Outcomes of flexor tendon repairs in zone 2 subzones with early active mobilization.

We report on the outcomes of flexor tendon repair in zone 2 subzones with early active mobilization in 102 fingers in 88 consecutive patients. There were 28, 53, 15, and six fingers with repairs in zones 2A to 2D, respectively. Rupture of the repair occurred in four fingers, all in zone 2B. Excluding those with repair ruptures, the mean total active motion was 230° (range 143°-286°). Evaluated with Tang's criteria, the outcomes were ranked excellent in 39 fingers, good in 46, fair in ten, poor in three, and failure in four. The outcomes in zone 2C were significantly inferior to those in zones 2B and 2D ( p = 0.02). Our results suggest that the tendon laceration in the area covered by the A2 pulley (zone 2C) is the most difficult area to obtain satisfactory active digital motion and tendon repair in zone 2B is the area where the risk of rupture is highest. LEVEL OF EVIDENCE: IV.

Clinical results of releasing the entire A2 pulley after flexor tendon repair in zone 2C.

UNLABELLED: We report the results of complete release of the entire A2 pulley after zone 2C flexor tendon repair followed by early postoperative active mobilization in seven fingers and their comparisons with 33 fingers with partial A2 pulley release. In seven fingers, release of the entire A2 pulley was necessary to allow free gliding of the repairs in five fingers and complete release of both the A2 and C1 pulleys was necessary in two. No bowstringing was clinically evident in any finger. Two fingers required tenolysis. Using Tang's criteria, the function of two digits was ranked as excellent, four good and one fair; there was no failure. The functional return in these seven fingers was similar with that in 33 fingers with partial A2 pulley release; in these patients only one finger required tenolysis. Our results support the suggestion that release of the entire A2 pulley together with the adjacent C1 pulley does not clinically affect finger motion or cause tendon bowstringing, provided that the other pulleys are left intact. LEVEL OF EVIDENCE: IV.

Outcomes of release of the entire A4 pulley after flexor tendon repairs in zone 2A followed by early active mobilization.

We report the outcomes of repair of the flexor digitorum profundus tendon in zone 2a in 22 fingers. The tendon was repaired with a six-strand repair method and the A4 pulley was completely released. Release of the C2 pulley combined with the A4 pulley was necessary in 12 fingers, nine fingers underwent a complete release of the A3, C2, and A4 pulleys, and one finger underwent a release of the C1, A3, C2, and A4 pulleys. The mean total active motion of the three finger joints was 234° at 5 to 12 months of follow-up. No bowstringing was noted in these fingers. The good and excellent recovery of active digital motion was in 20 (91%) out of 22 fingers according to Strickland's criteria or Tang's criteria. Our results suggest that release of the A3, C2, and A4 pulleys makes the repair surgery easier and does not cause tendon bowstringing.

Clinical outcomes of early active mobilization following flexor tendon repair using the six-strand technique: short- and long-term evaluations.

We evaluated the factors influencing outcomes of flexor tendon repair in 112 fingers using a six-strand suture with the Yoshizu #1 technique and early postoperative active mobilization in 101 consecutive patients. A total of 32 fingers had injuries in Zone I, 78 in Zone II, and two in Zone III. The mean follow-up period was 6 months; 16 patients (19 fingers) participated in long-term follow-up of 2 to 16 years. The total active motion was 230° SD 29°; it correlated negatively with age. The total active motion was 231° SD 28° after repair of the lacerated flexor digitorum superficialis tendon, and was 205° SD 37° after excision of the flexor digitorum superficialis tendon ends (p = 0.0093). A total of 19 fingers showed no significant increases in total active motion more than 2 years after surgery. The rupture rate was 5.4% in our patients and related to surgeons' level of expertise. Five out of six ruptured tendons were repaired by inexperienced surgeons. Level of Evidence IV.

Inflammatory pseudotumor of the liver in association with spilled gallstones 3 years after laparoscopic cholecystectomy: report of a case.

We report on a case of a female patient diagnosed with inflammatory pseudotumor of the liver in association with spilled gallstones 3 years after laparoscopic cholecystectomy for calculous acute cholecystitis. She was asymptomatic, but CT revealed an intrahepatic mass and two other extrahepatic masses between the liver and the diaphragm. Furthermore, diffusion-weighted MRI and PET suggested all three lesions could be malignant tumors. As the preoperative diagnosis was intrahepatic cholangiocellular carcinoma with peritoneal disseminations, we performed a posterior segmentectomy of the liver combined with partial resection of the diaphragm. Histological examination showed the intrahepatic tumor was an inflammatory granuloma with abscess formations. There were bilirubin stones between the liver and the diaphragm. Therefore, the tumor was diagnosed as inflammatory pseudotumor of the liver in association with spilled gallstones. In conclusion, the liver tumor emerged after laparoscopic cholecystectomy and may involve inflammatory pseudotumor of the liver in association with spilled gallstones.

Comparison of the neurotropic effects of motor and sensory Schwann cells during regeneration of peripheral nerves.

We examined the inductive ability of motor and sensory Schwann cells on regeneration of motor and sensory axons using a silastic Y chamber, and Lewis rats L5 ventral root (motor) and saphenous nerve (sensory). We developed four experimental models: motor-motor nerve group-proximal motor stump with distal fresh and frozen/thawed motor nerve segments (n = 7); sensory-sensory nerve group-proximal sensory stump with distal fresh and frozen/thawed sensory nerve segments (n = 7); motor-sensory nerve group-proximal motor stump with distal fresh and frozen/thawed sensory segments (n = 8); and sensory-motor nerve group-proximal sensory stump with distal fresh and frozen/thawed motor segments (n = 8). The gap was set at 4 mm. Six weeks postoperatively we compared the number of regenerated myelinated axons in the two distal channels, and found that sensory Schwann cells have a strong inductive ability for regeneration of both sensory and motor axons. Motor Schwann cells have weak inductive ability for regeneration of motor axons and no inductive ability for regeneration of sensory axons.

Flexor tendon repair in a rabbit model using a "core" of extensor retinaculum with synovial membrane. An experimental study.

In this histological and biomechanical study in two groups of rabbits, a piece of the extensor retinaculum with its synovial membrane was inserted as a biological "core" into a hole at the centre of both stumps of a severed tendon, which was repaired with interrupted sutures. In the other group, the tendon was sutured without a "core". In the "core" group, proliferation and migration of fibroblasts from both tendon surfaces and the "core" surface toward the deep layer of the suture site was seen 2 weeks after operation. New collagen fibres, aligned parallel to the long axis of the tendon, could also be seen 4 weeks after operation, and healing was more advanced than in the coreless model. The maximum force to produce a gap in the "core" tendon was 82% greater than in the coreless tendon 4 weeks after operation.