed.     

Complications after treatment of flexor tendon injuries

The goals of flexor tendon repair are to promote intrinsic tendon healing and minimize extrinsic scarring in order to optimize tendon gliding and range of motion. Despite advances in the materials and methods used in surgical repair and postoperative rehabilitation, complications following flexor tendon injuries continue to occur, even in patients treated by experienced surgeons and therapists. The most common complication is adhesion formation, which limits active range of motion. Other complications include joint contracture, tendon rupture, triggering, and pulley failure with tendon bowstringing. Less common problems include quadriga, swan-neck deformity, and lumbrical plus deformity. Meticulous surgical technique and early postoperative tendon mobilization in a well-supervised therapy program can minimize the frequency and severity of these complications. Prompt recognition of problems and treatment with hand therapy, splinting, and/or surgery may help minimize recovery time and improve function. In the future, the use of novel biologic modulators of healing may nearly eliminate complications associated with flexor tendon injuries.     

Extensor hallucis longus tenorrhaphy by using the Massachusetts General Hospital repair

Extensor hallucis longus tendon injury and surgical treatment recommendations are infrequently reported. In contrast to long extensor tendon injuries to the foot, flexor and extensor tendon injuries of the hand have been extensively studied and surgical treatment protocols have been delineated. In biomechanical studies, the Massachusetts General Hospital technique has been shown to have superior strength to other tenorrhaphies and to allow for early active mobilization. The purpose of this study was to examine the use of this technique for repair of extensor hallucis longus tendon injuries to allow for early active motion with minimal risk of rupture. We performed a retrospective review of 6 extensor hallucis longus tendon repairs at the toe level. These patients all regained active motion of the great toe. None had loss of extension. There were no tendon ruptures with this technique of tendon repair. The Massachusetts General Hospital technique can be used to repair the extensor hallucis longus tendon with good functional outcome and minimal risk of tendon rupture.     

Tendon injuries across the world: treatment

This article outlines current status of primary and secondary surgical treatment of flexor and extensor tendon injuries in the hand and rehabilitation regimens worldwide. Unsolved problems associated with tendon repairs in the hand are tendon adhesions, rupture of the repairs, finger stiffness, power of hand motion, and surgical skills. Future development may include improvement of tendon healing through biological approaches, repair techniques, and, in particular, establishment of adequate rehabilitation systems and training of surgeons in some regions of the world.     

Retrieval of the retracted flexor tendons for long fingers: New tip

Zone II flexor tendon injuries continue to be a challenge for hand surgeons. During the injury event, the tendon ends may retract towards the palm. Retrieval of these lacerated ends can be problematic because the tendon sheath is unstretchable. This demanding surgery requires a precise repair technique where the tendon stumps are handled in an atraumatic manner. Microtrauma to the tendon sheath must be avoided as this can induce adhesions and lead to poor functional outcomes. Several retrieval methods for retracted tendon ends have been described in published studies. In this technical note, we will describe a technical variation that streamlines the surgical procedure and uses commonly available materials. This simple trick makes the procedure easier and avoids having to suture the tendon to the tubing.     

Flexor tendon pulley reconstruction

The flexor tendon pulley mechanism causes the tendons to work with maximum efficiency. Without its competency,flexor tendons will bowstring causing significant losses of digital motion and strength. Without an intact pulley system, increased flexor tendon excursion is required to affect joint motion and flexion contractures may develop over time. Recent investigators have described the properties of the intact flexor pulley system as well as those of flexor pulley reconstructive techniques. Reconstruction of the flexor pulley system should take into account both strength and length of the construct and in most cases a loop of either flexor tendon graft or wrist extensor retinaculum is used. Other methods are available including the use of the palmar plate as well as the superficialis tendon.     

促进肌腱愈合及预防肌腱粘连的研究进展

目的 较全面了解在促进肌腱愈合和防止肌腱粘连的材料和方法的现状，为今后相关研究及临床应用提供必要参考。方法 广泛查阅近年国内外相关文献，总结分析肌腱愈合的方式，及促进肌腱愈合的药物和方法。结果 肌腱愈合由内、外源愈合共同作用，以内源性愈合方式为主，同时又与腱鞘、腱纽及滑液等条件有密切联系；肌腱粘连多是由于外源性愈合参与过多及腱周损坏所致。通过修复或重建腱周组织、电刺激、理疗、加入药物、生长因子及基因干预等，可促进肌腱愈合；而通过修复腱鞘或采用代用品、加入药物及改进缝合技术等能有效预防肌腱粘连。结论 通过恰当的中西医治疗方法和技术．可在促进肌腱愈合速度、提高愈合质量的同时，预防或避免肌腱粘连的发生。     

