[Comparison between different anchors for zone I flexor tendon repair]. / Comparaison des différentes ancres dans les réinsertions transosseuses de tendons fléchisseurs profonds en zone I.

INTRODUCTION: Transosseous reinsertion has been used to complement the Bunnell pull-out technique in the repair of zone I deep flexor tendon injuries. The aim of this study is to compare the different devices on the market in terms of complication, functional recovery and ease of use. MATERIAL AND METHOD: This is a single-center study including all patients who underwent transosseous anchor reinsertion from 2010 to 2021 with a minimum of 6 months of follow-up. Twenty-seven patients were included. The anchors used were of different types: Microfix® Quickanchor plus® and Miniquick anchor® from DePuy Mitek; Juggerknot® Soft Anchor 1.0mm from Zimmer-Biomet; or Kerifix® 4.0 from KeriMedical. We analyzed intraoperative data, complications and functional recovery by quickDASH score. RESULTS: The average age was 38.6 years (± 16.1), the demographic characteristics were identical in the different groups. There was a significant difference in the number of anchors used intraoperatively before definitive placement (P=0.02), to the disadvantage of the Juggerknot® anchors. There was no significant difference in terms of complications and functional recovery evaluated by the quickDASH. CONCLUSION: Our study did not find significant differences between the different anchors in terms of complications and functional recovery. Some anchors seem to have a better grip during placement than others.

Relative efficacy of three different tendon repairs in complete flexor digitorum profundus laceration in Zone I: A randomized controlled study.

Hand flexor tendon injuries are common and biomechanically challenging to achieve good functional outcomes. Several approaches using the Pennington-modified Kessler repair technique have been attempted, but high-level evidence is still lacking. Here, we evaluated the relative efficacy of three versions of the Pennington-modified Kessler technique in repairing complete flexor digitorum profundus (FDP) laceration in Zone 1. We conducted a 2-year, single-center, double-blind, randomized clinical trial involving 85 patients with 105 digits enrolled between June 1, 2017 and January 1, 2019. Eligible participants were 20-60 years of age and underwent tendon repair in the acute phase for complete FDP laceration distal to the insertion of the superficial flexor tendon. The digits were randomized 1:1:1 to three treatment groups: (1) Pennington-modified Kessler repair; (2) Pennington-modified Kessler repair followed by circumferential tendon suture; or (3) Pennington-modified Kessler repair followed by circumferential epitenon suture. The primary endpoint was total active range of motion (TAROM) at 2 years after the initial surgery. The secondary endpoint was the reoperation rate. Compared with group 1, both techniques for peripheral suture were associated with a decrease in TAROM at 2 years after surgery. The total reoperation rates of the three groups were 11.4%, 18.2%, and 17.6%, and we found no significant differences among the three groups possibly due to the limited sample size. Unexpectedly, among participants with complete FDP laceration in Zone I, both circumferential-tendon and circumferential-epitenon sutures caused worsening of TAROM after 2 years. No conclusions can be drawn regarding reoperation rates among the groups. Level of evidence: Therapeutic level I.

Outcomes of Acute Repair Versus Nonrepair of Zone I Flexor Digitorum Profundus Tendon Injuries.

