Traumatic flexor tendon injuries

The flexor system of the fingers consisting of flexor tendons and finger pulleys is a key anatomic structure for the grasping function. Athletes and manual workers are particularly at risk for closed injuries of the flexor system: ruptured pulleys, ruptures of the flexor digitorum profundus from its distal attachment (“jersey finger”), and less frequently, ruptures of the flexor digitorum superficialis and of the lumbrical muscles. Open injuries vary more and their imaging features are more complex since tendons may be torn in several locations, the locations may be unusual, the injuries may be associated with nerve and vascular injuries, fibrosis… Sonography is the best imaging modality to associate with the clinical exam for it allows an experienced physician to make an accurate and early diagnosis, crucial to appropriate early treatment planning.     

The effect of tendon excursion velocity on longitudinal median nerve displacement: Differences between carpal tunnel syndrome patients and controls

The subsynovial connective tissue (SSCT) is a viscoelastic structure connecting the median nerve (MN) and the flexor tendons in the carpal tunnel. Increased strain rates increases stiffness in viscoelastic tissues, and thereby its capacity to transfer shear load. Therefore, tendon excursion velocity may impact the MN displacement. In carpal tunnel syndrome (CTS) the SSCT is fibrotic and may be ruptured, and this may affect MN motion. In this study, ultrasonography was performed on 14 wrists of healthy controls and 25 wrists of CTS patients during controlled finger motions performed at three different velocities. Longitudinal MN and tendon excursion were assessed using a custom speckle tracking algorithm and compared across the three different velocities. CTS patients exhibited significantly less MN motion than controls (p ≤ 0.002). While in general, MN displacement increased with increasing tendon excursion velocity (p ≤ 0.031). These findings are consistent with current knowledge of SSCT mechanics in CTS, in which in some patients the fibrotic SSCT appears to have ruptured from the tendon surface. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 33:483–487, 2015.     

“阳气者,精则养神,柔则养筋”新论

“阳气者,精则养神,柔则养筋”出自《素问·生气通天论》,历代注家多有不同注释.从阳气升降浮沉之圆运动的角度出发,提出新的见解,认为其内涵为人体的阳气与自然界的阳气一样,是持续的有规律的运动,总体表现出与太阳类似的升降浮沉之圆运动状态.只有阳气正常的收敛与潜藏,才能营卫血气调和而养神;只有阳气适时的萌动与升发,才能气血调达而筋肉有力.可见“阳气者,精则养神,柔则养筋”表达了阳气变动不居的特点,及其在不同的状态下对人们神与形的影响.     

鸡爪5种屈肌腱中心缝合方法的即刻生物力学比较

目的:比较5种临床常用肌腱中心缝合方法的即刻生物力学特性,为临床肌腱修复提供参考。方法:成年AA白羽鸡爪50只,随机分为5组。锐刀横断Ⅱ区趾深屈肌肌腱,分别用改良Kessler法、津下(Tsuge)法、Cruciate法、改良Tsuge法、Tang法进行中心缝合,不做周边修复。缝合后立即取下肌腱,用冰冻卡具固定两端,在生物力学材料动态力学性能测试仪进行拉伸-断裂测试。测定极限载荷、应变,记录断裂方式,计算出各组肌腱的韧度、极限拉伸强度、弹性模量和断裂功耗并进行统计学分析。结果:Tang法组的极限载荷、极限拉伸强度、韧度和断裂功耗均大于其他4种方法(P0.05),改良Kessler法组各参数均小于其他4种方法(P0.05)。结论:临床中最常用的改良Kessler法操作简单,缝合后外观光滑,组织反应轻,但其缝线股数少,抗拉强度较低,有待进一步增加强度。Tang法缝合的各生物力学性能优于其他方法,高抗拉强度可以满足术后早期功能锻炼,为一种可靠的肌腱修复方法。     

Sonographic Evaluation and Sonographic-Guided Therapeutic Options of Lateral Ankle Pain: Peroneal Tendon Pathology Associated with the Presence of an Os Peroneum

Clinical implications of acute injuries of the os peroneum have been described, with the recommendation in some cases being the excision of the bone fragments. We describe the spectrum of sonographic appearances associated with pain in the region of the os peroneum, document associated peroneal tendon pathology, and describe the use of sonography to direct and guide therapeutic and/or diagnostic injections. All sonographic examinations in our ultrasound database from Jan 1, 2001–Jan 30, 2007 with the words “os peroneum” were reviewed. Patients were cross-referenced in our radiology database to find relevant foot or ankle radiographs for correlation. There were 47 patients (18 men and 29 women, age range 16 to 83) referred for sonographic evaluation of lateral foot and/or ankle pain who had an os peroneum identified during the sonographic evaluation. Eighteen patients were referred specifically for targeted injection of the lateral ankle, including peroneal tendon sheath injections (N = 10), calcaneocuboid joint injections (N = 1), and injections around symptomatic os peroneum (N = 7). All 47 patients had tendinosis of the peroneus longus, in varying degrees of severity. Radiographs were available for correlation in 28 patients. The causes of lateral ankle pain with a co-existent os peroneum are multifactorial and may not directly relate to the presence of an os peroneum. Ultrasound can be of value in separating out the specific etiology for pain, as well as provide a method for problem solving by the performance of targeted diagnostic or therapeutic injections in the lateral ankle.     

