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PubMed2006

A new technique to improve tissue grip: "the lasso-loop stitch".

In the chain of reattachment of the rotator cuff, links extend from the tendon to the anchor within the bone. Passage of the suture through the tendon is noted at the start of the chain, but as shown before, this is most vulnerable, depending on the quality of the tendon. We present a new technique of suture placement designed to improve tissue grip: "The lasso-loop stitch." One side of the wire is passed through the edge of the tendon, which is ruptured by the wire in the middle-not at the end. The wire is not pulled through completely. Through this process, a loop is created at the upper side of the tendon. The end of the wire, at the same side used to make the loop, is passed through the loop with a grasp. The wire is passed through the loop, and the end of the wire is brought extra-articularly. Through this technique, the reduction force of a suture is augmented, and a constricting factor is added. We have not changed the location of the anchors. So far, we have used the technique in rotator cuff repair, biceps tenodesis, and the Bankart procedure.

Arthroscopy↗

PubMed2006

Flexor tendon rupture 55 years following a wrist laceration.

Flexor tendon rupture at the wrist or palm is rare. We present a case of index flexor digitorum profundus rupture at the level of the wrist associated with the site of a laceration 55 years earlier. Associated pathology included a large neuroma-in-continuity of the median nerve and adhesions involving the flexor digitorum superficialis tendons. The rupture was treated by tenodesis to the relatively unaffected flexor digitorum profundus to the adjacent long finger.

Cicatrix↗

PubMed2004

The minimum number of muscles to control a chain of joints with and without tenodeses, arthrodeses, or braces--application to the human finger.

While the underlying principles of controlling a single joint have been well described, the principles of simultaneously controlling multiple joints have not been comprehensively addressed in the literature of reconstructive hand surgery. This article analyzes (1) how many muscles are minimally required to fully control a chain of joints with in total N Degrees of Freedom (DoF), and (2) to what degree tenodeses, arthrodeses or braces can reduce the required number of muscles. It is demonstrated by mathematical analysis and illustrated by examples that the minimal number of muscles to control a chain of N DoF is N + 1. The number of muscles required for control can be reduced by mechanisms that reduce the number of DoF in the chain. (i) An arthrodesis is a permanent surgical fixation of a joint. An arthrodesis eliminates as many DoF in the chain as the arthrodized joints contributed. (ii) Tenodeses are coordinative tendon constructions. Each independent tenodesis eliminates one DoF from the chain. (iii) Braces are removable external supports. They eliminate as many DoF for muscle control as they immobilize. These principles are applied to illustrate the fundamental importance of tendinous structures in control in the human finger. Being able to determine the minimum number of muscles needed for multiarticular control gives additional knowledge in the design of functional reconstruction.

Arthrodesis↗

PubMed2005

Fixation of tendon grafts for collateral ligament reconstructions: a cadaveric biomechanical study.

PURPOSE: To compare the biomechanical properties of 4 methods of fixation of tendon grafts to bone as used for ligament reconstructions. METHODS: Thirty-two metacarpals were harvested from fresh-frozen cadavers and stripped of soft tissue. Flexor tendons were harvested from the same cadavers and cut into 2-mm-wide strips. Each tendon was fixed to a metacarpal head at the site of origin of a collateral ligament. Four different methods of fixation were tested. In group 1 the tendon was fixed to the bone with a 4.0-mm Arthrex bio-tenodesis interference screw (Arthrex, Inc., Naples, FL). In group 2 the tendon was passed through a bone tunnel and fixed with a 3.2-mm mini-Acutrak screw (Acumed, LLC, Hillsboro, OR) that was inserted in interference mode. In group 3 the tendon was passed through a bone tunnel and fixed with sutures tied over a polyethylene button. In group 4 the tendon was fixed with a mini-Mitek bone suture anchor (Mitek Worldwide, Norwood, MA). All specimens were clamped into a linear loading machine and loaded until failure. Statistical analysis was performed by 1-way analysis of variance testing. RESULTS: The differences in maximal tensile strength and stiffness were statistically significant when comparing any 2 groups. The Arthrex biotenodesis interference screw was the strongest and stiffest fixation method, followed by the Acutrak screw inserted in interference mode. Next was the suture tied over a button method. The mini-Mitek bone suture anchor was the weakest. CONCLUSIONS: Interference screw fixation of tendons to bone has statistically significant higher pullout strength and stiffness than 2 other commonly used fixation methods. The use of interference screws for fixation of tendon grafts to bone for hand ligament reconstructions is a promising new surgical technique.