PURPOSE: The aim of this study was to determine whether the clinical results of zone I flexor digitorum profundus (FDP) tendon injuries managed with acute surgical repair are comparable to the clinical results of those managed without repair (eg, primary FDP excision or observation). METHODS: Patients aged ≥18 years presenting to a level 1 trauma center between 2015 and 2020 with zone I FDP tendon injury were identified with retrospective chart review. We assessed the following data: age, sex, physical therapy visits, surgical intervention, surgical complications (including infection, repeat surgery after the primary intervention, and rupture of repair), and patient-reported outcomes measurement information system scores. RESULTS: Twenty-six patients met the inclusion criteria. Group 1 (N = 15 patients, 23 fingers) patients were treated with acute surgical repair. Group 2 (N = 11 patients, 11 fingers) patients were managed without surgical repair, including FDP excision (N = 7) or observation alone (N = 4). In group 1, the average distance from the distal palmar crease to fingertip at the final follow-up was 1.6 cm (range, 0-4 cm). Fourteen of the 15 patients participated in >3 therapy visits. The following complications occurred: 4 fingers with rerupture (2 patients), 4 fingers with surgical wound dehiscence (2 patients), 3 infections (2 patients), and 4 repeat surgeries for these complications. In group 2, the average distance from the distal palmar crease to fingertip at the final follow-up was 1.1 cm (range, 0.5-3 cm). There were no infections, episodes of wound dehiscence, or repeat surgeries. At the final follow-up, both groups showed clinically meaningful improvement on Patient Reported Outcomes Measurement Information System (PROMIS) upper extremity, pain interference, and physical function scores, with similar PROMIS domain scores between groups. CONCLUSIONS: Patients treated without FDP tendon repair had similar outcomes to, and fewer complications than, patients treated with acute tendon repair. Our data suggest that the notable commitment of health care costs, time, and adherence to protocols/restrictions after surgical repair may not confer functional benefit. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Complications and Clinical Outcomes Following Zone I Flexor Tendon Repair Using All-Inside Suture Fixation.

PURPOSE: The purpose of this study was to evaluate complications and outcomes of an all-inside repair technique for flexor digitorum profundus (FDP) avulsions. METHODS: A retrospective review of a single institution database identified all FDP avulsions that were repaired using an all-inside technique by a single surgeon. In this method, 2 Keith needles are drilled from the volar to dorsal aspect, exiting proximal to the nail matrix and within the extensor tendon. Nonabsorbable sutures were placed in the flexor tendon and passed through the bone tunnels, tying dorsally over the distal phalanx. The demographics characteristics, injury characteristics, the surgical procedure, postoperative complications, and outcomes were reviewed. RESULTS: Seventeen patients were included in the study. The average age was 40 years (range, 21-68 years), and 2 patients were women. Seventeen fingers were included: 14 ring fingers, 1 index finger, and 2 little fingers. Six patients had an associated distal phalanx fracture and one had an associated distal interphalangeal joint dislocation. The average time between injury and surgery was 9 days (range, 2-18 days). Four patients had complications: 3 with erythema related to infection, which appeared to be a reaction to the suture prompting removal, and 1 with a subungual mass related to the suture at removal. One patient had persistent pain. Postoperative range of motion, assessed using the Strickland criteria, was excellent or good in 5 (33%) of 15 patients, but this was predominantly due to motion at the proximal joints as overall DIP motion was limited. Patients had a mean distal interphalangeal joint range of motion of 24° (range, 0° to 55°). CONCLUSIONS: In our series, repair of FDP avulsions via all-inside suture fixation is associated with limited distal interphalangeal joint motion and an incidence of infection (24%) at final follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

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.

Combined intravitreal ranibizumab and zone I sparing laser ablation in infants with posterior zone I retinopathy of prematurity.

Purpose: To evaluate the efficacy of combined intravitreal ranibizumab (IVR) and zone I sparing laser ablation in infants with posterior zone I Retinopathy of Prematurity (ROP). Methods: This was a retrospective, interventional case series including premature infants diagnosed with posterior zone I ROP (n = 24) on ROP screening. Charts and RetCam images of preterm infants with posterior zone I ROP treated with immediate IVR and zone I sparing laser ablation at 4 weeks between April 2016 and September 2019 were reviewed. Data were analyzed and tabulated using frequency and descriptive statistics to describe the demography, morphology, and treatment outcomes. Primary outcome measure was structural outcome at 6 months. It was further categorized as favorable and unfavorable. Results: Twenty-four infants (48 eyes) with a mean gestational age of 28.54 ± 1.98 weeks and birth weight of 1180.33 ± 280.65 grams were analyzed. Thirty-six (75%) eyes had persistent tunica vasculosa lentis and twenty-six (54.1%) eyes had iris neovascularization. All eyes had features of aggressive posterior retinopathy of prematurity (APROP) limited to posterior zone I. The mean duration between IVR and zone I sparing laser ablation was 29.62 ± 6.36 (range: 24-34) days. One infant (2 eyes) received a second IVR treatment for recurrence of plus disease and persistent new vessels close to the fovea. Laser augmentation was done in 13 (27.1%) eyes. A favorable structural outcome was seen in 45 (93.7%) eyes. Conclusion: Posterior zone I ROP presents as APROP. Combined IVR and zone I sparing laser ablation appears effective treatment option in these eyes.

