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PubMed1998

[Secondary reconstruction of flexor tendon function of the fingers].

Among the various procedures to restore flexor tendon function after failed or omitted primary suture flexor tendon grafting is the most frequently applied technique. It can be performed in a one-stage procedure using a palmaris- or plantaris graft in cases with less scarring or in a two-stage procedure for cases in unsuitable conditions. The main purpose for using silicone rods is to prepare an artificial tendon sheath to avoid adhesions of the tendon graft. The disadvantage of two operations seems to be justified by better results. We performed this technique in 168 zone-II-lesions. According to the Buck-Gramcko score we achieved excellent results in 30.9% and good results in 25.6%. In 76 fingers we applied the combination of the Paneva-Holevich technique of using a pedicled superficialis tendon with Hunters method without obtaining better results (22.4% and 32.9% respectively). The various techniques of grafting are described as well as indication and technique of tenodesis and alternatively staged procedure for isolated profunda lesions.

Cicatrix↗
PubMed2004

[Ulnar instability of the carpus].

Ulnar instabilities of the carpus are rare findings depending on a dissociation of the lunotriquetral (LT-) junction. They are frequently not recognized or confused with ulnocarpal complaints of other origin due to missing typical clinical or radiological indications. The central structures are the os triquetrum and its connections to the os lunatum, the distal carpal row, radius and ulna. The most important causes are injuries, but degeneration, ulnar impaction syndrome or the ulna plus variant can also be involved. The symptoms are ulnar-sided pain, sensations of instability and weakness as well as "clunking" sensations in the ulnar wrist. Clinical examination may reveal tenderness in the LT-interval, between the ECU- and FCU-tendons, and displacement of the triquetrum on palpation. The LT-interval is rarely extended in conventional X-rays. A VISI position of the os lunatum is found in instabilities of higher degree. A distinct diagnosis is only achieved by arthroscopy. Conservative treatment consists of 4-8 weeks of arm immobilization. Diagnostic arthroscopy can be combined with débridement and/or closed reduction of the LT-interval with consecutive percutaneous k-wire fixation. If a repair of the LT-ligament is not possible, reconstructive methods are indicated. They include extrinsic tenodesis with part of the extensor carpi ulnaris tendon, ligamentoplasty or osteoligamentous autografts. The role of lunotriquetral arthrodesis is considered to be controversial, due to a high rate of non-fusions. Simple correction of the LT-dissociation does not resolve the static instability of the proximal row (VISI-position of the lunatum). In these cases, salvage procedures such as limited arthrodesis of the wrist, proximal row carpectomy or complete arthrodesis are indicated.

Arthroscopy↗
PubMed2005

3D kinematic in-vitro comparison of posterolateral corner reconstruction techniques in a combined injury model.

With the variable injury pattern to the posterolateral structures (PLS) of the knee, a number of reconstructive procedures have been introduced. It was the aim of the present study to evaluate the resulting 3D kinematics following three different surgical techniques of reconstruction in a combined posterior cruciate ligament (PCL)/PLS injury model. In nine human cadaveric knees, 3D kinematics were recorded during the path of flexion-extension using a computer based custom made 6-degree-of-freedom (DOF) testing apparatus. Additional laxity tests were conducted at 30 and 90 degrees of flexion. Testing was performed before and after cutting the PLS and PCL, followed by PCL reconstruction alone. Reconstructing the posterolateral corner, three surgical techniques were compared: (a) the posterolateral corner sling procedure (PLCS), (b) the biceps tenodesis (BT), and (c) a bone patellar-tendon bone (BTB) allograft reconstruction. Posterior as well as rotational laxity were significantly increased after PCL/PLS transection at 30 and 90 degrees of flexion. Isolated PCL reconstruction resulted in a remaining external rotational deficiency for both tested flexion angles. Additional PLS reconstruction closely restored external rotation as well as posterior translation to intact values by all tested procedures. Compared to the intact knee, dynamic testing revealed a significant internal tibial rotation for (b) BT (mean=3.9 degrees, p=0.043) and for (c) BTB allograft (mean=4.3 degrees, p=0.012). (a) The PLCS demonstrated a tendency to internal tibial rotation between 0 and 60 degrees of flexion (mean=2.2 degrees, p=0.079). Varus/valgus rotation as well as anterior/posterior translation did not show significant differences for any of the tested techniques. The present study shows that despite satisfying results in static laxity testing, pathological 3D knee kinematics were not restored to normal, demonstrated by a nonphysiological internal tibial rotation during the path of flexion-extension.

