儿童Ⅱ区指屈肌腱损伤21例分析

目的探讨儿童Ⅱ区指屈肌腱损伤的治疗方法和疗效。方法１９９０年至１９９７年间共收治２１例２３指儿童Ⅱ区指屈肌腱损伤,分析其病史后进行总结。其中男１９例,女２例,年龄５～１４岁,平均１２．１岁。早期１０例１０指,用０号丝线作Ｋｅｓｓｌｅｒ或双十字法缝合。后期１１例１３指在手术显微镜下,用５－０无创尼龙线缝合肌腱及修复腱鞘,均用Ｋｅｓｓｌｅｒ法缝合。非急性期修复者在腱周放置透明质酸钠。结果按ＴＡＭ法评定疗效,早期１０例１０指中,优２指,良６指,可２指,优良率为８０％。后期１１例１３指中,优８指,良５指,优良率为１００％。两组总优良率达９１．３％。结论儿童Ⅱ区指屈肌腱损伤修复后疗效较佳;应用透明质酸钠有助于功能的恢复。     

Factors that influence the outcome of zone I and zone II flexor tendon repairs in children

PURPOSE: To evaluate the factors that influenced the clinical results of zone I and II flexor tendon repairs in children at a single institution. METHODS: Forty-one fingers (35 patients) in patients ages 2 to 14 years with zone I or II flexor tendon injuries were identified. There was a zone I tendon injury in 16 fingers and a zone II tendon injury in 25 fingers. Concomitant injuries to the digital nerves were seen in 18 fingers. Primary repair was performed within 1 week in 35 fingers and delayed repair (2-9 wk) was performed in 6 fingers. After surgery 22 fingers (21 patients) were treated with early controlled mobilization and 19 fingers (14 patients) were treated with plaster immobilization. RESULTS: All patients were available for evaluation at a mean follow-up period of 42 months. Patients were subdivided into 2 age groups: (1) 0 to 7 years and (2) 8 to 15 years. Digital performance was evaluated by determining the percentage return of normal finger function according to a total active motion formula. Functional evaluation of all digits in both groups showed excellent or good results. Zone I repairs had better results than zone II repairs and isolated tendon repairs had better results than those with associated nerve repairs. The age of the patients nor postoperative protocol did not influence the final digital motion. CONCLUSIONS: A good outcome can be expected after repair of zone I or II flexor tendon injuries in children. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III.     

肌腱移植加生物膜包裹修复Ⅱ区屈肌腱陈旧性断裂

目的 报告应用肌腱移植加生物膜包裹修复Ⅱ区屈肌腱陈旧性断裂的临床效果.方法 对27例36指屈肌腱陈旧性断裂患者,采用肌腱移植加医用可吸收生物膜包裹的方法进行修复,术后进行系统的康复锻炼,观察临床效果.结果 27例36指伤口均Ⅰ期愈合,术后随访4～36个月(平均13个月),按Strickland和Glogovac评价标准进行评价:优10指,良17指,一般和差共9指;优良率为75%.术后无一例发生肌腱再次断裂.9指效果一般和差者再次行肌腱松解术后3个月随访,优2指、良4指、一般和差共3指,总的优良率为92%.结论 肌腱移植加可吸收生物膜包裹修复Ⅱ区屈肌腱陈旧性断裂,可获得较满意的效果.肌腱牢固的缝合、可吸收生物膜的应用及术后早期系统的康复锻炼是获得良好效果的关键因素.     

Long-term results after primary repairs of zone 2 flexor tendon lacerations in children younger than age 6 years

In young children, methods of primary flexor tendon repair in the digital canal are controversial. The authors reviewed 12 children younger than age 6 years with zone 2 flexor tendon repairs. The mean follow-up period was 8 years. In all cases, the flexor digitorum profundus tendons were repaired according to the Kessler modified technique and the hands were immobilized by an above-elbow cast. As for postoperative complications, there were no fingers with tendon rupture and two fingers with tendon adhesion. One finger needed tenolysis. The total active motion (TAM) in the interphalangeal joints evaluated with the Strickland formula averaged 155 degrees, and the TAM percentage averaged 89% (range 74%-100%). Eleven patients had an excellent result and one had a good result. The percentage phalangeal length averaged 99% (range 96%-100%). Functional motion and nearly normal growth of the finger can be expected after primary zone 2 flexor tendon repairs in children younger than age 6 years.     