Complications Following Transosseous Repair of Zone I Flexor Tendon Injuries.

PURPOSE: Multiple techniques are described for repair of zone I flexor tendon injuries, many of which are fraught with complications. This study evaluated the clinical complications after a transosseous repair technique. METHODS: A retrospective review of a single institutional database identified all zone I flexor digitorum profundus (FDP) injuries repaired using a transosseous technique. In this technique, 2 nonabsorbable sutures were passed from volar to dorsal through transosseous tunnels and tied dorsally over the distal phalanx proximal to the germinal matrix. Demographics, injury characteristics, operative details, and complications were reviewed. RESULTS: Eight patients met the inclusion criteria. Average age was 31 years (range, 15-66 years) and all patients were male. Eight fingers were included: ring (4), small (3), and middle (1). Seven injuries were closed and one was open. Average time between injury and surgery was 13 days (range, 4-34 days). Five patients experienced complications, including osteomyelitis, chronic draining granuloma, and abnormal nail growth. Three patients required an additional operative procedure for management of complications. CONCLUSIONS: Transosseous repair of zone I flexor digitorum profundus injuries with a buried dorsal suture is associated with a high rate of clinical complications. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Prognostic factors for digital range of motion after intrasynovial flexor tendon injury and repair: Long-term follow-up on 273 patients treated with active extension-passive flexion with rubber bands.

STUDY DESIGN: Observational cohort study. INTRODUCTION: Investigating prognostic factors using population-based data may be used to improve functional outcome after flexor tendon injury and repair. PURPOSE OF THE STUDY: The aim of this study is to investigate the effect of concomitant nerve transection, combined flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) tendon transection and the age of the patient, on digital range of motion (ROM) more than 1 year after FDP tendon transection and repair in zone I and II. METHODS: Two hundred seventy-three patients with a total of 311 fingers admitted for FDP injury in zone I and II were treated with active extension-passive flexion with rubber bands and followed for at least 1 year. We compared outcome by evaluating digital mobility using Strickland's evaluation system. RESULTS: At 12 months 72% of patients aged > 50 had fair or poor ROM compared to 17% of patients aged 0-25 years. At 24 months the results for patients aged > 50 had improved to 33% with fair or poor ROM, whereas no improvement had occurred for patients aged 0-25 (17% with fair or poor ROM). Concomitant nerve transection and FDS tendon transection had no negative effects on digital mobility. DISCUSSION: Age above 50 was significantly associated with impaired digital ROM during the first year after flexor tendon injury and repair but not at 2 years follow-up. Concomitant nerve transection and combined transection of FDP and FDS do not affect digital mobility. CONCLUSIONS: Older patients are likely to have a slower healing process and impaired digital ROM during the first year after surgery.

A prospective randomised comparison of fixation methods in Tamai's zone I amputation.