Aged↗
PubMed2005

A study for evaluating the effect of the deltoid-flap repair in massive rotator cuff defects.

The repair of massive cuff defects by direct suture often is impossible. In these cases, a repair by musculo-tendineous flaps (latissimus-dorsi, pectoralis or deltoideus) is required. It was the goal of this study to evaluate the result of delta-flap repair in case of massive cuff defects with a diameter of 5 cm or more. Between 1998 and 2000 for all patients who were suffering from a massive rotator cuff tear more than 5 cm a deltoid transfer was performed. A total of 20 patients (14 male, 6 female; age: 60.9+/-8.7 years) were available for a follow-up after 47.2+/-8.0 (range, 36 to 60) month. The operation included an arthroscopic evaluation, acromioplasty with resection of the lateral clavicular end, and biceps tenodesis. The cuff defect was repaired by transfer a muscular flap from the anterior part of the deltoid (about 2 x 6 cm) into the defect. The patients subjectively rated their result-10 excellent, 9 good, and 1 poor. Preoperatively, the Constant amounted 26.3+/-5.1 points. At follow-up, the score significantly increased to 74.5+/-8.5 points. The acromiohumeral distance increased from 4.9+/-1.1 to 9.2+/-1.7 mm. In MRI examination of 11 patients all had an intact flap. Two complications (a wound hematoma and a deep infection) did not influence the result. The repair of massive rotator cuff tears by a deltoid transfer produces acceptable clinical and radiological results.

Acromion↗
PubMed1991

MacIntosh-Jones reconstruction for the unstable knee.

A group of 45 patients who underwent replacement of a ruptured anterior cruciate ligament with a free graft of one-third of the patellar tendon combined with a lateral extra-articular tenodesis have been reviewed. The average age of the patients was 26.4 years and the mean follow-up period 3.2 years. Stability was achieved in 42 patients (93 per cent), judged on clinical criteria. Overall patient satisfaction was high at 73 per cent and 38 patients (84 per cent) maintained their sporting activity at a social or competitive level. Those who had unsatisfactory results had undergone significant delay before anterior cruciate ligament reconstruction.

Adolescent↗
PubMed1986

Palmaris longus transfer for replacement of the first dorsal interosseous.

Using palmaris longus, the first dorsal interosseous was reconstructed without free tendon graft. Palmaris longus prolonged with a strip of palmar fascia was transferred rectilinearly to the site of insertion of the first dorsal interosseous via a subcutaneous tunnel and fixed. This method was applied to seven hands of six patients and the follow-up observation continued for more than six months postoperatively. In six hands, favourable stability and abduction function of the index finger was achieved. In one hand, adhesion occurred at the site of the first dorsal interosseous muscle resulting in tenodesis. This operative method appears to be useful in the reconstruction of the first dorsal interosseous muscle from non-recovering paralysis following injury of the first dorsal interosseous muscle, or ulnar nerve. This method may also be utilized after decompression of chronic compression of the ulnar nerve giving no expectation of complete recovery by the reconstruction and augmentation of the first dorsal interosseous muscle. No unpleasant side effect was encountered.

Fasciotomy↗
PubMed1992

Operative findings in camptodactyly of the little finger.

In five of six cases of camptodactyly in which an abnormality of the flexor tendon was examined at operation, the flexor digitorum superficialis tendon was hypoplastic and there was no continuity of the normal tendon between the muscle belly and bony insertion. The proximal end of the flexor digitorum superficialis tendon was attached to the palmar aponeurosis and the flexor tendon sheath of the ring finger in two patients, to the palmar aponeurosis in one, to the undersurface of the transverse carpal ligament in one and to the flexor tendon sheath of the ring finger in one. The tenodesis effect of the abnormal tendon of the flexor digitorum superficialis is considered to play an important role in the cause and rapid increase of the deformity of camptodactyly.

Adolescent↗
PubMed1993

Resection arthroplasty of the proximal interphalangeal joint.

Palmar plate resection arthroplasty of the PIP joint, a new technique for operative treatment of destroyed PIP joints, is presented. By combining palmar plate arthroplasty with a flexor tenodesis a stable arthroplasty with adequate active motion can be performed. It can be used even in severely destroyed joints and still provide adequate post-operative stability and motion. Exercise can be started early.

Arthroplasty↗
PubMed1993

Cysticercosis of the flexor digitorum profundus muscle producing flexion deformity of the fingers.

