Effects of A2 Pulley Venting on Bowstringing and Tendon Slack: A Biomechanical Investigation.

BACKGROUND: A2 pulley release is often needed for exposure of the lacerated tendon, retrieval of retracted tendons, placement of core sutures, or to permit full motion and gliding of the repaired and edematous tendon. However, there is no agreement in the literature on the specific quantity of pulley venting that can be performed and recommendations are limited to an undefined "judicious release" of the pulleys when necessary. METHODS: Following a previously developed testing protocols, finger kinematics, tendon excursion, and bowstringing were evaluated on cadaveric hands for venting in increments of 20% of the pulley length. RESULTS: In our study, we found a statistically significant influence of venting on bowstringing, although no difference was found between fingers, and a significant difference in tendon slack, which was variable depending on the finger. Bowstringing started increasing at 20% of A2 venting and peaked at full release. Tendon slack did not start until 40% of A2 venting on the index finger, but started at 20% on the middle, ring, and small fingers. CONCLUSIONS: Venting of the A2 pulley leads to an incremental increase in tendon bowstringing and tendon slack. However, differences in metacarpophalangeal flexion angle were not observed until full A2 pulley release, and only observed in the index finger, and no differences were observed in proximal interphalangeal flexion angles. Therefore, the benefit of releasing the A2 pulley when clinically necessary will likely outweigh the risks of loss of motion or strength.

Mapping Origins of Tendons on the Medial Epicondyle to Improve Treatment of Medial Epicondylitis: Anatomical Study.

PURPOSE: Medial epicondylitis is a tendinosis found commonly in throwing and golfing athletes. Although there are choices for nonsurgical treatments, when these fail, surgical intervention can be considered. When surgical treatment is performed, the objective is to debride the diseased tissue from the epicondyle. The purpose of this study was to clarify the locations and size of the common flexor tendons and medial collateral ligament (MCL) relative to each other and to the posterior ridge of the medial epicondyle. METHODS: The common flexor tendons and MCL were dissected and reflected their origin on the medial epicondyle in six cadaver elbows. Measurements were taken from the posterior and distal ridges of the medial epicondyle with respect to the humerus. Each origin was also measured for its height and width. RESULTS: The flexor carpi ulnaris origin starts at a mean of 4.2 mm from the posterior ridge of the medial epicondyle and extends anteriorly an average of 4.8 mm. The flexor carpi radialis starts at a mean of 4.2 mm from the posterior ridge and extends anteriorly an average of 7.4 mm. The pronator teres begins at a mean of 4.6 mm from the posterior ridge and extends an average of 5.7 mm anteriorly. The MCL starts at an average of 10.4 mm from the posterior ridge and extends 5.2 mm anteriorly. CONCLUSIONS: The measurements found have allowed the creation of a map of the specific common flexor tendon origins and their sizes on the medial epicondyle, as well as their position relative to the MCL. CLINICAL RELEVANCE: A surgeon may debride 1 cm anteriorly from the posterior ridge of the medial epicondyle to safely address the affected tissues and ensure the safety and integrity of the MCL.

Pseudo-Volkmann Contracture: A Case Report.

Pseudo-Volkmann contracture, also known as entrapment of the flexor muscles, occurs due to mechanical entrapment of the flexor myotendinous units in the fracture or adhesions after both bone forearm fractures. It differs from Volkmann contracture in that there is no ischemia or compartment syndrome, and there is an absence of muscle fibrosis intra-operatively. Patients with pseudo-Volkmann contracture typically present with an inability to extend the fingers passively or actively when the wrist is in extension. However, finger extension is possible when the wrist is flexed. We present the case of a 16-year-old female who developed pseudo-Volkmann contracture subsequent to sustaining a both bone forearm fracture at the age of 4. Despite early recognition of finger flexion issues, the diagnosis was delayed until the age of 16 due to parental reassurance. Consequently, further medical consultation was not sought as the child exhibited satisfactory functional abilities. Understanding these complications is crucial for administering appropriate treatment and mitigating the risk of long-term issues such as flexion contracture.