腱缝合后鞘内置入法在Ⅱ区屈肌腱修复中的临床应用

目的介绍用腱缝合后鞘内置入法，治疗Ⅱ区屈肌腱损伤的方法和疗效。方法按该法治疗屈肌腱损伤４６例７７指。伸直型１２例２６指：经原腱鞘伤口缝合肌腱，术毕将肌腱缝合部置于近侧健康鞘管内。屈曲型３４例５１指：在肌腱远断端以远约０．５ｃｍ处另作腱鞘切口，经此切口将损伤腱近端拉出进行缝合，术毕将腱缝合口置于远端切口和原伤口间的完整鞘管内。结果术后随访到３８例５９指，随访时间为２个月～３年，平均１年８个月。按ＴＡＭ评定法评定疗效，优级：３０指，良级：１７指，余为中差级；总优良率达到７９．７％。锐器切割伤４３指，疗效优良者４２指占９７．７％；合并腱鞘及周围组织损伤１６指，疗效优良者５指占３１．３％。结论该术式对单纯指屈肌腱损伤疗效满意，这可能和术时腱鞘损伤轻，肌腱缝合口被健康鞘管包绕后，有利于肌腱的内源性愈合并减少了外源性愈合的参与有关     

Remodeling of the gliding surface after flexor tendon repair in a canine model in vivo.

Maintaining a smooth lubricated surface between the flexor tendon and sheath after tendon repair is very important for restoration of digit function. We studied the tendon surface after tendon repair mechanically in a canine model in vivo by measuring frictional force. One hundred and twenty flexor digitorum profundus (FDP) tendons were lacerated to 80% of their cross-section and repaired with either a modified Kessler (MK) or Becker (MGH) repair. The postoperative therapeutic regimen was either synergistic wrist and digit motion (SWM) or passive digit flexion and extension with the wrist fixed in 45 degrees of flexion (FIX). The dogs were sacrificed at one, three, or six weeks postoperatively. Thirty six FDP tendons from normal paws served as the control group, with each control tendon tested in two different conditions: intact and immediately after partial laceration and repair (0 time), making a total of five different timing points (intact, 0 time, one week, three weeks, and six weeks) for each repair type and each postoperative therapy. Frictional force between tendon and proximal pulley was evaluated after breaking any adhesions. Compared to intact tendons, friction was significantly increased immediately after tendon repair. The friction of the MK repair was significantly less than that of the MGH repair at all time and therapy groups, except at six weeks in the SWM group. For the MGH repair, at six weeks friction in the SWM group was significantly less than friction in the FIX group. This study showed that postoperative tendon gliding depends on the method of tendon repair and the postoperative therapy regimen. Furthermore, we have demonstrated that the gliding surface after tendon repair remodels with time.     

Establishment of an in vivo turkey model for the study of flexor tendon repair

Flexor tendon injuries are common and pose a clinical challenge for functional restoration. The purpose of our study was to assess the adequacy of the turkey as a large animal model for flexor tendon injuries in vivo. Twenty‐four male turkeys underwent surgical flexor tendon cut and repair. Turkeys were allocated to five groups postoperatively: (1) foot casted in extension and sacrificed after 3 weeks; (2) foot casted in extension and sacrificed after 6 weeks; (3) foot casted in flexion and sacrificed after 3 weeks; (4) foot casted in flexion and sacrificed after 6 weeks; and (5) foot casted in flexion for 6 weeks and then free roaming allowed for an additional 3 weeks before sacrifice. After sacrifice, digits were collected and analyzed for adhesion formation, healing at the macrolevel and histologically, and biomechanical properties—including friction, work of flexion, stiffness, and strength of repair. All turkeys survived anesthesia and surgery. Tendon rupture occurred in all extension casts and in 11% of those casted in flexion. Friction and work of flexion were significantly higher in the repaired digit than the control digit. There was a correlation between duration of immobilization and repair strength. Histologically, the tendon healed with tenocytes migrating into the gap and producing collagen fibers. We have, for the first time, studied flexor tendon injury and repair using turkeys in terms of anesthesia, surgical procedures, postoperative care, and animal husbandry. The findings regarding functional and histological results from this novel avian model were comparable to the most commonly used mammal model. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2497–2505, 2018.