Clinical Results of Flexor Tendon Repair in Zone II Using a six Strand Double Loop Technique

The purpose of this study is to report the clinical results after repair of flexor tendon zone II injuries utilizing a 6-strand double-loop technique and early post-operative active rehabilitation. We retrospectively reviewed 22 patients involving 51 cases with zone II flexor tendon repair using a six strand double loop technique from September 1996 to December 2012. Most common mechanism of injuries was sharp lacerations (86.5 %). Tendon injuries occurred equally in manual and non-manual workers and were work-related in 33 % of the cases. The Strickland score for active range of motion (ROM) postoperatively was excellent and good in the majority of the cases (81 %). The rupture rate was 1.9 %. The six strand double loop technique for Zone II flexor tendon repair leads to good and excellent motion in the majority of patients and low re- rupture rate. It is clinically effective and allows for early postoperative active rehabilitation.     

The effect of vincular injury on the results of flexor tendon surgery in zone 2

From a consecutive series of 82 fingers (69 patients) that sustained flexor tendon lacerations in zone 2, 47 fingers (39 patients) had the status of the vincular system determined during primary repair. The vincula were intact in 22 fingers and not intact in 25. Total active motion (TAM) after rehabilitation and before a reconstructive procedure, such as repair of a rupture, tenolysis, or grafting of a tendon, was the end point of the study. The overall mean TAM was 196 degrees. The mean TAM was 222 degrees for fingers with intact vincula and 176 degrees for fingers with vincula not intact (p less than 0.01). There were no statistical differences between the two groups regarding surgical results when the number of tendons injured per finger and sheath closure were analyzed. This study suggests that the integrity of the vincular system is a determinant of end result TAM and flexor tendon lacerations in zone 2.     

Flexor tendon injuries in pediatric patients

PURPOSE: The purpose of this research was to study the incidence and outcome of flexor tendon injuries in pediatric patients. METHODS: A survey of flexor tendon repair in children less than 16 years of age was performed in the City of Helsinki during 2000-2005. A retrospective clinical outcome study of all consecutive 28 patients with 45 involved fingers treated in Children's Hospital was also performed at a mean 38 months (range 12-53 months) after surgery. Active motion program after multistrand tendon repair was used in 33 fingers, cast immobilization in 11 fingers, and elastic bands in 1 finger. Functional and cosmetic subjective result was evaluated by a visual analog scale (VAS, 0-100). Range of motion (ROM) of metacarpophalangeal (MCP) and interphalangeal (IP) joints were measured. Grip strength was recorded. Functional outcome methods of Buck-Gramcko, ASSH, Strickland, and distal interphalangeal joint (DIP) ROM methods were applied. RESULTS: The calculated annual incidence of finger flexor injury per child in Helsinki was 0.036 per 1000. There were no ruptures of the multistrand repairs with active motion program, but three 2-strand core sutures failed within 1 month of the repair. Mean functional and cosmetic VAS scores (all 28 patients) were 87 and 84. Mean ROM ratio of the DIP joint in zone 1 and 2 injuries was 60%, compared to 98% in zone 3 and 5 injuries. Ranges of motion of the proximal interphalangeal (PIP) and MCP joints were practically normal in all patients. There was a discrepancy among the functional outcome scores, with good and excellent results in all 45 fingers (Buck-Gramcko), in 39 fingers (ASSH), in 36 fingers (original Strickland), and in 32 fingers (DIP ROM). CONCLUSIONS: Flexor tendon injuries in children are rare. Both subjective and objective outcomes are generally good. Active motion program is an effective technique after multistrand flexor tendon repair at all levels in children. Range of motion of the DIP joint may be a more effective means of evaluating outcome in pediatric flexor tendon injuries. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.     

Two-stage flexor tendon reconstruction in zone II using Hunter's technique

Tendon injuries in the digital flexor sheath area (zone II) are the most difficult to treat and remain a focus of both clinical attention and basic investigations. Although some new techniques have been developed, the clinical results are still not satisfying, especially in old injuries. This retrospective study was designed to investigate the results of delayed zone II flexor tendon repair using Hunter rods. Between July 1974 and June 1998, 81 patients at our institution underwent 2-stage reconstruction using Hunter's technique. Sixty-one patients with 106 fingers were included in this study. Digital flexor tendon resection and Hunter rod implantation were performed in the first-stage operation. Combined digital nerve injuries and damaged pulleys were repaired or reconstructed at the same time. Plaster was used to immobilize the hand for 3 weeks. During the second-stage operation, performed 2 to 6 months later, palmaris longus or plantaris were grafted into the pseudosheath formed surrounding the Hunter rods. The proximal end of the transplanted tendon was fixated with flexor digitorum profundus tendon using the Pulvertaft method, and the distal end was fixated to the distal phalanx using Bunnell's pullout wire method. Early controlled motion was performed in all cases. Evaluation based on total active motion was good to excellent in 84%, fair in 12%, and poor in 4% of patients. Flexor tendon reconstruction using Hunter technique is an effective way to restore digital function in delayed zone II flexor tendon injuries.     