The Outcomes of 2,154 Endoscopic Trigger Finger Releases.

BACKGROUND: Trigger finger is one of the most frequent causes of hand pain and disability. Recently, an endoscopic trigger finger release technique was developed, but outcomes have rarely been reported. Here, we present the outcomes of 2154 endoscopic trigger finger release procedures in a single center. METHODS: In this retrospective study, 2154 endoscopic trigger finger release procedures were performed on 2034 patients. Outcome assessment at 90 days after surgery was classified as excellent, good, fair or poor according to a combination of patient satisfaction with the scar and pain at rest or under load on a numeric rating scale. RESULTS: The therapeutic outcomes were: 1027 excellent, 607 good, 400 fair, and none poor. No major surgical complications were observed. Minor complications occurred in 231 fingers (10.7%). CONCLUSIONS: All patients were satisfied with their outcome after endoscopic trigger finger release. Endoscopic release can be an effective and efficient therapeutic method for the treatment of trigger finger.

Outcome of Flexor Tendon Repair Using Eight-Strand Core Stitch Without Postoperative Finger Splinting.

BACKGROUND: There are no reports that detail clinical outcomes using the 8-strand suture techniques and early active mobilization. We aim to report the outcome of using an 8-strand double-cruciate core suture followed by early active motion without finger splinting. MATERIALS AND METHODS: Thirty-five patients with 41 affected digits were operated and followed up for at least 6 months. A double cruciate repair with 4 single cross-grasping stitches on either side was employed. Active full-range finger flexion/extension exercises were allowed from the third postoperative day with the wrist held in the neutral position. RESULTS: The total active motion (TAM) calculated for the proximal interphalangeal and distal interphalangeal joints averaged 151° ± 22°, and the TAM% averaged 86% ± 13%. Based on the original Strickland-Glocovac criteria, excellent and good outcomes were achieved in 25 of 29 fingers (86.2%). An average extension lag of 21° ± 11° (range 10°-40°) was observed in 11 (38%) fingers. The Buck-Gramcko scale showed excellent and good results in 10 (83.4%) thumbs. Active interphalangeal range of motion averaged 68° ± 23°. An average extension lag of 12° ± 4° (range 10°-20°) was observed in 7 (58%) thumbs. Complications occurred in 4 thumbs, including bowstringing (2), rupture (1), and flexion contracture of 60° (1). CONCLUSIONS: Using the 8-strand repair technique and active mobilization performed by the patient is both practical and cost-saving. Intensive supervision of a hand therapist is generally not required. Notably improved outcomes have been achieved while preventing adhesions at the repair site. Further clinical outcome studies devoted specifically to the flexor pollicis longus are recommended to validate early-phase active mobilization following the 8-strand repair.

ZM suture combined with early functional exercise can promote finger functional recovery in patients with finger flexor tendon rupture.

OBJECTIVE: To investigate the efficacy of ZM suture combined with early functional exercise in repairing flexor tendons and its impact on finger function recovery in patients. METHODS: A retrospective analysis was conducted on 60 patients who sought medical treatment at the Orthopedics Hospital of Xingtai City from August 2019 to August 2022. Among them, 29 patients treated with the modified Kessler suture technique were assigned to the control group, while 31 patients treated with ZM suture technique were assigned to the observation group. Both groups of patients underwent early functional exercise after surgery and were followed up regularly for 6 months. Finger function, grip strength, pinch strength at 6 months after operation, upper limb function before and after treatment, visual analog pain scale (VAS) at 1 and 2 weeks postoperatively, quality of life, and incidence of complications were compared between the two groups. The risk factors affecting the prognosis of patients were analyzed. RESULTS: At 6 months postoperatively, the observation group showed significantly better finger function, grip strength and grip strength ratio, and upper limb function compared to the control group (all P<0.05). The observation group had significantly lower VAS scores at 1 and 2 weeks postoperatively and a significantly lower incidence of complications compared to the control group, while their quality of life was significantly better than that of the control group (all P<0.05). The choice of treatment method is an independent risk factor affecting the prognosis of patients (P<0.05). CONCLUSION: The ZM suture technique combined with early functional exercise has significant efficacy in repairing flexor tendons, effectively promoting finger function recovery in patients. It is also associated with a high level of safety and warrants clinical application and promotion.

