Biomechanical properties of alternative suture technique for flexor tendon repair.

PURPOSE: Flexor injuries are most common in the hand and require special attention and experience from the surgeon. Both quality and technique affect the stability of the suture. The selection of the optimum method will influence the process of rehabilitation. The aim of this study was to compare three different suture techniques based on the strength, depending on the method of breakage, i.e., axial or pulley load. METHODS: The study was divided into six sessions. The research material was dissected deep flexor porcine tendons. Three types of stitches were used: the modified Kessler suture with an additional running suture, the cruciate four-strand suture with an additional running suture and the multistrand running suture. We obtained 120 sutures, 40 for each technique. Breaking strength was assessed using a tensile machine in two ways, i.e., axial or pulley load, with 20 sutures per group. RESULTS: The strongest suture for both axial and pulley load was the cruciate four-strand suture. Between the multistrand running suture and the modified Kessler suture, there was no statistically significant difference in the strength of breaking for both axial and pulley load. Comparing the two ways of breaking, there was no statistically significant difference in the strength of the suture. CONCLUSIONS: The multistrand running locking suture is a good alternative to widely used core sutures. It not only provides the same strength as other techniques examined by us but also reduces the procedure time and trauma to the tips of the tendon.

[Animal model of humeral joint for shoulder arthroscopy training]. / Zwierzecy model barku jako narzedzie do nauki artroskopii.

UNLABELLED: Shoulder arthroscopy used since sixties of the XXth century, becomes now dominating operative technique. Surgeon's skills are most important that's why perfect training model is still needed. Ideal training model for shoulder arthroscopy should combine best possible image of human anatomical structures, good accessibility and low price. Despite of great similarity, animal shoulder joint differs from human one. More spherical shape of animal glenoid gives better support for humeral head. As a result of different shape of glenoid, labrum is significantly less developed, and can actually be clearly seen on dorsal part of the glenoid rim. Glenohumeral ligaments are visible but not as well developed as in human joint. METHODS: We have used pig shoulder joints, all of the muscles externally surrounding joint capsulewere resected. Classical 30 degrees optical equipment and standard arthroscopy tools were used. Labrum stabilization was achieved using anchors and screws. Cannulas were used only in a few cases, in others, joint access was very easy and did not require one. RESULTS: Animal shoulder model is useful only in case of arthroscopic practice of instability treatment. Implants can be snapped back after practice.

[Influence of tendon surgery training on the quality of the suture]. / Wplyw treningu zespalania sciegien na jakosc zalozonego szwu.

Injuries of flexor tendons are one of the most common injuries that need surgical treatment at emergency room. Technique and quality of the surgery was performed are two factors of the utmost importance. The aim of the study was to determine influence of basic surgical training on the quality of suture. Research was divided into four surgical sessions which were held each once a week. Sutures were put by three medical students. Material that was used were deep flexor tendons dissected from fresh pig's legs. Sessions 1st, 2nd and 4th were preceded by training done by experienced surgeon. During study 90 modified-Kessler sutures without additional running suture were made. Breaking strength was assesed by tensile machine (INSTRON 4481). Time of each suture was also recorded. Outcomes were analyzed by tests: ANOVA and post-hoc LSD tests. Time significantly dropped by 64% after the first session and was held on the same level. Strength of sutures rises in each session preceded by training. There was statistically significant difference between session 1 (mean 13.58; SD 9.86N) and 2nd (mean 42.69; SD 9.27N) and 3rd (mean 38.42; SD 12.28N) and 4th (mean 57.12; SD 12.78N). Conclusions. Time of procedure significantly dropped after first teaching course and was held on the same level despite further training. Breaking strength rise in every session that was preceded by teaching course.

Dynamic correction of scapholunate instability using ECRB tendon transfer.

Background. Instability of the wrist, leading to the appearance of a fissure between the scaphoid and lunate bones (SLD), is generally attributed to damage of the scapholunate ligaments (SLIL). However, repair of the SLIL does not give a good outcome. SLD recurs in many cases, despite correct reconstruction. The structures of the joint may be exposed to further overloading and damage, with all the attendant consequences. Material and methods. This article presents the preliminary results of the operative treatment of 7 cases of scapholunate instability. Partial ECRB transfer to the distal pole of the scaphoid was performed. The DASH form was used for outcome assessment. Results. Better alignment and dynamic stabilisation of the scaphoid were achieved. All patients had less pain and better grip strength without limitation of wrist flexion. Conclusions. Preliminary treatment outcomes after dynamic transfer of the ECRB tendon using the method described here are encouraging. Our observations indicate that the dynamic stabilization of rotatory instability of the scaphoid bone can be recommended in cases of predynamic and dynamic scapho-lunate instability.