Primary flexor tendon repair in zone 1

This paper presents an analysis of the results of repair of 102 complete flexor tendon disruptions in zone 1 which were rehabilitated by an early active mobilization technique during a 7 year period from 1992 to 1998. These injuries were subdivided into: distal tendon divisions requiring reinsertion; more proximal tendon divisions but still distal to the A4 pulley; tendon divisions under or just proximal to the A4 pulley; and closed avulsions of the flexor digitorum profundus tendon from the distal phalanx. Assessment by Strickland's original criteria showed good and excellent results of 64%, 60%, 55% and 67% respectively in the four groups. However, examination of the results measuring the range of movement of the distal interphalangeal (DIP) joint alone provided a more realistic assessment of the affect of this injury on DIP joint function, with good and excellent results of only 50%, 46%, 50% and 22% respectively in the four groups.     

Extensor tendon injuries in children

INTRODUCTION: This study retrospectively analyzes primary extensor tendon repairs in children younger than 15 years. METHODS: Exclusion criteria were skin loss, devascularization, fractures, or flexor tendon injuries. Fifty patients who had sustained extensor tendon laceration with 53 digits injured were available for review. Treatment consisted of primary repair of the extensor tendon injury within the first 24 hours. The results were assessed by means of total active motion system and by Miller's rating system. The mean follow-up was 2 years. RESULTS: Although 98% of the digits were rated as good or excellent according to the total active motion system and 95% according to Miller's classification, 22% of the fingers showed extension lag or loss of flexion at the last follow-up. DISCUSSION: Pejorative influencing factors were injuries in zones I, II, and III; children younger than 5 years (P < 0.05), and complete tendon laceration. Articular involvement had no significant influence on final outcome.     

Active mobilisation after flexor tendon repair: comparison of results following injuries in zone 2 and other zones

PURPOSE: To prospectively study the role of active mobilisation after flexor tendon repair. METHODS: The standard modified Kessler's technique was used to repair 46 digits in 32 patients with flexor tendon injuries. Early active mobilisation of the repaired digit was commenced on the third postoperative day. Range of movement was monitored and recovery from injury in zone 2 was compared with injury in other zones. RESULTS: There were 24 and 22 injuries in zone 2 and other zones respectively. The total active motion score of the American Society for Surgery of the Hand was measured. Patients with zone-2 injuries achieved similar results to those with other-zone injuries apart from a 3-week delay in recovery. The final results were good to excellent in 71% and 77% of zone-2 and other-zone cases respectively (p < 0.05). There were 2 ruptures in zone-2 and one rupture in zone-3 repairs (6.5%). CONCLUSION: Preliminary results of this study showed that active mobilisation following flexor tendon repair provides comparable clinical results and is as safe as conventional mobilisation programmes although recovery in patients with zone-2 injury was delayed.     

Primary flexor tendon suture in the "no man's land" of the hand

If the conditions of the wound are favourable, flexor tendon divisions in zone 2 should be sutured and functionally treated early according to Kleinert's method. Different modifications of the Kirchmayr-suture can be used. Out of 24 primarily and delayed primarily repaired flexor tendon divisions 22 showed very good results. When applying this method for the early secondary treatment of flexor tendon divisions 8 cases out of 14 showed very good results. The flexor tendon repair in the region of the tendon sheath of the fingers is difficult and can therefore only be performed by a skilled hand surgeon. Success depends on the quality of postoperative supervision and physiotherapy practised.     

Isolated flexor digitorum profundus tendon injuries in zones IIA and IIB repaired with figure of eight sutures

The 'figure of eight' suture technique for flexor tendon repair is known to be simple and strong but it has the major disadvantage of being bulky, with the knots outside the repair site. When the superficialis tendon is intact it may cause impingement and/or increase the work of flexion with postoperative mobilization and it is not known whether this bulky repair is suitable for isolated profundus injuries in zone II. A series of 36 patients (36 fingers) with clean-cut isolated flexor digitorum profundus tendon injuries in zones IIA/IIB were reviewed retrospectively. Repairs were done with three 'figure of eight' sutures and the pulleys proximal to the tendon laceration level were vented. Postoperatively, early active exercises were carried out. There were no ruptures. At a mean final follow-up of 6 months, the outcome (in range of motion) was excellent in 27 fingers and good in the remaining nine fingers by the Strickland criteria. It was concluded that the bulky 'figure of eight' technique can be used in isolated profundus tendon injuries in zones IIA/IIB.     