New perspectives in rotator cuff tendon regeneration: review of tissue engineered therapies

Tissue engineering may play a major role in the treatment of rotator cuff tendon lesions through replacement of an injured tendon segment. Tendons have very poor spontaneous regenerative capabilities, and despite intensive remodelling, complete regeneration is never achieved and the strength of tendon and ligaments remains as much as 30% lower than normal even months or years following an acute injury. Tendons seem to be the least complex of the connective tissues with respect to their composition and architecture and this leads to the expectation that they would be more amenable to tissue engineered approaches than other tissues. An accurate literature revision was done in order to know the state of the art of tissue engineering therapies in the field of rotator cuff regeneration. The following techniques of tissue engineering were considered: local injection of stem cells or growth factors, gene transfer, in situ tissue engineering and in vitro production of bioengineered tendons to be further transplanted in the lesion site. So far, few experimental or clinical studies have been done on tendon tissue engineering compared to the extensive work on other tissues of orthopaedic interest, such as bone and cartilage. The existing studies are related to the following tissue engineering methodologies: gene transfer, in situ tissue engineering and in vitro production of bioengineered tendons. In our opinion the previously described literature revision showed the necessity for future studies in this area also because of recent advances in biological and bioactive scaffolds.     

Pathologisch-anatomisches Läsionsmuster und klinische Symptomatologie der rheumatischen Handflexorensehnenerkrankung

Summary Objectives: To assess complaints and clinical findings of rheumatoid hand flexor tendon disease in relationship to the anatomical site and the type of lesion in order to improve the diagnosis and enable early operative treatment with preservation of hand function. Methods: 123 patients of the hands of 78 patients (66 female, 12 male) with a mean age of 57 years were analyzed retrospectively. Preoperative complaints and clinical findings were recorded according to their frequency. Three different types of flexor tendon disease were distinguished intraoperatively: isolated tenosynovitis, tenosynovitis with tendon lesion, and complete tendon rupture. Results: 188 tendons showed isolated synovitis, 208 had a tendon lesion with synovitis, and 30 tendons a rupture. Tenosynovitis was found in the palm and wrist mainly. The 2nd, 3rd and 4th finger were most frequently involved. 81 tendon adhesions, 12 nodules, 63 superficial lesions and 52 defects were detected. These lesions were found mainly in the palm and the second and third ray. The profundus tendon was affected most often. Ruptures were detected most often in the wrist caused by bony spurs and tenosynovitis. A clinical difference between tenosynovitis with and without tendon lesion was not found. However, complaints and findings were different in the digit, palm, wrist and forearm. Ruptures had characteristic clinical findings. Conclusions: Rheumatoid flexor tendon disease is common. Tenosynovitis is often accompanied by tendon lesions. Ruptures occur as disease progresses. Exact assessment of complaints and clinical findings is mandatory to diagnose and localize flexor tendon disease. Early operative intervention helps to preserve the function of the hand. Eingegangen: 7. September 1998 Akzeptiert: 10. August 1999     

The tendons of Todaro and the "triangle of Koch": lessons from eponymous hagiolatry

INTRODUCTION: There is growing use of the Todaro tendon and triangle of Koch as anatomic icons for invasive cardiac electrophysiologists. Reasons exist to doubt this validity. METHODS AND RESULTS: Histologic sections were prepared from 96 anatomically normal human hearts. The study area extended from the crista supraventricularis to the eustachian valve and included the AV node and His bundle. This encompasses any tendon of Todaro. Because the purported triangle of Koch includes the tendon of Todaro, all of Koch's available publications were examined. The tendon of Todaro is absent in only one fourth of infant hearts, but in two thirds of adult hearts. Tendons present were less often single than double or more, rarely exceeded 4 mm in length, and were seldom > 1 mm in diameter. Tendons usually originated from the central fibrous body and ended in the eustachian valve. Their origin most often was over the His bundle or its junction with the AV node, rather than the AV node. Tendons were primarily composed of collagen. Koch never described any triangle or acknowledged existence of tendons of Todaro. CONCLUSION: Todaro tendons are too often absent (or multiple) to warrant use as anatomic landmarks. Without this side of the supposed triangle of Koch, the entire tendon and triangle concept collapses and should be abandoned. There are numerous far more constant anatomic landmarks available to orient one to the human AV node and His bundle; these are briefly reviewed.     

The role of periosteal flap in the prevention of femoral widening in anterior cruciate ligament reconstruction using hamstring tendons

Tunnel widening in anterior cruciate ligament reconstruction has been reported for many years, whatever the type of plasty (allo- or autograft) or graft (patellar or hamstring tendons). Recently, the hypothesis has been formulated that widening would be responsible for later laxity of the knees. Micromobility of the graft or biological factors are classically responsible for the enlargement. In order to improve the biological conditions around the graft within the tunnel, we have developed a surgical technique using a periosteal flap. The periosteal flap is harvested at the superior and medial metaphysis of the tibia and wrapped around the proximal part of the four strands of gracilis and semitendinosus tendons near the outlet of the femoral tunnel. Forty-one patients with isolated rupture of the ACL were included in a prospective and randomized study: the first group of 20 patients had femoral fixation by Transfix and resorbable screw, the second group of 21 patients had femoral fixation by Transfix and periosteal flap. The diameters of the tunnel were measured between the sclerotic margins at the tunnel entrance and 1 cm above, and compared to the peroperative drill size. The percentage change in diameter was calculated as: (tunnel diameter–drill size)/drill size. The two groups of patients were comparable as to gender, side, age, KT-1000 side to side difference, femoral tunnel diameter and follow-up. At 2.5 months and 11 months postoperatively on average, there was a significant reduction of enlargement at the outlet of the tunnel with the use of a periosteal flap but widening was constant.