Utility of early active motion for flexor tendon repair with concomitant injuries: A multivariate analysis

IntroductionFlexor tendon injury often occurs with concomitant injuries such as fracture, vascular injury, and extensor tendon injury. These injuries are repaired independently, without a comprehensive strategy. We aimed to identify the effect of concomitant injuries and treatment choice on the outcome of flexor tendon repair.Patients and methodsWe evaluated 118 fingers of 102 adult patients with zone 1–3 flexor digitorum profundus (FDP) tendon injuries who underwent primary surgery at our hospital between April 2009 and December 2017. The 2-strand pull-out, 4-strand Tsuge, 6-strand Lim & Tsai, and 8-strand cross-locked cruciate suturing techniques were used. We performed multivariate analyses, with the active range of motion (AROM) of the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints as dependent variables, and age, existence of concomitant injuries, and their treatment as independent variables.ResultsThe average AROM of the PIP + DIP joints was 130° at the last follow-up, and ‘excellent’ or ‘good’ function was obtained in 74 (63%) of 118 fingers by using the Strickland criteria. Old age, concomitant diaphyseal fractures, and specific methods of osteosynthesis, such as pinning, flexor digitorum superficialis injury, and immobilisation for 3 weeks, significantly worsened the results. However, wiring for osteosynthesis and early active motion protocol improved postoperative functional outcome. Although the outcome did not differ among the suture techniques, the 4-strand Tsuge procedure was performed for the two surgically confirmed ruptures of repair that occurred in our series.DiscussionWe clarified the superiority of early mobilisation protocols with rigid osteosynthesis procedure, other than pinning. To minimise tendon adhesion or joint stiffness, surgeons should repair the tendon and fractured bone appropriately, to ensure early mobilisation without serious complications.     

Quantifying catch‐and‐release: The extensor tendon force needed to overcome the catching flexors in trigger fingers

The extensor tendon forces required to overcome the catching flexors in trigger fingers are unknown. A biomechanical model with moment equilibrium equations and method of least squares was developed for estimating the tendon force at triggering in trigger fingers. Trigger fingers that exhibited significant catching and sudden release during finger extension were tested. A customized “pulling tester” was used to pull the finger from flexion to extension and provide synchronic measurement of the pulling force. The displacement of the tested finger was measured by a motion capture system. This preliminary study presents kinematic and kinetic data at triggering of 10 trigger fingers. The distal and proximal interphalangeal (PIP) joints presented sudden release while the metacarpophalangeal (MCP) joint started extension in the early phase of finger extension. The tendon tension of flexor digitorum profundus was greater than that of flexor digitorum superficialis (FDS) in six fingers, and less than that of FDS in three fingers. The tension of two flexor tendons was almost equal in one finger. At the PIP and MCP joints, 1.54 times the force of flexors was needed for the extensors to overcome the catching flexors in trigger fingers. This biomechanical model provides clinicians with a clearer idea of the tendon force at triggering. The quantitative results may help in the understanding of movement characteristics of trigger fingers. These findings are useful to better understand the etiology and nature of trigger finger development, and thus aid in further development of better assessments and treatments related to this. © 2013 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 31:1130–1135, 2013     

先天性手部关节挛缩症的治疗

目的 探讨先天性多发性手部关节挛缩症手术方法的选择.方法 对8例(23指)先天性手部关节挛缩症的患儿,分别采用关节囊掌板松解、指浅屈肌腱止点切断、深浅肌腱交替术、皮片移植术等方法,术中以挛缩的关节能被动伸直为标准,采用克氏针内固定和术后石膏外固定相结合的方法进行治疗.结果 术后23指伤口均I期愈合.随访时间为12～25个月,关节功能及手指外形良好,除1例(4指)出现肌腱轻度粘连外,7例中14指(累及掌指关节1指,近指间关节13指)主、被动活动达到正常.其余手指背伸损害值V伸=5°～10°.结论 手部先天性多发性关节挛缩症根据组织的挛缩程度,通过上述方法可获得良好的治疗效果.     