Biomechanical Phenomena↗

PubMed2006

Arthroscopic debridement and closed pinning for chronic dynamic scapholunate instability.

PURPOSE: For chronic dynamic scapholunate (SL) instability (>3 months after injury) open procedures (capsulodesis, limited intercarpal fusions, tenodesis, SL ligament reconstruction) have become popular in recent years but their long-term results have been suboptimal. We evaluated retrospectively the results of aggressive arthroscopic debridement of the SL ligament to bleeding bone in an effort to induce scar formation and closed pinning of the SL joint in patients unwilling to have an open procedure. METHODS: Eleven patients (mean age, 37 y) presenting with persistent posttraumatic pain and weakness to the wrist were diagnosed with dynamic SL instability (positive Watson scaphoid shift test result, SL gapping on grip-view radiographs, arthroscopic findings of a Geissler grade III or IV SL tear) and treated. Range of motion, grip strength, radiographic measurements, and the Mayo wrist score were used to evaluate the results. RESULTS: The mean follow-up period was 33 months (range, 12-76 mo). Three patients had subsequent surgery 9 to 11 months after the procedure. Subsequent surgeries included a dorsal capsulodesis, a four-corner fusion, and a wrist arthrodesis. Of the 8 remaining patients there were 2 excellent, 4 good, 1 fair, and 1 poor result based on the Mayo wrist score. In these patients the mean range of motion was 65 degrees of extension to 59 degrees of flexion and the mean grip strength was 82% of the uninjured contralateral extremity. Although persistent radiographic SL gapping in grip views was noted in all 8 patients none progressed to static instability or dorsal intercalated segment instability. CONCLUSIONS: The results of this technique are suboptimal; however, it may be an option for patients unwilling to have more than an arthroscopic procedure or those requiring maintenance of wrist motion, provided they understand the risks and benefits of this approach. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.

Adult↗

PubMed2006

Long-term results of tendon transfers in radial and posterior interosseous nerve paralysis.

Eighteen cases of tendon transfer for isolated radial or posterior interosseous nerve palsy have been carried out in our unit over a period of 21 years. Fifteen patients were reviewed with a mean follow-up of 9.5 years. Nine had sustained high and six low radial nerve injury. We achieved 11 excellent, two good, one fair and one bad result. The main problems were loss of power of gripping and the occurrence of radial deviation, particularly in patients with flexor carpi ulnaris transfer to the extensor digitorum communis. During this time, our technique has evolved, including changes of the tendons transferred. Our final preference is a modified Tsuge procedure, using the pronator teres to restore extension of the wrist, the flexor carpi radialis for extension of the fingers and the palmaris longus for extension of the thumb. Abduction of the thumb is restored by a tenodesis of the abductor pollicis longus to the brachioradialis. This review justifies the final policy, in particular the preservation of flexor carpi ulnaris to maintain wrist stability and flexion.

Adolescent↗

PubMedDate not supplied

Long head of the biceps pathology as a cause of anterior shoulder pain after shoulder arthroplasty.

The use of shoulder arthroplasty has been increasing over the last decade, with nearly 20,000 shoulder arthroplasties being performed each year. Although many patients have excellent results, there exists a subset of patients in whom anterior catching shoulder pain develops after arthroplasty. The purpose of this study was to examine this group of patients and explore treatment options and outcomes for this condition. We undertook a review of 8 shoulders in 7 patients who were treated for anterior shoulder pain radiating into the biceps muscle after shoulder arthroplasty. Three patients had a hemiarthroplasty for fracture, and five had a total shoulder arthroplasty. All patients had anterior shoulder pain with physical examination findings consistent with biceps tendon pathology. Definitive diagnosis and treatment consisted of either arthroscopy, in 7 of 8 shoulders, or an open procedure, in 1 of 8 shoulders. The range of motion improved in all shoulders. The hemiarthroplasty group showed an increase in flexion of 36 degrees (range, 68 degrees -104 degrees ), external rotation of 23 degrees (range, 11 degrees -34 degrees ), and internal rotation to L4. The total shoulder group demonstrated an increase in flexion of 50 degrees (range, 66 degrees -166 degrees ), external rotation of 27 degrees (range, 22 degrees -39 degrees ), and internal rotation to L3. The Hospital for Special Surgery score improved in all shoulders, with all patients being satisfied with their final outcome. Pain scores improved from a mean of 6.9 (range, 4-9) preoperatively to 1.4 (range, 0.5-2) postoperatively on a scale of 1 to 10, with 10 indicating the most pain. The role of the biceps tendon in the pathology of anterior shoulder pain after shoulder arthroplasty appears to be consistent with fibrosis and inflammation. Initial results, achieved with arthroscopic debridement or tenodesis, were encouraging.