Selective flexion deformity of the middle and ring fingers resembling a mild type of Volkmann's contracture resulted from Cysticercus cellulosa infection within the deep flexor muscle of the forearm in a middle-aged woman. Excision of the fibrotic segment of the muscle and tenodesis of all the flexor profundus tendons restored normal range of motion to these fingers. Vascular compromise in addition to the inflammatory response to the infection were considered causes for the deformity. There is no previous report of this kind in the literature.

Adult↗
PubMed1989

Early dynamic splinting for extensor tendon injuries.

Extensor tendon injuries are traditionally splinted with no motion for 3 to 4 weeks after repair. This may result in limitation of flexion because of extensor tenodesis at the site of repair. To prevent this, we used a dynamic splinting program opposite to the one that is used for flexor tendon repair, with an outrigger splint holding the fingers in extension and allowing full active flexion. Fifty-two patients who had extensor tendon repairs in the area from the wrist to the middle of the proximal phalanx were treated. Motion was begun 2 to 5 days after repair and was continued for approximately 5 weeks. No tendon ruptures occurred, and all patients recovered full flexion.

Adult↗
PubMed1992

One-stage key pinch and release with thumb carpal-metacarpal fusion in tetraplegia.

One-stage key pinch and release with carpal-metacarpal fusion, extensor pollicis longus tenodesis, and motor transfer to flexor pollicis longus were analyzed for functional results in tetraplegic patients. Eighteen patients (21 hands)--all with International Classification OCu:4 hand function or worse--were studied. Average follow-up was 42 months. All patients experienced significant increase in functional ability and thought the surgery was highly beneficial. Average pinch strength was 3.3 kg, whereas it had been nonmeasurable preoperatively. Both activities of daily living and pinch strength correlated with tetraplegic functional level. The patients with higher preoperative functional level had better postoperative activities of daily living scores and pinch strength. Sixteen hands had solid fusions, and patients with fibrous nonunions showed no decrease in pinch strength, pain, or functional limitations when compared with the patients who had solid fusions. Six hands showed degenerative changes at one or more adjacent joints, but this was not related to results.

Adolescent↗
PubMed1993

Biomechanical evaluation of distal radioulnar reconstructions.

Numerous reconstructive procedures have been described for the treatment of chronic instability of the distal radioulnar joint or instability of the stump of the resected distal ulna. This biomechanical study presents an evaluation of the three basic design types that have been used in reconstruction. The initial static stability provided by the reconstructions was tested and compared with the stability of the intact joint. Our findings show that all reconstructive procedures failed to restore natural joint stability. A radioulnar sling design was the most effective of the three types, whereas tenodesis procedures and ulnar collateral ligament reconstruction were much less effective in providing stability. We conclude that current designs have significant biomechanical shortcomings. On the basis of our observations during testing, we believe that improved designs will require an intra-articular reconstruction that more closely duplicates the biomechanical functions of the triangular fibrocartilage complex.

Adult↗
PubMed1994

Central slip attenuation in Dupuytren's contracture: a cause of persistent flexion of the proximal interphalangeal joint.

This paper stresses the importance of central slip attenuation in the management of Dupuytren's contracture. Such attenuation occurs in patients who have had prolonged proximal interphalangeal joint contractures and is a common problem when the flexion contracture exceeds 60 degrees. The diagnosis can be made at the time of surgical correction by a tenodesis test. If central slip attenuation is confirmed, the postoperative regime described here will give a better correction of what at first might appear to be an intractable proximal interphalangeal joint flexion deformity.

Dupuytren Contracture↗
PubMed1991

Anterior cruciate ligament reconstruction without drill holes.

Anterior cruciate ligament (ACL) reconstruction in adolescents with open physes remains a difficult problem for the orthopedic surgeon, especially in view of growing teenage participation in contact sports. Traditionally, treatment of ACL tears in adolescents has been conservative; the patient is advised to delay surgery up to several years for fear of damaging physes by drilling holes across them. Unfortunately, this waiting period may inflict irreparable knee damage. This paper suggests an ACL reconstruction technique that utilizes no drill holes, thus causing no harm to physes or other essential knee structures. A graft consisting of semitendinosus and gracilis (SG) tendons is passed under the anterior horn of the medial meniscus through the knee joint, then brought out through the posterior capsule and secured to the lateral femoral metaphysis. The graft is augmented with an iliotibial band tenodesis. Designed primarily but not exclusively for teenagers with open physes, the procedure has produced encouraging results thus far in a small series.

Adolescent↗
PubMed1992

Medial patellofemoral ligament reconstruction for recurrent dislocation of the patella: a preliminary report.