Two-staged tendon reconstruction in flexor tendon ruptures secondary to fracture of the hamate hook

We report a case of 2-staged reconstruction of flexor tendons ruptured spontaneously by attrition. A 49-year-old man presented with inability to flex the ring and little fingers of his left hand. Preoperative computed tomographic scans revealed fracture of the hamate hook. At the time of the operation, both the flexor superficialis and profundus of the little finger and the flexor profundus tendon of the ring finger were ruptured adjacent to the fracture site of the hamate. Because the flexor tendon rupture secondary to the fracture of the hamate is extremely rare, and surgical outcomes of previous reports are not satisfactory, a decision was made to perform 2-staged reconstruction of ruptured flexor tendons. The surgical result was excellent with complete restoration of full range of motion. This report describes for the first time to our knowledge, the technique, and rehabilitation of 2-staged tendon reconstruction in a patient with hook of hamate fracture.     

Central slip tenotomy for the treatment of chronic mallet finger: an anatomic study

PURPOSE: Tenotomy of the central slip, described by Fowler, can clinically improve chronic distal interphalangeal joint (DIP) extensor lag secondary to mallet finger (terminal tendon disruption). The goal of this study is to evaluate the potential of central slip tenotomy to restore DIP joint extension. METHODS: A mallet deformity was reproduced in 15 fresh-frozen cadaver fingers after the extensor tendon insertion was sectioned over the DIP joint. A suture anchor inserted at the terminal insertion was then secured to the extensor tendon over the middle phalanx to reconstruct the extensor mechanism. A 500-g weight attached to the proximal extensor tendon applied extensor tension. Central slip tenotomy was then performed. DIP extensor lags before and after tenotomy were recorded. RESULTS: After sectioning of the terminal tendon over the DIP joint the average amount of extensor tendon lag produced was 45 degrees. After central slip tenotomy was performed the average amount of extensor lag correction was 36 degrees (range, 30 degrees-46 degrees). CONCLUSIONS: Several clinical studies have shown that central slip tenotomy is an effective treatment for chronic mallet finger but may not fully restore DIP joint extension. Our data suggest that patients with a pre-existing extensor lag of greater than 36 degrees may not achieve full extension from central slip tenotomy, although extensor lags of up to 46 degrees may be corrected.     

Biomechanical analyses of the human flexor tendon adhesion models in the hand: A cadaveric study

Patients with longstanding trigger finger may develop flexion contracture at the proximal interphalangeal (PIP) joint that persists even after division of the A1 pulley. The purpose of this study was to explore the hypothesis that flexion deformity of the PIP joint in advanced trigger finger is caused by severe adhesion between the flexor digitorum superficialis (FDS) and the flexor digitorum profundus (FDP) tendons. Ten freshly frozen cadaveric hands were used in the experiments. After preparation of the extrinsic flexor, extrinsic extensor, and intrinsic muscle tendons, we applied weights to the flexor tendons and minimal tension to the extrinsic extensor and intrinsic muscle tendons. We then measured the initial flexion angles of the metacarpophalangeal (MCP) and PIP joints. Next, we measured the flexion angles of the MCP and PIP joints as increasing tension was applied to the extrinsic extensor and intrinsic muscle tendons, respectively. We repeated these experiments after constructing flexor tendon adhesion model. The initial flexion angles of the MCP and PIP joints were greater in the adhesion model, as were the average tensions required for full extension of these joints. Our results suggest that adhesion between two flexor tendons contributes to progression of flexion deformity in the PIP joint. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 33:717–725, 2015.     

Trigger finger treatment by ulnar superficialis slip resection (U.S.S.R.)

Surgical release of the A1 pulley for treatment of trigger finger normally produces excellent results. However, in patients with long-standing disease, there may be a persistent fixed flexion deformity of the proximal interphalangeal joint. This is sometimes due to a degenerative thickening of the flexor tendons and may be treated by resection of the ulnar slip of flexor digitorum superficialis tendon. One hundred seventy-two patients (228 fingers) who had undergone this procedure were reviewed at a mean follow-up of 66 months. Mean pre-operative fixed flexion deformity of the proximal interphalangeal joint was 33 degrees. All but eight fingers were improved by surgery and there was an average gain of 26 degrees in passive extension (7 degrees residual fixed flexion deformity) of the proximal interphalangeal joint. Full extension was attained in 141 of the 228 fingers, and in all 101 fingers with a pre-operative loss of passive extension of 30 degrees or less. This technique is indicated for patients with loss passive extension in the proximal interphalangeal joint and a long history of triggering.     

