Early active mobilization after tendon transfers using mesh reinforced suture techniques.

23 tendon transfers in the hand and forearm were performed using a polyester mesh sleeve to reinforce conventional suture techniques. All transfers were mobilized with active flexion and extension within 3 days of operation. Excluding one rupture (due to extreme unintentional loading) and depending on the type of transfer used, a mean of between 69% and 78% of the final active range of motion was obtained 1 month post-operatively. With the exception of transfers for wrist extension, the mean final active range of motion amounted to between 91% and 100% of the available passive range of motion and between 75% and 100% of the corresponding "normal" active range of motion in the opposite hand. The mean final active range of motion after reconstructions for wrist extension amounted to 85% of the passive range of motion and to at least 80% of the maximum range of motion potentially available with the transfers used. The results indicate that early active mobilization after tendon transfers may offer significant advantages in terms of quicker and simpler rehabilitation as well as improved results.

Early active mobilization of tendon grafts using mesh reinforced suture techniques.

The flexor digitorum profundus tendon in 11 digits with division of both flexor tendons in zone 2 was reconstructed with a palmaris longus tendon graft in a two-stage procedure. The distal and proximal fixation of the graft was reinforced with a polyester mesh sleeve placed around the ends of the graft during stage 1. All digits were mobilized with a combination of active extension and active and passive flexion within 3 days of the second stage. There were three ruptures, one due to faulty technique and two due to falls on outstretched hands during alcohol intoxication and football. Excluding the ruptures, the mean active composite distal and proximal interphalangeal joint range of motion 6 weeks and 6 months post-operatively was 141 degrees and 136 degrees respectively. The results indicate that palmaris longus tendon grafts can survive and heal during early active mobilization, with few or no adhesions of functional significance. The techniques described here represent one possible approach to the safe implementation of early active mobilization after tendon grafting procedures.

Flexor tendon repair in zone II with a new suture technique and an early mobilization program combining passive and active flexion.

A new epitendinal suture technique (cross-stitch) was used for flexor tendon repair in zone II in 46 consecutive patients with 55 injured digits. For the first 4 weeks after the operation, the digits were mobilized with a combination of active extension and passive and active flexion. Postoperative tendon excursions and gap formation were measured with intraoperatively placed metal markers. There were two ruptures. In the remaining digits, the mean active distal interphalangeal and proximal interphalangeal range of motion 6 weeks postoperatively was 50 degrees and 83 degrees, respectively. Six months postoperatively the corresponding figures were 63 degrees and 94 degrees. Three weeks postoperatively the mean tendon excursions per 10 degrees of joint motion varied from 82% (distal interphalangeal joint motion) to 88% (proximal interphalangeal joint motion) of the maximum possible. The results indicate that the cross-stitch is a reliable suture technique that, when used in combination with a program incorporating early active and passive flexion, can produce very good results after flexor tendon repair in zone II.

Gap formation after flexor tendon repair in zone II. Results with a new controlled motion programme.

Intratendinous metal markers were used to study gap formation in 36 flexor digitorum profundus repairs during and after early controlled motion with a programme combining dynamic traction and passive flexion to all four digits. The mean gap 3 weeks after operation was 2.5 mm. The mean final gap was 2.6 mm. The results of linear regression analysis showed that gap formation within the observed range from 0 to 8.5 mm did not negatively affect tendon excursions or clinical results in terms of active interphalangeal joint range of motion. These findings are in accordance with the results of a previous study of gap formation in patients treated with a modified traditional Kleinert traction programme. Together the two studies confirm that controlled motion is effective in restricting the adhesions associated with gap formation during postoperative immobilisation.

Factors affecting results after flexor tendon repair in zone II: a multivariate prospective analysis.

A stepwise multiple regression procedure was used to examine the influence of 12 to 13 independent variables on five outcome variables, 1 year after flexor tendon repair in zone II, in a consecutive series of 135 patients treated with early controlled motion. Of the included variables, controlled interphalangeal joint range of motion 3 weeks postoperatively was the single most influential factor with regard to final active interphalangeal joint range of motion. Together with age, swelling, the number of digits, and the number of tendons injured, it accounted for 18% to 19% of the total variance in active range of motion; 14% to 15% of the variance in extension deficits and 41% of the variance in grip strength could be accounted for by variables included in the study. A large part of the variance in all the outcome variables was probably related to the psychological and biologic characteristics of the patient.

Tendon excursions after flexor tendon repair in zone. II: Results with a new controlled-motion program.

Metal markers were used to study flexor digitorum profundus tendon excursions during early controlled motion with a new program combining dynamic traction and passive flexion to all four digits. The mean excursion was 2.3 mm along the middle phalanx and 11.7 mm along the proximal phalanx. This was more than twice the mean size of excursions previously achieved with a modified traditional Kleinert traction program. The mean excursion per 10 degrees of combined distal and proximal interphalangeal controlled joint motion amounted to 73% of the corresponding excursion recorded during active motion. Taken together with the findings of our previous study on tendon excursions, the results also indicate that the magnitude of excursions induced by both the distal and the proximal interphalangeal joints during controlled motion has a significant effect on adhesion formation and clinical results. However, in the region of 6 to 9 mm there appears to be a threshold beyond which the effect of a further increase in excursions becomes insignificant.

Rate of recovery after flexor tendon repair in zone II. A prospective longitudinal study of 145 digits.