Incidencia, funcionalidad y reintegración laboral de pacientes con lesión de sistema flexor de la mano tratados quirúrgicamente en el Hospital Central Militar / Incidence, functionality and labor reintegration of patients with injury to the flexor system of the hand treated surgically at the Hospital Central Militar

Resumen Introducción: Las lesiones de la mano son uno de los padecimientos más frecuentemente atendidos en el Servicio de Cirugía Plástica y Reconstructiva del Hospital Central Militar, dentro de la amplia variedad de estas lesiones se encuentran las lesiones del sistema flexor. Objetivo: Estimar la incidencia, funcionalidad y tiempo de reintegración laboral en pacientes con lesiones de sistema flexor de la mano tratados en el Hospital Central Militar en el periodo del 1º de marzo del 2020 al 1º de marzo del 2022. Metodología: Estudio observacional, retrospectivo, longitudinal descriptivo en pacientes adultos con lesión de sistema flexor de la mano, en los cuales la causa de la lesión no haya condicionado un trauma complejo de la mano. Se utilizó como referencia los criterios de recuperación funcional de Strickland y Goglovac. Resultados: A pesar de que las lesiones de la zona II flexora en la literatura presentan un peor pronóstico para la recuperación de la función normal de la mano, los resultados demuestran que la mayor parte de los pacientes se encuentra en una escala funcional buena. Limitaciones del estudio: El estudio fue llevado a cabo durante el periodo comprendido por la pandemia COVID, por lo que las consultas subsecuentes con tiempos más alargados y el inicio tardío de las consultas de rehabilitación pudieron haber contribuido hacia una recuperación más deficiente de la recuperación funcional de los pacientes.

Abstract Introduction: Hand injuries are one of the conditions most frequently treated in the Plastic and Reconstructive Surgery Service of the Hospital Central Militar, within the wide variety of these injuries are injuries to the flexor system. Objective: To estimate the incidence, functionality and labor reintegration time in patients with hand flexor system injuries treated at the Hospital Central Militar in the period from March 1, 2020 to March 1, 2022. Methodology: Observational, retrospective, longitudinal, descriptive study in adult patients with injury to the flexor system of the hand, in whom the cause of the injury did not result in complex trauma to the hand. The Strickland and Goglovac functional recovery criteria were used as reference. Results: Despite the fact that flexor zone II lesions in the literature present a worse prognosis for the recovery of normal hand function, the results show that most of the patients are in a good functional scale. Limitations of the study: The study was carried out during the period covered by the COVID pandemic, so that subsequent consultations with longer times and the late start of rehabilitation consultations could have contributed to a poorer recovery of functional recovery. from the patients.

An extensor tenosynovitis complicated with extensor tendon rupture revealing a hand tuberculosis.

Tuberculous hand tenosynovitis is a rare localization of tuberculosis. It is dominated by flexor tendon involvement; tenosynovitis of the extensor tendons is exceptional. The diagnosis is usually delayed and sometimes overlooked because of the paucity and the chronicity of the symptoms and signs with the patients often seen at the stage of tendon rupture. We, hereby, report the case of a tuberculous tenosynovitis of the extensors of the left hand having evolved into a ruptured extensor tendons to the 4th and 5th digits. The surgical treatment in conjunction with the antituberculous drugs resulted in the healing of this condition.

A rare case of an intratendinous ganglion cyst extending into the muscle belly of flexor carpi radialis: a case report and review of the literature.

ITGCs (intratendinous ganglion cysts) involving the flexor compartment of the wrist are uncommon, and reports are scarce in the literature. The differential diagnosis is wide and can mimic sinister lesions. We report a case of a 62-year-old male, that presented to our tertiary orthopaedic oncology service with an intratendinous ganglion cyst, extending into the muscle belly of flexor carpi radialis. We describe this rare presentation and review the literature.