Complications experienced in the rehabilitation of zone I flexor tendon injuries with dynamic traction splinting

A retrospective review of all flexor tendon repairs done between January 1985 to June 1987 determined the complication rate with our method of rehabilitation. One hundred sixty-three flexor tendon lacerations in 83 patients were reviewed. Follow-up ranged from 6 to 42 months. All patients participated in the same 12-week rehabilitation protocol. All patients had passive motion exercises of the interphalangeal joints in the first 2 weeks. We believe that passive stretching of zone I injuries during the first 2 weeks contributed to the zone I complication rate. Of the 20 patients with zone I tendon-to-tendon repairs, 7 patients had significant complications. The 35% complication rate found with zone I injuries has prompted us to modify our postoperative rehabilitation protocol in zone I injuries.     

Functional outcome of the hand following flexor tendon repair at the 'no man's land'

PURPOSE: To evaluate the functional outcome of the hand following flexor tendon repair at 'no man's land' using 2 strands of a modified Kessler core suture and combined controlled motion rehabilitation protocol. METHODS: Records of 31 zone-2 flexor tendon injuries in 21 digits of 16 patients between July 2000 and June 2005 were reviewed retrospectively. The injured tendons were repaired within 24 hours using 2 strands of a modified Kessler core suture, reinforced by a continuous circumferential epitendon suture. All patients completed a rehabilitation protocol that included active extension against a rubber band, passive flexion, and controlled passive extension and passive flexion exercises. Functional outcome of the fingers was assessed using the Buck-Gramcko II score. Hand grip strength, rehabilitation period, and rupture rate were also measured. RESULTS: 17 (81%) out of 21 digits in 15 out of 16 patients achieved an excellent-to-good functional grade. The remaining patient with concomitant injuries to 4 (19%) digits attained a poor functional grade, attributable to poor compliance with the rehabilitation protocol. The mean rehabilitation period was 130 days and the mean grip strength was 78% that of the uninjured side. Concomitant digital nerve injury did not adversely affect the final outcome. Only one (4.8%) patient experienced a rupture. CONCLUSION: The surgical method and rehabilitation protocol used for zone-2 flexor tendon injury is safe and results in a reasonably good functional outcome.     

Flexor tendon repair and rehabilitation in zone II open sheath technique versus closed sheath technique

A comparative prospective study of the surgical management of the tendon sheath after repair of flexor tendons in zone II is reported. The study included only patients with lacerations of both flexor tendons and no other associated injuries. A modified Kessler suture was used to repair the profundus tendon and the superficialis tendon was repaired with a horizontal mattress suture. In 48 fingers the flexor tendon sheath was left open and it was closed in the second group of 42 fingers. When it was impossible to close the tendon sheath, a vein patch was taken from the dorsal veins of the hand. Both groups of patients were treated with the same regimen of controlled motion rehabilitation and supervised by the same hand therapist. Results were evaluated by the Strickland formula for total active motion of the proximal and distal interphalangeal joints. There was no statistical difference between the results of open sheath versus closed sheath in these two groups of patients treated postoperatively with the same controlled motion rehabilitation program.     

Optimizing independent finger flexion with zone V flexor repairs using the Massachusetts General Hospital flexor tenorrhaphy and early protected active motion