Instability of the rheumatoid wrist: patterns and treatment.

Pathology of the wrist is frequent in rheumatoid arthritis. The proper treatment leading to improvement in function and symptoms relief is of a big importance. The classification based on natural pattern of the disease is presented including three types: ankylotic, arthritic changes with artrodesis and instability leading to wrist collapse. It the third type it is important to add partial or total arthrodesis to the common synovectomy and ulnar head resection.

Instability of the distal radioulnar joint (DRUJ): a description of the problem and own experience.

Introduction. The distal radioulnar joint (DRUJ) is important for rotation of the forearm and stability of the ulnar wrist. Any DRUJ injury can cause limitation of the range of motion, decreased strength, pain, and instability. This paper deals with DRUJ instability, and reviews treatment methods and outcome. Disturbances in DRUJ stability result from bone damage, TFCC and ligament injuries, and/or other soft tissue deficiencies (capsule, tendon). Instability due to injury may be acute or chronic in nature. Most acute cases are best treated conservatively. Chronic problems resulting in disability may require surgical treatment. Material and methods. We studied 7 patients (age 23-55) with DRUJ instability, operated in our Department between 2000 and 2004. The patients were qualified for surgery based on a clinical examination supported by imaging techniques. All were traumatic cases, and three had a history of distal radius fracture. Different operative procedures were used due to the variety of clinical presentations: extraarticular ligament reconstruction acc. to Bunnel-Boys, anatomic ligament reconstruction with PL acc. to Adams, restabilization of TFCC, retinacular reconstruction, and capsular duplication. Results. Pain was significantly decreased in all patients. The range of motion postoperatively did not differ compared to preoperative findings. DRUJ stability was restored in all cases. Conclusions. DRUJ instability can result in significant disability. In such cases surgical treatment restores stability and decreases symptoms. Return to preinjury activities is possible following treatment.

Treatment of injury of the triangular fibrocartilage complex (TFCC).

Background. The triangular fibrocartilage complex (TFCC) supplies stability and cushioning for proper wrist function. TFCC lesions, a common cause of ulnar-sided wrist pain, can be traumatic (Palmer I) or degenerative (Palmer II) in nature. Clinical assessment is basic for making the diagnosis, but imaging may be helpful. Conservative treatment is the best choice for most acute cases. If the symptoms persist, however, operative treatment has a better prognosis for pain relief. Wrist arthroscopy has a major role to play in the diagnosis and treatment of TFCC lesions. Material and methods. 29 patients were operated in the Hand Surgery Department in Poznan due to TFCC lesions. 16 patients were qualified as Palmer type I (9 sport injuries, 7 sprains). while 13 patients had Palmer type II secondary to distal radial fractures. All patients suffered ulnar wrist pain and were positive on provocation tests. The indication for surgery was a lack of response to conservative treatment. Different operative procedures were used, depending on the type of lesion: arthroscopic debridement, open or arthroscopic restabilization of the TFCC, ulnar shortening, or partial resection of the ulnar head (Wafer). Rehabilitation was introduced following a period of immobilization. Results. Wrist pain was significantly diminished or disappeared after surgical treatment and rehabilitation. Conclusions. Good functional result and pain relief can be expected following surgical treatment of TFCC injuries.

Magnetic resonance artfrography of the shoulder.

Background. There is constant increase in number of patients seeking medical help due to shoulder diseases. Imaging techniques may facilitate making the diagnosis and decide about the treatment modality, including decision on operative treatment. Magnetic resonance is widely accepted for imaging of soft tissue lesions of the shoulder.
Material and Methods. This study was based on material of 26 patients with shoulder pain and dysfunction with diagnostic difficulties or postoperative monitoring. Standard MR was performed first, followed by direct arthrography in MR.
Results. MR arthrography of the shoulder revealed more labral and capsule (ligament) as well as SLAP lesions than standard MR. Arthrography enabled better visualization of degree of rotator cuff lesion. There was more III and IV grade lesions shown in the cuff.
Conclusions. MR arthrography enabled better assessment of rotator cuff lesions and better visualization of capsulo-labral complex lesions.

Arthroscopy surgery of atraumatic instability of the shoulder.