Ulnar Superficialis Slip Resection Versus Radial Superficialis Slip Resection: A Biomechanical Pilot Study.

BACKGROUND: There are numerous clinical scenarios during which the surgeon contemplates whether the radial or ulnar slip of the flexor digitorum superficialis (FDS) should be sacrificed. To date no study has assessed the point of failure of each one of the FDS slips in each digit, aiding the avid surgeon in deciding which slip to sacrifice. METHODS: A total of 41 digits were assessed, each digit was dissected, and a specimen containing the denuded bone of the middle phalanx with the attachments of the ulnar and radial FDS slips was obtained. An Instron 4502 device was utilized to biomechanically assess the point of failure of each slip of each digit. RESULTS: There was no statistical difference between ulnar and radial slip point of failure when compared across all digits and subjects. There was no statistical difference between male and female subject's specimens. The point of failure was higher in the ulnar slips of the second and third digits, whereas the point of failure was higher in the radial slips of the fourth and fifth digits. CONCLUSIONS: Sacrifice of a FDS slip may cause loss of grip strength. In several clinical scenarios one may be faced with the dilemma which FDS slip to sacrifice. Our findings show this is not an arbitrary choice. Hand surgeons should keep our findings in mind when deciding which slip to sacrifice, in effort to preserve function and strength in the injured hand.

Differential Pulley Release in Trigger Finger: A Prospective, Randomized Clinical Trial.

BACKGROUND: The palmar aponeurosis or "A0 pulley" may play a role in trigger finger pathology. This study assesses the involvement of the A0 pulley in patients receiving trigger finger release. METHODS: This single-surgeon, prospective, randomized clinical trial was conducted among consenting patients with symptomatic trigger finger. Intraoperative coin toss was used to randomize initial release of either the A0 or A1 pulley. Following release, active flexion and extension of the affected digit were examined. The remaining pulley was then released in sequence, and clinical trigger status was recorded. RESULTS: Thirty fingers from 24 patients were released; 17 fingers received A0 release first, and 13 received A1 release. Following initial A0 release, 8 fingers (47%) demonstrated complete resolution of symptoms, 4 (24%) demonstrated improvement but incomplete resolution of triggering, and 5 (29.4%) demonstrated no improvement. Following initial A1 release, 6 fingers (46%) demonstrated complete resolution, 3 (23%) demonstrated improvement but incomplete resolution of triggering, and 4 (31%) demonstrated no improvement. All patients demonstrated complete resolution after surgical release of both sites. Neither initial A1 release nor initial A0 release was statistically associated with complete, incomplete, or failed symptom resolution. CONCLUSIONS: These data implicate the A0 pulley as the primary cause of 31% to 47% of trigger fingers in our study. Although larger trials are needed to validate these results, our study suggests that release of both A0 and A1 pulleys may offer greater symptom resolution than release of the A1 pulley alone.

The origins of the camper's chiasm asymmetry: a cadaveric study and clinical implications for flexor tendons surgery.

The Camper's chiasm (CC) originates from the decussation of tendon fibers of the flexor digitorum superficialis at the level of the proximal phalanx. Previous studies described several conformations of the CC, but none has studied the asymmetry pattern for each finger. We lack studies about the relationship between the vincula tendinum and the morphology of the CC. We aimed to study the precise pattern of asymmetry and the aforementioned relationship in a cadaveric study. We studied the fingers of 9 fresh frozen human hands (thumb excluded). We observed the distribution of the fibers and categorized each CC according to the Gonzalez classification. Finally, we recorded the inset point of the vincula longa superficiales (VLS) according to Schmidt. We found 7 symmetrical CCs, while the remaining 29 showed an asymmetrical pattern that matched with the site of insertion of the VLS. For the index and long fingers, we detected a dominance of the ulnar slip. For the ring and little finger, we found a higher radial dominance. The inset point of the VLS always coincided with the side of slip dominance, whereas in symmetrical CCs, the VLS was symmetrical as well. Since the vascular role of the vincula tendinum, we speculate that the asymmetry of the CC may be of vascular origin.