Aged↗

PubMed2006

The evolution of osteoarthritis in 103 patients with ACL reconstruction at 17 years follow-up.

AIM: To evaluate the functional and radiological outcome of a bone-tendon-bone anterior cruciate ligament reconstruction, at long-term follow-up. METHODS: A retrospective study of 148 patients, of which 103 were available for long-term follow-up. Complete functional and radiological evaluation (International Knee Documentation Committee scale) were performed in 89 out of the 103 patients [Anderson AF. Rating scales. In: Fu FH, Harner CD, Vince KG, (Eds.). Knee Surgery, Baltimore, Williams and Wilkins vol. 1, 1994; 12, pp. 275-296]. RESULTS: The mean follow-up time was 17.4 years. Subjectively, 88% of the patients were very satisfied or satisfied. According to the IKDC score 55% had type A symptoms, 29% type B, 12% type C, and 4% type D. The IKDC ligament evaluation showed 14.9% type A, 44.8% type B, 35.8% type C, and 4.5% type D. At the review 22.7% had a narrowing <50% (C) and 4.7% a narrowing >50% (D). Onset of osteoarthritis showed an association with the status of the medial meniscus. Knees with a preserved (healthy or sutured) medial meniscus had a significantly (p < 0.05) better radiological outcome. Among these, 9% had a joint space narrowing <50% (C) and 2% had a narrowing >50% (D). Medial meniscectomy, residual laxity, and femoral chondral defects were associated with osteoarthritis. CONCLUSION: The outcome of anterior cruciate ligament reconstruction plus extra-articular tenodesis is good in the very long term, particularly in knees with a preserved medial meniscus.

Adult↗

PubMed1997

Implanted functional electrical stimulation hand system in adolescents with spinal injuries: an evaluation.

OBJECTIVE: To study the utility and functional benefits of an implanted functional electrical stimulation (FES) system for hand grasp and release in adolescents with tetraplegia secondary to spinal cord injuries. DESIGN: Intervention study with before-after trial measurement with each subject as his or her own control. SETTING: Nonprofit pediatric orthopedic rehabilitation facility specializing in spinal cord injury. PARTICIPANTS: A convenience sample of five adolescents between 16 and 18 years of age with C5 or C6 level tetraplegia at least 1 year after traumatic spinal cord injury. Key muscles for palmar and lateral grasp and release were excitable by electrical stimulation. INTERVENTIONS: A multichannel stimulator/receiver and eight electrodes were surgically implanted to provide stimulated palmar and lateral grasp and release. In conjunction with implantation of the FES hand system, surgical reconstruction in the form of tendon transfers, tendon lengthenings and releases, and joint arthrodeses was performed to augment stimulated hand function. Rehabilitation of the tendon transfers and training in the use of the FES hand system were provided. MAIN OUTCOME MEASURES: Measurements of pinch and grasp force, the Grasp and Release Test (GRT), and an assessment of six activities of daily living (ADL) were administered before implantation of the FES hand system and at regular follow-up intervals. Results of the stimulated response of individual muscles and surgical reconstruction were evaluated using standard and stimulated muscle testing techniques and standard assessment of joint range of motion. All subjects completed followup testing. RESULTS: Lateral and palmar forces were significantly greater than baseline forces (p = .043). Heavy objects on the GRT could only be manipulated with FES, and FES increased the level of independence in 25 of 30 ADL comparisons (5 subjects, 6 activities) as compared to baseline. After training, FES was preferred in 21 of 30 comparisons over the typical means of task completion. Of the 40 electrodes implanted, 37 continue to provide excellent stimulated responses and all of the implanted stimulators have functioned without problems. The surgical reconstruction procedures greatly enhanced FES hand function by either expanding the workspace in which to utilize FES (deltoid to triceps transfer), stabilizing the wrist (brachioradialis to wrist extensor transfer), or stabilizing joints (intrinsic tenodesis transfer, FPL split transfer). CONCLUSION: For five adolescents with tetraplegia, the combination of FES and surgical reconstruction provided active palmar and lateral grasp and release. Laboratory-based assessments demonstrated that the FES system increased pinch force, improved the manipulation of objects, and typically increased independence in six standard ADL as compared to pre-FES hand function. The study also showed that the five adolescents generally preferred FES for most of the ADL tested. Data on the benefits of the implanted FES hand system outside of the laboratory are needed to understand the full potential of FES.

