The Effect of Flexor Digitorum Profundus Repair Position Relative to Camper Chiasm on Tendon Biomechanics.

PURPOSE: The purpose of this study was to investigate the impact of repairing a zone II flexor digitorum profundus (FDP) laceration anatomically versus extra-anatomically on tendon loads and work of flexion (WOF). METHODS: Twenty digits from 5 cadaveric specimens were tested using an in vitro active finger motion simulator under 2 FDP tendon repair conditions: anatomic and extra-anatomic. Tensile loads in FDP and flexor digitorum superficialis (FDS), WOF, and total active finger range of motion (ROM) were measured using in-line load cells and electromagnetic tracking, respectively. RESULTS: The anatomic repairs had no effect on tendon loads or WOF for either FDP or FDS. The extra-anatomic repairs increased FDP loads by 32% and decreased FDS loads by 9% compared with those in the intact condition. This pattern was similar for WOF following extra-anatomic repairs, which increased FDP WOF by 31% and decreased FDS WOF by 18%. Comparing the 2 repairs, FDP loads and WOF were 25% and 22% greater, respectively, with extra-anatomic repairs compared with anatomic repairs, with no significant change in FDS. Total active ROM was not affected by either repair. CONCLUSIONS: In this in vitro cadaveric model, extra-anatomic repairs of FDP increased tendon loads and WOF compared with anatomic repairs. CLINICAL RELEVANCE: On the basis of this study, reconstitution of the anatomic relationship of FDP and FDS at the Camper chiasm during the repair of zone II flexor tendon lacerations is recommended.

Effect of a Flexor Digitorum Superficialis Hemitenodesis on Reducing Volar Plate Strains for Swan Neck Deformities.

BACKGROUND: Flexor digitorum superficialis (FDS) hemitenodesis is a common procedure to treat swan neck deformity (SND). We hypothesize that this surgical technique is a biomechanically effective way to reduce strain in the volar plate at the proximal interphalangeal joint (PIPJ). METHODS: Fifteen digits from 5 cadaveric specimens were tested using a novel in vitro active finger motion simulator under 4 finger conditions: intact, SND, FDS hemitenodesis, and FDS hemitenodesis with distal interphalangeal (DIP) joint fusion. Tensile loads in FDS and flexor digitorum profundus (FDP) and joint ranges of motion were measured by electromagnetic tracking. In addition, strain gauges were inserted under the volar plate to measure strain during PIPJ hyperextension. Results were analyzed using 1-way repeated-measures analysis of variance tests. RESULTS: The SND condition increased volar plate strain by 176% ± 25% (P < .001) compared with the intact condition. The FDS hemitenodesis repair relieved more than 50% of the SND strain, restoring it to within no statistical difference from intact. The DIP fusion further reduced strain with no further statistical significance. At full flexion, FDS and FDP tendon loads diverged as a function of the test condition (P < .001). With the FDS hemitenodesis, the FDP load increased by 2.1 ± 1.5 N from the SND condition (P < .001), whereas the FDS load decreased by 1.3 ± 1.3 N (P = .012). CONCLUSION: The FDS hemitenodesis repair restored strains to within 3.0 milli-strain of the intact condition with no significant difference. Application of DIP fusion did not further protect the PIPJ from increased hyperextension and further exacerbated the imbalance of flexor tendon loads.

Strength Comparison of Fibrin Glue and Suture Constructs in Upper Extremity Peripheral Nerve Coaptations: An In Vitro Study.

PURPOSE: To compare in vitro failure loads of nerve coaptations using fibrin glue alone, a suture alone, and a combination of fibrin glue and a suture. METHODS: The median, radial, and ulnar nerves of 15 fresh-frozen cadaveric upper extremity specimens (45 nerves in total) were dissected in vitro and transected 5 cm proximal to the wrist crease to simulate an injury requiring coaptation. Three coaptation techniques were used: fibrin glue alone, a suture alone, and a suture augmented with fibrin glue. The load to failure of each repair was measured using a linear servo-actuator with an in-line force sensor. The results were analyzed using 2-way repeated measures analysis of variance tests and pairwise comparisons with Bonferroni correction. RESULTS: Both the nerve coaptation technique and the specific nerve that was repaired had a significant effect on failure load. Suture-glue repair had the highest load to failure, 11.2 ± 2.9 N, and significantly increased the load to failure by 2.9 ± 1.7 N compared with glue repair alone. There was no significant difference between suture-glue repair and suture repair alone or between glue repair alone and suture repair alone. CONCLUSIONS: In this in vitro cadaveric model, nerve injury coaptation using both a suture and fibrin glue resulted in the strongest repair. The addition of fibrin glue may provide some benefit when used to augment suture repair, but when used in isolation, it is inferior to combined suture-and-glue constructs. CLINICAL RELEVANCE: Combined suture-and-glue nerve coaptations might be useful in the early postoperative period in increasing nerve repair strength and potentially reducing rupture rates.

The Evaluation of a Flexor Digitorum Profundus-to-Volar Plate Zone I Repair Versus Button Repair: An In vitro Biomechanics Study.