     

The Omega "Omega" pulley plasty. A new technique to increase the diameter of the annular flexor digital pulleys

The authors report a new technique of pulley plasty of the flexor digital system. It is not an operative procedure to reconstruct a damaged pulley but an original way to expand the volume of an intact pulley in order to adapt its volume to the diameter of the repaired flexor tendon. The flexor tendons ruptures in Verdan zone II and particularly in Tang zones IIA and IIB are often accompanied by an osteofibrous tunnel injury. Initially, the tendon sheath closure was advised after tendons repair. This sheath recovery had to have an effect on tendons nutrition by establishing the synovial cavity continuity and particularly to protect the tendons from adhesions formation. The closure of the digital tube was rapidly shown to be unnecessary creating an obstacle to the tendons movements without any effect on tendons healing. In primary tendon management, the tendon repair is associated with an increase of the tendon diameter. An incongruence appears with the surrounding digital tube with gliding resistance complicating the tendon injury recovery. In secondary tendon injury management, the flexor digital tube is subject to healing and inflammatory process. This situation with the absence of the flexor tendon generates a retraction with a collapse of the digital tunnel over the injured area. This incongruence between the repaired flexor tendons and the narrowed digital tube required a release of the retracted zone to restore an adequate volume. The only way reported is the "Venting" of a part or the total length of the pulley. This procedure even if it resolves the tendon gliding resistance, is still unacceptable. Indeed it destroys an important anatomical structure of the flexor tendon dynamic system. The flexor pulley Omega plasty "Omega" consists in releasing the lateral palmar attachment of the pulley enhancing its internal volume and increasing the flexor tendon gliding area. The digital tube is composed by the succession of five annular and three cruciform pulleys. The cruciform pulleys are thin and flexible. They retract during the digital flexion assuring the continuity of the digital tube, while the annular pulleys are thicker and fill a biomechanical function. There are two types of annular pulleys: the joint pulleys as A1, A3 and A5; they are attached to the palmar plates of the MP, PIP and DIP joints respectively. During the digital movement, they retract approximately 50% of their length. The osseous pulleys as A2 and A4 are fixed over the lateral and palmar borders of the first and the second phalanx respectively. It is on these pulleys that the Omega plasty is practised. The operative procedure is simple. It consists on a periosteal dissection over the one lateral border of the phalanx. The liberation is undergone palmarly releasing the lateral attachment of the pulley. It respects the anatomical continuity of the pulley and its mechanical properties. Indeed, the continuity of the pulley is fully respected with the periosteal flap of the digital tube floor maintaining sufficient attachment to the pulley to resist to the flexor tendon forces. The level of the flexor tendon injury and the digit position during the initial trauma will determine the level of tendon resistance and where the pulley plasty must be made. If the flexor zone II injury occurred with the digit in an extension position, the tendon conflict appears with the A2 pulley, while it arises with the A4 pulley if the digit was in flexed position. The Omega plasty creates the ideal conditions for an optimal flexor tendon movement recovery. It is a simple and a reproducible procedure. It doesn't distort the mechanical properties of the pulley and the digital tube. We used this pulley Omega plasty fifteen times in twelve patients. In 60% of the cases, the injury concerned the dominant hand, and in 67% of the cases, it was a work accident. In eight of our cases, the omega plasty was done in emergency at the same time of flexor tendon repair, while in the other seven cases, the pulley Omega plasty accompanied the late flexor tendon repair forgotten during the initial trauma management. In ten cases, the plasty concerned the A4 annular pulleys, while in the other five cases, it concerns the A2 annular pulleys. Four cases necessitate a secondary tenolysis three months after the tendon repair. Two patients moved out and cannot be included in our results. On the thirteen-remainder cases, nine retrieved a full digital flexion particularly those who underwent digital tenolysis, while the other four cases retrieved a satisfying digital function in spite of the partial DIP flexion. In our hand, the pulley Omega plasty "Omega" becomes almost a systematic procedure in conjunction with the flexor tendon repair. It offers the ideal conditions for a tendon healing and a physiological flexor tendons motion recovery.     

Excursion of the flexor digitorum profundus tendon: a kinematic study of the human and canine digits

The most common problem following primary flexor tendon repair is the failure of the tendon apparatus to glide, secondary to the formation of adhesions. Early motion following tendon repair has been shown to be effective in reducing adhesions between the tendon and the surrounding sheath. Therefore, it is important to determine the amount of flexor tendon excursion along the digit during joint motion. In this study, the excursion between the flexor digitorum profundus (FDP) tendon and the sheath was examined in both human and canine digits. Based on roentgenographic measurements and joint kinematic analysis, the motion of the bones, the FDP tendon, and the sheath were measured with respect to joint rotations. It was found that the canine flexor tendon apparatus behaved similarly to that of the human for the motions studied. The amount of tendon excursion was very small in regions distal to the joint in motion (approximately 0.1 mm/10 degrees of joint rotation). There was little displacement of the sheath (0.2-0.3 mm), except at the metacarpal joint region during metacarpophalangeal (MCP) joint motion and at the proximal interphalangeal (PIP) joint region during PIP joint motion. Tendon excursion relative to the tendon sheath was the largest in zone II during PIP joint rotation (1.7 mm/10 degrees of joint rotation). These results suggest that PIP joint motion may be most effective in reducing adhesions following tendon repair in zone II.     