BACKGROUND: The treatment of choice for fingertip amputation is replantation to restore function and aesthetics. The purpose of this study was to compare the success rates and salvage periods between patients with Tamai's zone I amputation injuries treated with bony fixation and suture fixation. METHODS: Fifty-five patients with Tamai's zone I amputations with bony involvement were included in this study. The patients were allocated randomly to two groups treated by bony fixation with Kirschner (K-)wire and suture fixation, respectively. In the bony fixation group (n = 21), the distal phalangeal bone was fixed with K-wire; in the suture fixation group (n = 34), the amputated portion was fixed with sutures alone. The success rate was defined as the percentage of fully viable replanted cases, and the salvage period was defined as extending from the first postoperative day to the cessation of salvation. RESULTS: The success rates for the bony and suture fixation groups were 90.0% and 91.1%, respectively, with no significant difference. The average salvage period was longer in the bony fixation group than in the suture fixation group (8.7 ± 1.25 vs. 6.4 ± 0.98 days; P = 0.01). No case of non-union of the distal phalangeal bone, limitation of motion, or disfigurement was observed in either group. CONCLUSION: The average salvage period was significantly longer for the bony fixation group, but the success rates did not differ between groups. We suggest that bony fixation is not mandatory in the treatment of Tamai's zone I amputation.

Efficacy of Intravitreal Bevacizumab for the Treatment of Zone I Type 1 Retinopathy of Prematurity.

PURPOSE: To describe the efficacy of intravitreal bevacizumab for the treatment of type 1 retinopathy of prematurity (ROP) in zone I. METHODS: Preterm infants with type 1 ROP in zone I (zone I ROP, any stage with plus disease or zone I ROP, stage 3 without plus disease) were enrolled in this prospective study. Intravitreal bevacizumab (0.625 mg/0.025 ml) was injected under topical anesthesia. Patients were followed weekly for 4 weeks and then biweekly till 90 weeks gestational age. RESULTS: Seventy eyes of 35 patients with type 1 ROP in zone I were enrolled. At a gestational age of 90 weeks, ROP regressed with complete or near-complete peripheral retinal vascularization, in 82.9% of eyes after a single injection and in 92.9% of eyes after up to two injections. In five eyes (7.1%), ROP progressed to stage 4B or 5, so surgical management was required. There were no major complications such as endophthalmitis, cataract, or vitreous hemorrhage after injection. CONCLUSION: Intravitreal bevacizumab injection is an effective method for the management of patients with Zone I ROP requiring treatment; however, some cases may progress to more advanced stages and require surgical management. Close monitoring for recurrence or progression is necessary. Eyes with persistent zone I ROP may progress to advanced stages when treated with intravitreal bevacizumab injection and re-treatment may be needed.

Fingertip replantation (zone I) without venous anastomosis: clinical experience and outcome analysis.

PURPOSE: The purpose of this study was to report our experience of fingertip replantation without venous anastomosis using alternate method to counter post-operative venous congestion. METHODS: 30 Patients (18 men and 12 women) with 30 fingertip amputations (Tamai zone I) were treated with artery-only anastomosis fingertip replantation between March 2010 and July 2014. Postoperative venous outflow was maintained by allowing bleeding through wound gaps combined with topical (12500u:250mlNS) and systemic (4000 IU SC once daily) heparin. The outcomes of replantation were evaluated using standard evaluating systems. RESULTS: The average duration of hospital stay was 10 days (range 7-14 days). Twenty-eight (93 %) replanted fingertips survived. Five replanted fingertip experienced postoperative vascular crisis. The estimated post-operative blood loss was about 200-450 ml (mean, 292 ml). Follow-up period ranged from 12 to 24 months (average, 18 months). At final follow-up examinations, the average value of static two point discrimination test was 5.6 mm (range 3-9 mm) and Semmes-Weinstein monofilament test was 3.35 g (range 2.83-4.56 g). The mean range of motion of distal interphalangeal joint was 65.2° (range 0-90°) and all patients returned to their work within 7-18 weeks (average, 11 weeks). CONCLUSION: Artery-only fingertip replantation can provide satisfactory cosmetic and functional results. Adequate venous outflow can be obtained by allowing minimal external bleeding through wound gaps combined with topical and systemic heparin.

Suturing of the flexor digitorum profundus tendon to the entire volar plate in distal zone I injuries.