Treating Trigger Finger in Diabetics using Excision of the Ulnar Slip of the Flexor Digitorum Superficialis with or without A1 Pulley Release

The purpose of this study was to evaluate the results of excision of the ulnar slip of the flexor digitorum superficialis tendon, with or without A1 pulley release, for the treatment of trigger finger in diabetic patients. We performed a retrospective review with long-term follow-up examinations. Short-term data was obtained on 18 consecutive patients (37 fingers). Long-term information was collected on 14 of these patients (24 fingers) at an average of 48 months after surgery. Short-term follow-up revealed average proximal interphalangeal joint (PIP) flexion of 81°. One patient had slight residual triggering. At long-term follow-up, 93% of patients were completely or very satisfied with the procedure. Total active finger motion averaged 218°, and PIP extension deficit averaged less than 5°. Pinch strength was equal to the contralateral corresponding finger. There were no significant complications. One finger had minimal residual triggering. In conclusion, this procedure is a safe and effective treatment for the often-difficult problem of stenosing flexor tenosynovitis in the diabetic patient.     

Treatment principles for proximal and middle phalangeal fractures.

After a proximal phalangeal fracture, optimal results are obtained by methods that permit active interphalangeal joint motion and tendon gliding during fracture healing. Typical apex palmar angulation of proximal phalangeal fractures demonstrates dorsal skeletal shortening and secondary incompetence of the extensor mechanism with PIP joint extensor lag. Apex palmar deformities of the middle phalangeal fractures demonstrate similar problems with skeletal shortening resulting in loss of distal joint extension. Proximal and middle phalangeal shaft fracture deformities rotate about their flexor tendons and their fibro-osseous tunnels. Functional restoration requires accurate skeletal realignment that restores normal skeletal length necessary for extensor tendon competence. A splint that holds the wrist in slight extension and all four finger MP joints in full flexion combined with active interphalangeal joint exercises form the essential elements of postoperative care.     

Reconstruction of the radial collateral ligament of the metacarpophalangeal joints of the fingers

Background

Injury to the collateral ligament of the metacarpophalangeal (MP) joint is less common in the finger than the thumb and can have a significant impact on function. When it affects the middle finger, we have observed a more extensive mechanical disturbance than that affecting just the MP joint, and for the central two fingers with less accessible ligaments, we have developed a strong method of reconstruction using a tendon graft which also corrects the mechanical disturbance caused by loss of suspension of the assemblage nucleus which holds the flexor tendons and adjacent structures into the convexity of the transverse palmar arch.

Methods

Ten patients with painful chronic radial collateral ligament injuries of the MP joint of the finger were treated surgically. Eight of these patients received reconstruction using a tendon graft, whilst in one case, the ligament was reattached directly using a suture and in one by a tendon transfer.

Results

All patients achieved a good outcome following their surgery. Of the six patients treated with the described tendon graft technique, the average post-operative QuickDASH score was 0; the average post-operative grip strength, as a percentage of the unaffected good side, was 100 %, and the average active flexion, active extension, and passive extension were 83°, ?8° and ?24°, respectively.

Conclusions

For the middle and ring fingers, we recommend reconstruction using a tendon graft in order to restore the support to the whole flexor mechanism in the palm and to overcome the difficulty presented by inaccessibility of the ligament. Our cases treated in this way have shown full recovery of the function and correction of incipient deformity even when subluxation had started to occur. Level of Evidence: Level V, therapeutic study.     

Closed rupture of the flexor tendons caused by carpal bone and joint disorders

We analysed 21 patients with closed rupture of the flexor tendons caused by carpal bone and joint disorders. The tendon that ruptured depended on the location of the bone perforation into the carpal tunnel. Radiocarpal arthrography was performed in 13 patients and capsular perforation was demonstrated by contrast medium leakage into the carpal canal in 11 patients. This proved a useful diagnostic test. The flexor tendon(s) were reconstructed with free tendon graft in 17 patients, cross-over transfer of flexor tendons from adjacent digits in two and buddying to an adjacent flexor tendon in one patient. Postoperative total active range of motion in the fingers after 13 free tendon graft reconstructions averaged 213 degrees (range 170-265 degrees ). The active range of motion of the thumb-interphalangeal joint after free tendon graft reconstruction in three cases improved from 0 degrees to 33 degrees on average (range 10 degrees -40 degrees ).     