A Low Virulence Infective Tenosynovitis Triggered by a Neisseria Species.

A persistent infective tenosynovitis, caused by a non-pathogenic Neisseria species and involving the little finger and the thumb of a middle-aged woman, forming a horseshoe-type infection is presented. An extensive volar approach was utilised for excision of the granulomatous synovium and drainage of turbid fluid. Neisseria spp was isolated by tissue microbiology and targeted antibiotic therapy for 6 weeks was required to eradicate infection. The presence of low virulence microorganisms which might act as true pathogens should always be considered as a causative factor leading to persistent infections that require open surgical debridement and washout. Level of Evidence: Level V (Therapeutic).

Tendon Reconstruction With Cadaveric Allograft in a Patient With Flexor Tendon Injury Without Treatment for Six Months.

We present the case of an 18-year-old male patient with a penetrating lesion at zone II of the flexor compartment of the left hand. During surgery, complete reabsorption of the second deep and superficial flexor tendons was evidenced, prompting the decision to perform a two-stage procedure. First, a spacer was placed, and pulley reconstruction was performed. Six weeks later, we placed a cadaveric allograft and splint with the Kleinert-Duran technique for proper rehabilitation. Our case report highlights that a two-stage procedure with an allograft is a feasible technique resulting in good post-surgical functional status despite tendon reabsorption and six months between trauma and surgical intervention.

Rehabilitation after flexor tendon repair and others: a safe and efficient protocol.

In this review I detail the protocol that I use after flexor tendon repair and outline my experience regarding how its framework might be used for other disorders. The early passive-active flexion protocol has a sufficient number of cycles of active flexion in each exercise session, which is at least 40, and ideally 60 to 80. The frequency of exercise sessions may range from 4 to 6 a day, distributed in the morning, afternoon and evening. Increasing the number of daily sessions without a sufficient number of runs in each session is ineffective. In the first 2-3 weeks after surgery, active digital flexion should go through only a partial range. In weeks 4-6, the patient gradually moves through the full range. With modifications, I suggest generalization of the partial-range finger motion to therapy after treating other hand injuries. I consider partial-range active flexion a generalizable working principle for different hand disorders.

Morphological features of the chiasma tendinum and its relation with surface landmarks and pulleys: a cadaveric study.

AIM: Chiasma tendinum (Camper's chiasm) is of great importance in the delicate movements and stability of the fingers and takes place poorly in the literature. This study aims to reveal the morphometric details of the chiasma tendinum in relation with pulleys and other relevant structures. MATERIALS AND METHODS: Palm and 2nd to 5th fingers of 10 (6 male, 4 female) formalin fixed cadavers were used bilaterally. After determining the superficial reference points on the fingers, the skin and the tendon sheath were incised, and then measurements of chiasma tendinum and related tendons were performed. The measurements were analyzed with respect to fingers, genders, and sides. Finally, the types of chiasma tendinum were identified and then grouped as symmetrical, asymmetrical, and pseudo chiasm. RESULTS: Pulley and chiasma tendinum positions were correlated with finger length (p < 0.01). Pulley lengths were significantly less in females. Asymmetrical chiasma tendinum types were found in 45% of the fingers. In most comparisons, values for fifth finger were significantly different than that of other fingers and chiasma tendinum types differed according to fingers and gender. The case of no fiber exchange was observed only in the 5th finger in 15%. CONCLUSION: Findings related to the prediction of location of the pulleys and chiasma tendinum according to the superficial signs, awareness of cases where one of the two arms of the flexor digitorum superficialis is extremely thin and no fiber exchanges that may be risk factors for spontaneous tendon rupture may help provide more accurate approaches in relevant clinical applications.

Comparative anatomic and morphometric examination of the interosseous muscle, sesamoid ligaments and flexor tendons of the fetlock in South American camelids.