PURPOSE: The author conducted an anatomical and a prospective clinical study to address the technique and complications of using the entire volar plate (VP) as a distally-based flap for distal Zone I flexor digitorum profundus (FDP) tendon repair. METHODS: In the anatomical study, eight fresh finger specimens were dissected to study the anatomy of the VP as well as the stability of the distal interphalangeal joint (DIPJ) after raising the entire VP as a distally-based flap. In the clinical series, six patients underwent repair of distal Zone I FDP lacerations using the VP flap technique and were assessed at a mean of 9 months for range of motion as well as DIPJ deformities. RESULTS: The results of the anatomical study showed that the intact collateral ligaments can still maintain the stability of the DIPJ after loss of joint support from the VP. In the clinical series, none of the patients showed joint hyper-extension or flexion contracture at the DIPJ. Using Moiemen-Elliot criteria, the post-operative active range of motion at the DIPJ was rated as excellent in one, good in three, and fair in two patients. CONCLUSION: It was concluded that the use of the entire VP as a distally based flap is an acceptable technique to repair distal FDP injuries and the technique does not result in DIPJ instability or flexion contracture.

Zone I extensor reconstruction with tendon salvaged from another finger.

Laceration, crush, and avulsion injuries are common acute extensor tendon injuries. Simple lacerations may often be repaired in the emergency room, but crush or avulsion injuries may involve tendon loss and gaps in the extensor tendons. Reconstruction can be difficult. The purpose of this article is to present a salvage technique for reconstruction of large extensor tendon gaps in extensor zone I in patients with severe injuries to multiple fingers. This technique, in which a tendon is transplanted from an unsalvageable finger to another with a terminal tendon gap in the same patient, may be a reasonable remedy for reconstruction of tendon loss or gaps and may offer advantages over other traditional reconstructive techniques in certain cases.

Acute exercise induces mitochondrial swelling of hepatocytes surrounding the terminal hepatic venule in rat liver acinus / 体力科学

In this study, we investigated the effect of acute exercise on the mitochondrial structure of hepatocytes surrounding the terminal hepatic venule (zone III) in the rat liver acinus. Male SD rats were assigned to a resting group (n=8) and to running groups ran on a motor-driven treadmill for 100 min (n = 8) or did continued running beyond 100 min until exhaustion (n = 5) . Plasma guanase activity was increased with duration time of exercise. The arterial ketone body rate (AKBR) increased during the 100 min of running, but the AKBR significantly diminished with exhaustive running as compared with that for 100 min of running. Although there was no change in the mitochondrial structure of hepatocytes in the perportal area (zone I) during exhaustion, remarkable swelling was observed in that in zone III.<BR>These results suggest that acute running affects mitochondrial structures in zone III, and that this might be a hypoxia zone during exercise.

The Effect of Cryotherapy and Laser Photocoagulation for the Retinopathy of Prematurity

It has been generally accepted that cryotherapy is a effective therapy in structural outcome in management of threshold retinopathy of prematurity. Despited of this structural success, several potential complications have been termed ocular damage. The purpose of this study is to determine whether diode laser photocoagulation, which has fewer adverse effect and is easier to administe, is as effective as cryotherapy in treatment of prethreshold and threshold retinophthy of prematurity. Twenty-one eyes received diode laser retinal photocoagulation, ranging from 1090 to 1750 g birth weight, and sixty-two eyes received cryotherapy, from 1000 to 1680 g birth weight. The laser-treated eyes had 14.3% unfavorable outcome, and the eyes threated with cryotherapy is as effective as cryotherapy in the result suggests that diode laser therapy is as effective as cryotherapy in the treatment of prethreshold and threshold retinopathy of prematurity. Our study, however, showed that posterior retinopathy of prematurity in zone I was more aggressive than retinopathy of prematurity in zone II and had 42% unfavorable outcome. This result suggests that posterior retinopathy of prematurity requires a careful follow-up examination and and earlier surgical intervention than threshold retinopathy of prematurity.