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.     

The aetiology of acute rupture of flexor tendon repairs in zones 1 and 2 of the fingers during early mobilization.

Five hundred and eight patients with 840 acute complete flexor tendon injuries in 605 fingers in zones 1 and 2 underwent surgery and postoperative mobilization in a controlled or early active motion (active flexion-active extension) regimen over a period of 7.5 years. Sixty-eight patients with 79 finger flexor divisions who did not complete the rehabilitation programme were excluded. Of the 440 patients with 728 complete tendon divisions in 526 fingers included in the study, 23 patients ruptured 28 tendon repair(s) in 23 fingers, an overall rupture rate of 4%. One hundred and twenty-nine fingers with zone 1 injuries had a rupture rate of 5%. Three hundred and ninety-seven fingers with zone 2 injuries had a rupture rate of 4%. This study analyses the 23 patients with flexor tendon rupture(s) to identify causative factors. In approximately half of these patients, tendon rupture followed acts of stupidity. The implications of this are discussed. There was no significant relationship between tendon rupture and the age or sex of the patients, smoking or delay between injury and tendon repair and there was no particular prevalence of zone 2C level injuries among the fingers in which tendon rupture occurred.     

Transposition der oberflächlichen Beugesehnen von Mittel- und Ringfinger zur Wiederherstellung der Daumen- und Fingerstreckung (Boyes-Transfer)

Objectives

Restoration of extension in the metacarpophalangeal joints of the fingers as well as in the interphalangeal joint of the thumb by transfer of the superficial flexor tendons of the long and ring fingers (flexor digitorum superficialis III and IV).

Indications

The indications for surgery are substantial loss and palsy of muscles innervated by the radial nerve and its roots.

Contraindications

The procedure is contraindicated by reversible radial palsy, palsy or substantial loss of flexors, limited passive mobility due to contracture, ankylosis or instability of the affected joints, instability of the wrist joint, palsy of the wrist flexors, ankylosis of the wrist joint in an unfavorable position, adhesions of flexor or extensor tendons, insufficient soft tissue coverage or soft tissue defects and passage of transposed tendons through scarred tissue.

Surgical technique

The surgical technique involves division of the superficialis tendons of the long and ring fingers proximal to Camper’s chiasm and routing of the tendons to the dorsum of the hand through separate fenestrations of the interosseus membrane. The flexor digitorum superficialis tendon III is interwoven into the tendons of the extensor pollicis longus und extensor indicis and the flexor digitorum superficialis IV is interwoven into the extensor digitorum tendons.

Postoperative management

Forearm splinting in 20° wrist extension including the metacarpophalangeal joints of the fingers in extension and the thumb in the automatic stop position for 4 weeks leaving the proximal and distal interphalangeal joints free.

Results

From March 1999 to January 2010 a Boyes’ transfer was performed in 13 patients (8 female and 5 male) and the right side was affected in 8, the left side in 5 and the dominant hand in 7 cases. The patient age at the time of surgery was an average of 47?±?17 (13–73) years. The interval between radial palsy and tendon transfer was an average of 79?±?144 (4–543) months. The final follow-up was performed at an average of 82?±?35 (32–165) months. According to the Haas scoring system finger extension was excellent in 5, good in 5, fair in 3 and unfavorable in 4 cases and thumb extension was excellent in 5, good in 3, fair in 1 and unfavorable in 5 patients. The mean disabilities of the arm, shoulder and hand (DASH) score was 36?±?24 (11–85) points. Although disability of varying degrees persisted in all patients, Boyes’ transfer is considered to be a safe procedure to restore finger and thumb extension with excellent and good functional results, a high degree of patient satisfaction and few complications.     

Dynamic profundus splint for flexor profundus repair

Flexor profundus is a mass action muscle so that when we fully extend one finger including full extension of the distal joint the entire muscle is pulled distally. By fully flexing the injured or operated finger at the metacarpophalangeal joint and fully extending the adjacent fingers, flexor digitorum profundus of the operated finger is made so redundant as to abolish all tension at the suture line. The position of the operated finger: metacarpophalangeal joint flexion with interphalangeal joint extension is ideal for the preservation of joint mobility and therefore ideal for the restoration of movement when the repaired flexor tendon is mobilized. It is permissible to splint a healthy finger in full extension for three weeks.     