BACKGROUND: [corrected] Atraumatic shoulder instability makes roughly 4% of all instability cases. Subluxation or dislocation may either have no actual cause or be the result of minor accident. Because of its multi-directional character and coexisting disturbances, atraumatic instability is a serious therapeutic issue. The basics of the treatment are strengthening the shoulder stabilizing muscles and exercises aimed at optimising nerve-muscle control. MATERIAL AND METHODS: 6 patients - 10 shoulders, who suffered non-traumatic multi-directional shoulder instability were operated on at our Dept. Lack of positive results after at least 6 months' rehabilitation was the direct indication for surgery, along with night and activity related pain. Three patients from the above mentioned group suffered additionally single sided idiopathic instability. Arthroscopy was carried from three portals: two front and one back. During the surgery we observed high capsule laxity, generally hypoplastic labrum, and partial cartilage loss within the humeral head. Non-absorbing sutures - Ethiobond 2, anchors, and screws we used to stabilize the capsule and labrum. After inserting the scope we made 3-4 anchors and sutures of capsule and labrum at the anterior and posterior aspect of the glenoid. The next thing to do was to apply sutures closing rotator intervals. Remaining, non-sutured parts of the capsule, were thermally shrunk. RESULTS: The observation covers period from six months to two years after the surgery. The decrease of pain score has been observed from 4 points before surgery to 0.33 points after the treatment. The UCLA score increased after the surgery by about 13 points. In Simple Shoulder Test the score of positive answers increased from 7 to 11. Results of the treatment were lack off pain and restored stability of the shoulder. There was stronger patients' motivation to exercise in order to strengthen the muscles and muscle coordination. CONCLUSIONS: Arthroscopic stabilization of shoulder joint is a encouraging method in atraumatic instability of the shoulder. In case of any failure, the method doesn't exclude the option of open-surgery methods.

Arthroscopic treatment of traumatic shoulder instability.

Background. Traumatic shoulder instability is a common sequel following first shoulder dislocation, especially in young population (< 30 y.a). Shoulder arthroscopy is getting more and more popular among orthopaedic community. Efficacy of arthroscopic treatment of shoulder instability approaches that of conventional operative techniques.
Aim. The purpose of the study was the analysis of arthroscopic treatment of traumatic shoulder instability.
Material and methods. Study was based on 22 patients, 24 shoulders were operated. Capsulolabral complex has been stabilized arthroscopically in all patients.
Functional was assessed by means of ASES, UCLA and SST scores. Function was improved significantly. There has been no recurrence of instability in follow-up period.
Conclusions. We have proved good efficacy of arthroscopic techniques in treatment of the instability.
Joint stability was restored with decreased invasiveness of operation (better cosmesis, easier rehabilitation).

Impingement and rotator cuff lesion an arthroscopic treatment.

There has been dynamic increase in arthroscopic treatment of shoulder diseases. This paper presents etiology, classification and symptoms of the rotator cuff disease. Indications and arthroscopic treatment have been also described.

The reconstruction of inveterate rotator cuff lesions and lesions of the glenoid labrum of the shoulder with open and arthroscopic techniques.

Background. The purpose of the paper is to present the treatment results of patients with injured rotator cuff, based on 6 months study, major limb dysfunction and severe pain.
Material and methods. Study is based on 14 patients, who underwent arthroscopic and open surgery of the shoulder. After arthroscopic repair of coexisting injuries and curbed mobility of the rotator cuff, open method was employed to reinsert rotator cuff with decompression of subacromial space. After the surgery, the arm was immobilised using orthosis with about 20-30 degrees abduction. Limited exercises of mobility range was started in the 4rd week after the surgery, increasing slightly the intensity and character of the exercises. External rotation movement was introduced in the third month after the surgery.
Results. The decrease of pain score has been observed from 6.28 points before surgery to 1.87 points after the treatment. The UCLA score increased after the surgery by about 26 points. In Simple Shoulder Test the score of positive answers increased from 2.2 to 7.6 after surgery. Results of the treatment were lack off pain and restored stability of the shoulder.
Conclusions. Decreased pain and better mobility seem to prove the efficacy of treatment of inveterate massive rotator cuff lesions.

Pre- and postoperative principles of rehabilitation in arthroscopic treatment of painfull shoulder.

Pain of the shoulder is becoming a serious clinical problem. A proper diagnosis, surgical, physiotherapycal, pharmacological and psychological treatment allow to achieve the best result. This shoulder's problem is very common in young, working people, who expect a quick and effective treatment. One of the procedures in the treatment of the painful shoulder is arthroscopy combined with physiotherapy. The very important part of the exercise program is the preparation of the injured extremity for surgical procedure. The time of the immobilization and the beginning of the exercises is being given by the surgeon. Generally it is important to start the exercises as soon as possible and to make it painless if it possible. One of the most effective methods is PNF (Proprioceptive Neuromuscular Fascilitation). It allows for the early beginning of the exercises by using proper patterns and techniques.