This study presents a comparative morphological and morphometrical examination of the interosseous muscle (IOM), digital flexor tendons and associated structures of all four species of South American Camelids (SACs): Lama (Lama glama), alpaca (Vicugna pacos), guanaco (Lama guanicoe) and vicuna (Vicugna vicugna). Our findings show that the lamoid interosseous muscle and digital flexor tendons are very similar between species and differences, which have been reported previously, are possibly due to diverging examiner interpretation. Lumbricalis muscles were mostly found as single muscles in this study. The definition of the terminal and dorsal branches of the interosseous muscle is critically revised. The analysis of morphometric data indicates that the size of the individual has a substantial influence on the cross-sectional area (CSA) of the examined structures. Metacarpal/metatarsal bone width is a main predictor of CSA, while the factor species only shows significance in specific sample points. For lama and alpaca, no differences in CSA in relation to species as factor were found. The IOM shows the largest CSAs of the three examined structures in all species, which implies an important load-bearing function. Considerable individual variation remains unexplained by the mentioned factors. This lowers the prospect of CSA reaching diagnostic importance in SAC fetlock pathology.

Feasibility of Homodigital Flexor Digitorum Superficialis transposition, a new technique for A2-C1 pulleys reconstruction: A kinematic cadaver study.

INTRODUCTION: Homodigital flexor digitorum superficialis transposition (HFT) is proposed as a new technique for A2-C1 pulley reconstruction. Flexor digitorum superficialis is transposed on the proximal phalanx and inserted on the pulley rims, crossing over flexor digitorum profundus and acting as a pulley. MATERIALS AND METHODS: The kinematic feasibility was investigated in a cadaveric bowstring model (after A2 and C1 pulley removal) on 22 fingers (thumb excluded). RESULTS: HFT was effective in restoring the correct flexion of proximal and distal interphalangeal joints, compared to bowstring model. No adverse events were registered. CONCLUSION: HFT is a feasible technique. Clinical application is encouraged.

Upper Extremity Tendon Transfers: A Brief Review of History, Common Applications, and Technical Tips.

Background Tendon transfer in the upper extremity represents a powerful tool in the armamentarium of a reconstructive surgeon in the setting of irreparable nerve injury or the anatomic loss of key portions of the muscle-tendon unit. The concept uses the redundancy/expendability of tendons by utilizing a nonessential tendon to restore the function of a lost or nonfunctional muscle-tendon unit of the upper extremity. This article does not aim to perform a comprehensive review of tendon transfers. Instead it is meant to familiarize the reader with salient historical features, common applications in the upper limb, and provide the reader with some technical tips, which may facilitate a successful tendon transfer. Learning Objectives (1) Familiarize the reader with some aspects of tendon transfer history. (2) Identify principles of tendon transfers. (3) Identify important preoperative considerations. (4) Understand the physiology of the muscle-tendon unit and the Blix curve. (5) Identify strategies for setting tension during a tendon transfer and rehabilitation strategies. Design This study was designed to review the relevant current literature and provide an expert opinion. Conclusions Tendon transfers have evolved from polio to tetraplegia to war and represent an extremely powerful technique to correct neurologic and musculotendinous deficits in a variety of patients affected by trauma, peripheral nerve palsies, cerebral palsy, stroke, and inflammatory arthritis. In the contemporary setting, these very same principles have also been very successfully applied to vascularized composite allotransplantation in the upper limb.

Irreducible Ankle Fracture Due to Incarceration of the Long Flexor Tendons Together With the Neurovascular Bundle in the Tibial Fibular Interosseous Space: A Case Report and Short Literature Review.

Ankle fracture dislocations with frustrating attempts at closed reduction are a rare traumatic entity. We present a case of an irreducible ankle fracture due to incarceration of all the flexor tendons including the neurovascular bundle in the tibial fibular interosseous space; to date, only one such case has been published in the literature. A computed tomography scan in both bone and soft tissue windows was necessary to clarify the structures that were inhibiting repositioning. The decisive step for surgical treatment was removal of the trapped structures from the tibial fibular interosseous space by a dorsomedial approach. The malleolar joint was then reconstructed anatomically. After 12 weeks, the patient was fully mobile without restrictions in his daily professional activities.