Immediate repair and early mobilization of the extensor pollicis longus tendon in zones 1 to 4.

We present the results of repair and early mobilization of 100 extensor pollicis longus (EPL) tendon injuries in zones 1 to 4 in 100 patients using a dynamic outrigger splint which controlled metacarpophalangeal joint movements but allowed free movement of the interphalangeal joint. Eighty-two were complete divisions of the tendon and 18 were 80% to 99% tendon divisions. Analysis of measurements obtained routinely at 8 weeks showed 81% excellent and good results using the TAM system. There were 90% excellent and good results in the 72 patients, who were followed-up and received therapy for 12 weeks. Except on the rare occasion when the repair rupture, loss of thumb extension was not a common functional problem, but scar tethering of the repaired tendon could result in loss of thumb flexion. While loss of metacarpophalangeal joint flexion appeared to have little functional importance, loss of interphalangeal joint flexion and slowing of the movements of this joint could cause functional problems. When interphalangeal joint hyperextension is present before the injury, it is frequently lost but this generally goes unnoticed by the patients. The problems of analysing the EPL injury using the methods of assessment available are discussed.

The use of Acufex wedge tag tissue anchors in hand surgery.

Over a period of 4 years, in various circumstances commonly seen in hand surgery, 100 patients underwent 127 soft tissue attachments to bone using the Acufex wedge tag system (Acufex Microsurgical, Inc, Mansfield, MA), a non-metallic bone anchor. No failures to maintain the attachment of the desired soft tissue to bone were identified. While less robust than the Mitek anchor, the other commonly available system of bone anchoring, and therefore possibly inappropriate for general orthopaedics, the Acufex wedge tag proved adequate for the smaller forces of hand surgery.

The flexor digitorum profundus "demi-tendon"--a new technique for passage of the flexor profundus tendon through the A4 pulley.

The flexor digitorum profundus (FDP) tendon may retract after avulsion or division in Zone 1. When treatment has been delayed, the oedematous tendon can be too swollen to pass freely through the A4 pulley. We present a new technique for dealing with this situation which depends on the "double-barrelled" nature of the distal part of the FDP tendon. One half of the tendon is excised longitudinally and the remaining "demi-tendon" is passed through the intact A4 pulley to allow tendon repair or re-attachment. This technique has been used in six cases in which passage of the FDP tendon through the A4 pulley would otherwise have been impossible.

Venous augmentation of the free TRAM flap.

Venous congestion in a free TRAM or DIEP flap when the main pedicle is still patent (both the artery and the vein) is an occasional dire situation. Here, we describe ways of salvaging the free TRAM or DIEP flap from imminent loss. In the last 4 years, we have had three patients who developed venous congestion after the use of the TRAM or DIEP flap for breast reconstruction. This was detected as late as the third postoperative day in our first patient. On exploration, patent arterial and venous anastomoses were found. Fortunately, the opposite pedicle had been dissected and preserved with the flap. The patent congested vein in this pedicle was anastomosed to the cephalic vein using an interpositional vein graft, relieving the congestion. In the other two patients congestion was detected earlier and relieved using the superficial inferior epigastric vein. It has been our policy to dissect a length of the opposite pedicle and/or preserve a length of the superficial inferior epigastric vein or the superficial circumflex iliac vein. These can then be used to augment venous drainage if inadequacy is noted at the end of the operation or during the postoperative period.

A comparison of dynamic extension splinting and controlled active mobilization of complete divisions of extensor tendons in zones 5 and 6.

We present a prospective randomized trial of two groups of 50 patients each having complete zone 5 and 6 extensor tendon injuries. These were rehabilitated by the use of either a dynamic outrigger splint or a palmar blocking splint. The results were analysed using the Miller and TAM assessments. Good and excellent results were achieved in 95 and 98% of cases following dynamic outrigger mobilization and 93 and 95% of cases using palmar blocking splint mobilization, using the Miller and TAM assessments respectively. There was no statistical difference in the results obtained between the two groups. Therefore, we prefer the latter technique which is simple, cheap, more convenient and requires less therapy time.

Anomalies of the flexor digitorum superficialis muscle.

Three anomalies of the human flexor digitorum superficialis are presented. The normal development of this muscle from the amphibian to the human is discussed and the described anomalies of the muscle in humans classified.