Effects of superficialis tendon repairs on lacerated profundus tendons within or proximal to the A2 pulley: an in vivo study in chickens

PURPOSE: In a flexor tendon injury model in chickens we undertook a study to evaluate effects of the flexor digitorum superficialis (FDS) tendon repairs on excursions, work of flexion, and adhesions of the repaired flexor digitorum profundus (FDP) tendon after their injuries within or proximal to the equivalent of the A2 pulley and early tendon motion. METHODS: Thirty-five leghorn chickens were divided into 3 groups. In group 1 the FDS and FDP tendons of the long toes on both sides were transected in the area covered by the pulley. In group 2 the tendons were transected proximal to the pulley. In the first 2 groups, both tendons were repaired on the left feet, and only the profundus was repaired with superficialis excision on the right. The operated toes underwent simulated passive flexion for 3 weeks and results were evaluated 8 weeks after surgery. Chickens in group 3 were unoperated and served as the controls. RESULTS: When the tendons were cut within the pulley the FDP excursions and work of flexion were significantly better in the toes in which the FDS was excised than in those with both tendon repairs. When they were cut proximal to the pulley the repairs of both tendons had outcomes similar to that with excision of the FDS. Adhesions were more severe when both tendons were repaired under the pulley as compared with those after repair of a single tendon. CONCLUSIONS: This study showed different effects of the surgical repair or excision of the FDS on the FDP tendon within or proximal to a major pulley. Repair of both tendons worsens the gliding of the FDP tendon and increases adhesions within the major pulley; however, repair of both tendons yields outcomes equivalent to that after repair of only the FDP tendon proximal to the pulley.     

Healing,Inflammation, and Fibrosis: Tendon: Principles of Healing and Repair

Tendon stores, releases, and dissipates energy to efficiently transmit contractile forces from muscle to bone. Tendon injury is exceedingly common, with the spectrum ranging from chronic tendinopathy to acute tendon rupture. Tendon generally develops according to three main steps: collagen fibrillogenesis, linear growth, and lateral growth. In the setting of injury, it also repairs and regenerates in three overlapping steps (inflammation, proliferation, and remodeling) with tendon-specific durations. Acute injury to the flexor and extensor tendons of the hand are of particular clinical importance to plastic surgeons, with tendon-specific treatment guided by the general principle of minimum protective immobilization followed by hand therapy to overcome potential adhesions. Thorough knowledge of the underlying biomechanical principles of tendon healing is required to provide optimal care to patients presenting with tendon injury.     

移植部分鹅足囊修复腱鞘预防指屈肌腱粘连

目的 探讨指屈肌腱损伤修复后重建腱鞘预防肌腱粘连的手术方法.方法 对78例屈肌腱损伤患者,按手术方法的不同随机分为2组.治疗组39例指屈肌腱损伤修复后切取自体部分鹅足囊修复腱鞘,重建腱鞘的完整,使之形成一完整的闭合鞘管并注入玻璃酸钠.对照组不修复腱鞘.结果 经6～38个月临床随访,按TAM手指功能评价治疗组：优21例,良11例,中6例,差1例,优良率82.1%;对照组优良率51.3%,差异有显著性（Х^2=8.34,P=0.004）.结论 切取部分鹅足囊移植修复并应用具有营养和润滑作用的玻璃酸钠,能有效预防指屈肌腱修复后的粘连,是实用的手术方法.     

Lacerations and ruptures of the flexor or extensor hallucis longus tendons

Lacerations and ruptures of the flexor hallucis longus or extensor hallucis longus tendon are frequently managed with operative repair. Tendon injuries of the hallux are not all alike; careful consideration should be given to the mechanism and site of injury, the timing of presentation, and the presence of other injuries. Not all tendon injuries of the hallux require repair. The effectiveness of a repair will depend on the goals of surgery, which may include pain relief, active joint motion, or correction of deformity. When goals are clearly defined, a satisfactory result can be expected in most patients.     

Flexor tendon reconstruction

The hand surgeon's familiarity with options for flexor tendon reconstruction is essential. Efforts at primary repair are not always successful nor are the conditions after injury necessarily conducive to primary coaptation of tendon ends. Single-stage and two-stage grafting, tenolysis, and pulley reconstruction are parts of the reconstructive surgeon's armamentarium. Future interventions of tissue engineering suggest the possibility of creating a theoretically endless supply of available donor material for use in tendon reconstruction.