A series of 145 digits were treated with three controlled motion programmes after flexor tendon repair in zone II. Active interphalangeal joint motion was measured four, six and 12 weeks; six months and one year after operation. Although there were differences in the final results among the groups, the rate of recovery from the end of the controlled motion period (four weeks after operation), was not significantly different in the three treatment groups. Overall, a mean of 37% of the final distal interphalangeal joint range of motion and 9% of the final proximal interphalangeal joint range of motion was recovered between three months and one year postoperatively. In only 10 of 27 digits with a poor result (combined interphalangeal joint range of motion less than 90 degrees) at three months, was the result still poor at one year; 10 regained another 40 degrees or more, and eight another 50 degrees or more. The results indicate that it is worth waiting six or 12 months before considering tenolysis.

Two new methods of tendon repair: an in vitro evaluation of tensile strength and gap formation.

A new tendon repair design incorporating a mesh sleeve was, together with a new epitendinal suture technique (cross-stitch), tested biomechanically on sheep tendons. The mean breaking strength with a 6-0 suture was 103 N for the mesh sleeve repair and 63 N for the cross-stitch alone, both significantly greater than the 48 N recorded for the modified Kessler repair performed with a 4-0 polyester suture and reinforced with a circumferential conventional 6-0 epitendinal stitch. The cross-stitch grasp was 117% stronger than the conventional epitendinal grasp reinforced by a core stitch. The new techniques effectively prevented the large gaps that occurred in the modified Kessler repair.

The correlation between controlled range of motion with dynamic traction and results after flexor tendon repair in zone II.

This prospective study investigated the extent to which the range of interphalangeal joint motion during early mobilization with dynamic traction influences the results after flexor tendon repair in zone II. The controlled interphalangeal joint range of motion within the splint was measured 3 weeks postoperatively in 51 digits (48 patients). The active range of motion was measured 4 weeks, 6 weeks, and 1 year postoperatively. Linear regression analysis showed that controlled interphalangeal range of motion had a significant effect on both early and late results. The results provide, for the first time, firm clinical evidence to support the rationale for early mobilization programs designed to maximize controlled interphalangeal joint range of motion.

Controlled mobilization after flexor tendon repair in zone II: a prospective comparison of three methods.

A new controlled-motion program that incorporates dynamic flexion traction to all four digits, a short splint leaving the interphalangeal joints free, and a nighttime extension splint was prospectively compared with a modification of the Kleinert technique and a combination of the modified Kleinert technique and passive movements. Each program was applied to approximately one third of 178 consecutively treated digits with tendon injuries in zone II. The mean total active interphalangeal joint range of motion 6 weeks and 1 year postoperatively was significantly better and extension deficits were significantly less frequent in the digits mobilized with the new program. The postoperative treatment input, in terms of frequency of reviews and time spent in therapy sessions, is not greater than with more traditional controlled-motion programs. Our results indicate that the new program is a safe, reliable, and cost-effective method that produces very good results in a general population.

Gap formation during controlled motion after flexor tendon repair in zone II: a prospective clinical study.

Intratendinous metal markers were used to study the formation of gaps in flexor digitorum profundus tendon repairs during and after early controlled motion with dynamic flexion traction and to evaluate their significance for results in 34 digits with repairs in zone II. The mean (+/- SD) final repair elongation was 3.2 (+/- 3.6) mm. Linear regression analysis showed a general trend toward an inverse relationship between elongation and clinical results in terms of active interphalangeal joint range of motion, but the correlation was weak, and in the individual case gap formation was a poor predictor of clinical result. Gaps of up to 10 mm were quite compatible with good function. The results indicate that controlled motion is effective in restricting the formation of adhesions associated with gap formation during postoperative immobilization.

Flexor digitorum profundus tendon excursions during controlled motion after flexor tendon repair in zone II: a prospective clinical study.

Intratendinous metal markers were used to study flexor digitorum profundus tendon excursions during early controlled motion with dynamic flexion traction and to evaluate their significance for results after flexor tendon repair in zone II. The mean excursion was 1 mm along the middle phalanx and 5.6 mm along the proximal phalanx. This corresponded to a mean excursion per 10 degrees of controlled distal and proximal interphalangeal joint motion of 0.3 and 1.2 mm, respectively. Compared to active motion, controlled motion of the distal interphalangeal joint mobilized the tendon with an efficiency of 36% and controlled motion of the proximal interphalangeal joint mobilized the tendon with an efficiency of 90%. Controlled-motion excursions induced by the distal interphalangeal joint along the middle phalanx had little influence on subsequent active range of motion in the distal interphalangeal joint, whereas excursions along the proximal phalanx (for which the proximal interphalangeal joint was largely responsible) did have a significant influence on subsequent total active interphalangeal range of motion.

Breast reconstruction without an implant: results and complications using an extended latissimus dorsi flap.

The results of 55 breast reconstructions using an extended latissimus dorsi myocutaneous flap without an implant are reported. A method for preoperatively estimating the flap volume, operative details, and a technique for insetting the flap are reviewed. Good, fair, and poor results were achieved in 69, 24, and 7 percent of patients, respectively. Examples are illustrated. The poor results were all due to major complications and are analyzed in detail. Significant complications affecting the end result occurred in 14.5 percent of patients, and nonsignificant and minor complications occurred in 33 percent. Flap volume is shown to be fairly accurately predictable. Seventy percent of flaps had a volume in excess of 400 cc. The reconstructed volume, cosmetic results, and complication rates are compared with those of other reported series. Good results can be achieved with this method, quite comparable to other methods, and with similar complication rates, but without the problems associated with the use of a prosthetic implant.

A new pressure device for securing skin grafts.

A method is described in which the traditional tie-over dressing is replaced by a pressure device, resulting in substantial savings in both time and material costs. The device will allow graft inspection with restoration of the pressure dressing.