PURPOSE: The purpose of the study was to evaluate joint kinematics and tendon work of flexion (WOF) following a flexor digitorum profundus (FDP)-to-volar plate (VP) repair technique relative to a pullout button for zone I flexor tendon injuries. METHODS: Fourteen digits were tested using an in vitro active finger motion simulator under 3 repaired conditions following a simulated zone I avulsion: button, FDP-VP, and "no slack" FDP-VP (corrected for additional VP length). Outcome metrics included active joint range of motion (ROM), fingertip strength, FDP and flexor digitorum superficialis tensile loads, and WOF. RESULTS: The button and FDP-VP techniques restored WOF to the intact condition for FDP and flexor digitorum superficialis. All repairs restored distal interphalangeal joint ROM and kinematics to the intact condition. Similarly, all repairs restored WOF; however, the "no slack" FDP-VP significantly increased WOF by 10% to 12% over the simple FDP-VP repair. The button technique had similar fingertip strength to the intact condition, whereas the FDP-VP repairs significantly reduced peak fingertip strength from intact, albeit only 1-2 N compared with the button repair. CONCLUSION: In this in vitro cadaveric model, the button and FDP-VP techniques restored WOF and ROM to within intact levels, with no difference between these repairs in all measured outcome metrics. CLINICAL RELEVANCE: Based on its initial strength and its equal biomechanical performance compared with the button repair, the FDP-VP technique may be a viable option for treating FDP avulsions.

Development of an In Vitro Swan Neck Deformity Biomechanical Model.

BACKGROUND: Injury to the finger's extensor mechanism is a common cause of swan neck deformity (SND). Progression of extensor and flexor tendon imbalance negatively affects laxity of the volar plate, resulting in the inhibition of proper finger motion. The complexity of finger anatomy, however, makes understanding the pathomechanics of these deformities challenging. Therefore, development of an SND model is imperative to understand its influence on finger biomechanics and to provide an in vitro model to evaluate the various treatment options. METHODS: The index, middle, and ring fingers from 8 cadaveric specimens were used in an in vitro active motion simulator to replicate finger flexion/extension. An SND model was developed through sectioning of the terminal extensor tendon at the distal insertion (creating a mallet finger) and transverse retinacular ligament (TRL). A strain gauge inserted under the volar plate measured laxity of the plate, and electromagnetic trackers recorded proximal interphalangeal joint (PIPJ) angles. RESULTS: Strain in the volar plate increased progressively with creation of the mallet and SND conditions (P = .015). Although not statistically significant, the mallet finger condition accounted for 26% of the increase, whereas sectioning of the TRL accounted for 74% (P = .031). As predicted, PIPJ hyperextension was not detectable by joint angle measurement; however, the PIPJ angle had a strong positive correlation with volar plate strain (R2 = 1.0, P < .001). CONCLUSION: Volar plate strain measurement, in an in vitro model, can detect an induced SND. Moreover, as a surrogate for PIPJ hyperextension, volar plate strain may be useful to evaluate the time-zero effectiveness of various surgical interventions.

A method for measuring in vivo finger kinematics using electromagnetic tracking.

Accurate in vivo measurement of finger joint kinematics is important for evaluation of treatment methods, implant designs, and for the development and validation of computer models of the hand. The main objective of this project was to develop a standardized finger kinematic measurement system employing electromagnetic (EM) tracking to measure in vivo finger motion pathways. A landmark digitization protocol was developed and used in vivo, in a biomechanical study using EM trackers secured to the finger segments. In vivo results for finger flexion/extension showed no significant differences between EM and goniometer results, 5°±3°; p = 0.735.

Use of Thermoplastic Rings Following Venting of Flexor Tendon Pulleys: A Biomechanical Analysis.

PURPOSE: Normal digital flexion relies on flexor tendon pulleys to convert linear muscular force to angular digital motion. However, there is a growing trend to vent them partially during flexor tendon repair. The objective of this study was to examine the effects of a thermoplastic ring, acting as an external pulley, on flexor tendon biomechanics and finger range of motion (ROM) after pulley venting. METHODS: We tested 15 cadaveric digits using an in vitro active finger motion simulator. We measured loads induced by flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) as well as joint ROM with sequential sectioning of the A2, A3, and A4 pulleys compared with an intact pulley condition. At each stage, external thermoplastic pulley rings were applied snugly over the proximal and middle phalanges to recreate A2 and A4 function, respectively. RESULTS: After complete venting of the A2, A3, and A4 pulleys, proximal interphalangeal joint ROM significantly decreased by 13.4° ± 2.7° and distal interphalangeal joint ROM decreased by 15.8° ± 2.1°. Application of external rings over the proximal and middle phalanx resulted in a residual ROM decrease of 8.3° ± 1.9° at the proximal interphalangeal joint and 7.9° ± 2.1° at the distal interphalangeal joint, nearly restoring ROM. Similarly, complete pulley venting resulted in reduced FDS load by 37% and FDP load by 50% compared with intact pulleys. After application of external rings, loads were restored almost to normal, with a 9% reduction for FDS load and 9% reduction for FDP load compared with intact pulleys. CONCLUSIONS: The application of thermoplastic rings acting as external pulleys is an effective, noninvasive, and reproducible approach to restore flexor tendon biomechanics and digit ROM after pulley venting. CLINICAL RELEVANCE: Thermoplastic rings may be a useful therapeutic adjunct in restoring joint ROM and flexor tendon loads after surgical venting of the pulleys.