We present a surgical technique for the treatment of recurring dislocation of the patella. The procedure, based on Galleazzi's tenodesis of the semitendinosus, uses minimal dissection and small incisions to improve cosmetic results and speed recovery. A polyester ligament is passed through a bone tunnel at the midline of the patella and fixed at the medial condyle, thus creating a medial patellofemoral neoligament. We have reviewed the results of 30 knees in 30 patients with an average follow-up of 39 months. Twenty-five patients (83.3%) showed significant improvement of their initial complaints.

Adolescent↗
PubMed1992

SLAP lesions in association with complete tears of the long head of the biceps tendon: a report of two cases.

Two patients were found to have superior labrum anterior and posterior (SLAP) lesions in association with complete tears of the long head of the biceps. Additional intraarticular pathology (retained biceps stump, loose body, and glenoid chondromalacia) was discovered in one patient. We recommend arthroscopy of the shoulder in two situations associated with rupture of the long head of the biceps: (a) in patients with acute ruptures in which the decision has been made to do a biceps tenodesis; and (b) in patients with persistent longstanding shoulder symptoms following nonoperative management.

Adult↗
PubMed2004

Rupture of the biceps tendon after arthroscopic thermal capsulorrhaphy.

The use of thermal energy in the shoulder to tighten capsular tissues through collagen denaturation is well established. Although reported complication rates are low, the natural history of thermal manipulation to both target and collateral tissue is poorly defined. We report two cases of biceps tendon rupture after arthroscopic capsular shrinkage. Both patients were young, athletic men with normal long head biceps tendons at the time of surgery. Each patient experienced a complete tear of the long head with distal muscle retraction, resulting in a "Popeye" deformity, at 3 months postoperatively. One patient elected further surgery with biceps tenodesis. Both patients have returned to their athletic activities with minimal functional deficits.

Adolescent↗
PubMed2004

Arthroscopic bicipital sheath repair: two-year follow-up with pulley lesions.

PURPOSE: The purpose of this study was to evaluate arthroscopic repair in patients who had lesions of both the subscapularis insertion/medial head of the coracohumeral ligament and the lateral head of the coracohumeral ligament and supraspinatus tendon (a type 5 biceps subluxation/instability classification), and to determine if primary repair of the torn structures used to reconstruct the bicipital sheath was associated with a high biceps rupture rate. The null hypothesis, that there is no difference between preoperative and postoperative outcomes, was tested. TYPE OF STUDY: Prospective cohort. METHODS: Since 1995, the author has had 18 patients who had lesions that affected both the medial and lateral wall of the bicipital sheath. An adjunct was added if tendonitis was present with fraying, and the biceps tendon was debrided if the fraying consisted of 50% or less the width of the tendon. This was chosen arbitrarily. Greater than 50% fraying of the biceps tendon was treated with repair of the supraspinatus and subscapularis. The biceps tendon was treated with tenotomy or tenodesis in these cases and these patients were not included in this study. This article reports on the repair technique and results having a minimum of 2-year follow-up. RESULTS: There were 12 male patients (age range, 45 to 80 years; average, 62 years) and 6 female patients (age range, 50 to 85 years; average, 66 years). The dominant extremity was involved in 12 of the 16 extremities. Preoperative, ASES Index, Total Constant scores, Subjective Constant scores, Objective Constant scores, visual analog pain scales, and percent function were 31 +/- 19, 53 +/- 13, 12 +/- 8, 41 +/- 8, 7 +/- 3, and 42 +/- 17, respectively. Postoperative scores were 80 +/- 14, 77 +/- 10, 30 +/- 4, 47 +/- 7, 2 +/- 2, and 84 +/- 14, respectively. The null hypothesis was rejected at a level of P = .001, .001, .001, .05, .001, and .001, respectively. CONCLUSIONS: There was 1 biceps disruption in this cohort following repair, for an incidence rate of 6%. There were 2 patients, active tennis players, who had recurrence of biceps inflammation in the follow-up period with no evidence of biceps subluxation. The arthroscopic technique reported is a primary repair used to reconstruct the normal structures of the groove. This may explain why previous recommendations not to reconstruct the groove because of the high biceps disruption rate have been noted previously. This study did not deepen the groove, tubulize the biceps tendon, or close the rotator interval in nonanatomic fashion. This arthroscopic technique is technically feasible and can alleviate the symptoms of biceps tendon inflammation and/or subluxation in the majority of cases in this cohort. LEVEL OF EVIDENCE: Level IV, Case Series.

Aged↗