PURPOSE: Independent FDS action has been cited to be problematic with repair of multiple tendons in zone V owing to adhesion formation between the flexor digitorum superficialis (FDS) and the flexor digitorum profundus (FDP) tendons. Of the several described flexor repair techniques the ideal tendon repair should be strong enough to allow for early active motion to minimize adhesion formation and maximize tendon healing. Biomechanical studies have proven the Massachusetts General Hospital (MGH) repair to be strong enough to allow for early active motion. The purpose of this study was to examine the use of the MGH technique for zone V flexor tendon injuries to allow for early protected active motion to achieve independent finger flexion through better differential gliding of the tendons. METHODS: We performed a retrospective review 168 zone V finger flexor tendon repairs for 29 patients performed consecutively over 4 years when early active motion was not contraindicated. The same early protected active motion protocol was used for all of these patients. We reviewed total active motion, independent flexion, rupture, and need for tenolysis. These injuries involved 103 FDS and 65 FDP tendons to 103 fingers. The median follow-up period was 24 weeks. Of these 29 patients 19 were men and 10 were women. The average patient age was 28 years. RESULTS: The total active motion for these zone V repairs was 236 degrees +/- 5 degrees Overall 97 of 103 digits attained good to excellent function and 88 of 103 developed some differential glide. One of these patients required a tenolysis. Three repairs ruptured in 1 patient owing to suture breakage that was associated with noncompliance with the dorsal extension block splint. CONCLUSIONS: Our retrospective review of 168 consecutive flexor tendon repairs showed that the MGH technique allowed for early protected active motion, which provided good to excellent functional outcomes with 88 of 103 developing independent finger flexion at an acceptably low complication risk.     

Two-stage reconstruction for flexor tendon injuries in zone II using a silicone rod and pedicled sublimis tendon graft

We report the results of staged flexor tendon reconstruction in 12 patients (12 fingers) with neglected or failed primary repair of flexor tendon injuries in zone II. Injuries involved both flexor digitorum profundus (FDP) and flexor digitorum sublimis (FDS), with poor prognosis (Boyes grades II–IV). The procedure included placing a silicone rod and creating a loop between the FDP and FDS in the first stage and reflecting the latter as a pedicled graft through the pseudosheath created around the silicone rod in the second stage. At a mean follow-up of 18 months (range 12–30 months), results were assessed by clinical examination and questionnaire. The mean total active motion of these fingers was 188°. The mean power grip was 80.0% and pinch grip was 76% of the contralateral hand. The rate of excellent and good results was 75% according to the Buck-Gramcko scale. These results were better than the subjective scores given by the patients. Complications included postoperative hematoma in two, infection in one, silicone synovitis in one (after stage I) and three flexion contractures after stage II. This study confirmed the usefulness of two-stage flexor tendon reconstruction using the combined technique as a salvage procedure to restore flexor tendon function with a few complications.     

Early active mobilization after primary repair of the flexor pollicis longus tendon

BackgroundThere have been few studies regarding primary flexor tendon repair of the thumb following early active mobilization, whereas there have been multiple such studies of the finger. This study examined the outcomes of patients who underwent early active mobilization after primary repair of the flexor pollicis longus tendon.MethodsThis study was a retrospective case series. Between 1993 and 2019, 17 thumbs of 17 consecutive patients with complete flexor pollicis longus tendon lacerations were treated using the Yoshizu #1 technique, followed by early active mobilization. The mean time between injury and primary flexor tendon repair was 2 days. Two thumbs had zone T1 injuries and 15 had zone T2 injuries. Mobilization of the thumb began on the first postoperative day with a combination of active extension and passive and active flexion. The mean follow-up period was 8 months. The percentage of total active motion of the thumb was regarded as the sum of the active motion of the two joints, divided by 140°. Functional outcomes were graded in accordance with the Strickland criteria.ResultsThree repair ruptures occurred in thumbs treated by inexperienced surgeons. Excluding tendon ruptures, the mean percentage of total active motion of the thumb was 83%. The mean active flexion of the interphalangeal and metacarpophalangeal joints was 62° and 64°. The mean extension deficit was 8.8° at the interphalangeal joint and 7.5° at the metacarpophalangeal joint. According to Strickland's criteria, repairs to eight thumbs were ranked excellent, three were good, one was fair, and five were poor.ConclusionsOur results are not inferior to the findings of previous reports regarding early postoperative mobilization after primary flexor pollicis longus tendon repair, in terms of the acquisition of active thumb motion. Poor outcomes result from repair rupture and increased extension deficits of the interphalangeal and metacarpophalangeal joints.     

A comparative analysis of the outcome of flexor tendon repair in the index and little fingers: does the little finger fare worse?

The clinical and hand therapy notes of 180 patients who had single digit flexor tendon repairs in zones I and II from January 2000 to December 2004 were reviewed. Data from 60 index and 108 little fingers at 5 weeks, 8 weeks and 12 weeks follow-up visits were included. In zone I injuries, there was a statistically significant difference in flexion contracture (worse in the little fingers ) at all follow-up points. Although the range of motion and percentage of patients in the excellent category of the Strickland and Glogovac criteria were greater in the index finger group than the little finger for zone I and II injuries, these differences were not statistically significant. The rupture rate was also higher in the little finger group.