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.     

Anterior tenoarthrolysis for severe flexion contracture of the fingers (the "TATA" operation): a review of 50 cases

The "hook finger", with both proximal interphalangeal (PIP) and distal interphalangeal (DIP) joint flexion contractures, often after multiple previous operations, is difficult to treat. This paper reports the results of 50 fingers in 49 patients in which the TATA (Téno-Arthrolyse Totale Antérieure) salvage procedure, described by Saffar in 1978, was carried out. Thirty-seven of 50 (74%) of these fingers had had at least one previous operation, most on the flexor apparatus. The mean PIP and DIP extension deficit pre-operatively was 133 degrees with a mean PIP lag of extension of 83 degrees . With a mean follow-up of 7.8 years, 45 fingers were improved, five were not and none was worsened. The mean PIP and DIP extension deficit postoperatively was 47 degrees , with a mean PIP lack of extension of 31 degrees . The overall gain in extension deficit of both joints was 86 degrees and of the PIP was 52 degrees . One PIP joint developed septic arthritis immediately after surgery. The benefit of this salvage operation is mainly in the change of the active range of motion to a more functional arc.     

Two-stage grafting of digital flexor tendons: a review of 43 patients after 3 to 15 years.

We reviewed 9 (3-15) years postoperatively all 43 two-stage flexor tendon transplantations in fingers that had not otherwise been severely injured that we had operated on during the years 1984 to 1996. One digit had been reconstructed in each patient. The interval between the first and second stage operations was 19 (14-51) weeks. Time away from work was 44 (4-140) days after the first procedure and 101 (38-297) days after the second stage operation. After the second stage, 26 further procedures had been done in 18 of the 43 fingers. These included seven resutures of the transplanted tendon (three in the same finger), five tenolyses, two capsulotomies of the proximal interphalangeal (PIP) joint, three arthrodeses of the distal interphalangeal (DIP) joint (two combined with reinsertion of the tendon to the middle phalanx), one DIP + PIP arthrodeses, and three amputations of PIP. One further finger will be amputated and two patients do not wish treatment for ruptured transplants. There were 15 excellent, six good, nine fair, and 12 poor results at review. A total of 31 of the 43 patients said they would have had the operation if they had known the outcome in advance. Reconstruction of a flexor tendon takes a long time and causes many complications. Even so, it is indicated in motivated and fully informed patients because of a lack of other viable options.     

Ultrasonic assistance in the diagnosis of hand flexor tendon injuries

In contrast to routine flexor tendon injuries, flexor tendon ruptures following blunt injury or re-ruptures following repair can be difficult to diagnose. The authors investigated the efficacy of using ultrasound to assist in the diagnosis. From 1996 to 1997, 8 patients underwent evaluation of the flexor tendons using an ATL HDI-3000 ultrasound machine with a high-resolution, 5 to 9-MHz hockey stick linear probe. Dynamic evaluation was performed in real time, simulating clinical symptoms. Six patients underwent surgical exploration. Sonographic diagnosis and intraoperative findings were correlated. Ultrasound was used to diagnose 3 patients with ruptured flexor digitorum profundus tendons. Mechanisms of injury included forceful extension, penetrating injury, and delayed rupture 3 weeks after tendon repair. Subsequent surgical exploration confirmed the ruptures and location of the stumps. Five patients had intact flexor tendons by ultrasound after forceful extension, penetrating injury, phalangeal fracture, crush injury, and unknown etiology. In 3 patients who underwent surgery for tenolysis, scar release, or arthrodesis, the flexor tendons were found to be intact, as predicted by ultrasound. The authors found ultrasound to be accurate in diagnosing the integrity of flexor tendons and in localizing the ruptured ends. They conclude that ultrasound is helpful in evaluating equivocal flexor tendon injuries.     

Rupture of flexor tendons after arthrodesis of the basal joint of the thumb.

We report a case of rupture of the flexor tendons to the index finger after arthrodesis of the basal joint of the thumb. The tendons ruptured as a result of the Kirschner wires having penetrated in the carpal tunnel. This unusual complication was treated by tendon graft of the palmaris longus tendon.