Activities of Daily Living↗

PubMed1997

The bionic glove: an electrical stimulator garment that provides controlled grasp and hand opening in quadriplegia.

OBJECTIVE: This report describes the operation of the Bionic Glove, a new functional electrical stimulation (FES) device designed to improve the function of the paralyzed hand after spinal cord injury (SCI) or stroke. DESIGN: Signals from a sensor in the glove detecting voluntary wrist movement are used to control FES of muscles either to produce hand-grasp or to open the hand. When the glove is donned, conductive areas on its inside surface automatically make contact with self-adhesive electrodes on the skin. SETTING AND PATIENTS: This report concerns nine people with SCI who have used the device in their daily lives for up to a year or more. Measurements were made at clinics in Edmonton, Miami, and Chicago as part of a multicenter clinical trial. OUTCOME MEASURES AND RESULTS: The mean peak force of tenodesis grasp in the nine subjects increased from 2.6N (passive) to 11.3N (glove active). Active force was significantly greater than passive grasp force even when muscles were fatigued after repetitive grasp-release cycles. Most manual tasks improved significantly with the use of the glove, as judged by the number of tasks completed in a minute or the subjects' qualitative ratings of task difficulty. CONCLUSION: The Bionic Glove can provide significant improvement of hand function in people with C6-C7 SCI.

Adult↗

PubMed1999

Clinical evaluation of the bionic glove.

OBJECTIVE: Clinical evaluation of the Bionic Glove, a prototype of a new functional electrical stimulation device designed to improve the function of the paralyzed hand after spinal cord injury. PATIENTS: Twelve people with spinal cord injury at C5-C7 who had used the device 6 months or more. SETTING: Measurements were made at the Institute "Dr Miroslav Zotović" in Belgrade as a part of a multicenter clinical trial. METHODS: Measures include Upper Extremity Function Test, Functional Independence Measure, and Quadriplegia Index of Function. RESULTS: The daily use of a Bionic Glove had two major effects: (1) increasing the power grasp; and (2) increasing the range of movements. Active force was significantly greater than passive tenodesis force, as shown in other studies. Most manual tasks improved significantly with the use of the assistive system, as judged by the time needed to complete a task or the subject's qualitative ratings of a task difficulty. Most subjects who retained some dexterity without the assistive system hesitated to use the assistive system to manipulate small objects. CONCLUSION: The Bionic Glove can significantly improve independence in people with C5-C7 spinal cord injury if their initial Functional Independence Measure and Quadriplegia Index of Function scores are 20% to 50% of the maximum values.

Activities of Daily Living↗

PubMed2003

Immediate full-weight-bearing mobilisation for repaired Achilles tendon ruptures: a pilot study.

Recent experimental and clinical evidence suggests that early loading and mobilisation for Achilles tendon ruptures may improve functional outcomes. This paper presents the results of a pilot study designed to assess the safety of immediate weight-bearing mobilisation. Twenty-eight operatively repaired patients were randomised to either immediate loading in an orthosis or traditional serial plaster casting. An independent observer, blinded to treatment, assessed the results. Improved clinical, anthropometric, and functional outcomes were noted in the immediate loading group. Ultrasound assessment confirmed no deleterious effects upon the tenodesis. There was one re-rupture of the tendon at a minimum follow-up of 1 year.

Achilles Tendon↗

PubMed2004

[Correction of acquired metatarsus elevatus and hallux flexus: technique used in nine cases].

Nine cases of acquired metatarus elevatus or horizontalization of the first metatarsal with hallux flexus (dorsal bunion) were treated surgically associating: plantar wedge resection of the base of the first metatarsal or the first cuneiform; distal disinsertion of the long hallux flexor which was then positioned under the base of the first metatarsal and finally fixed on the distal dorsal segment of the metatarsophalangeal capsule; distal disinsertion of the anterior tibial tendon and tenodesis of the posterior tibial tendon. Weight bearing was allowed after pinning for one Month to position the axis of the first ray. Morphological results, recorded at 11 Years follow-up (mean) were satisfactory. There were no recurrent deformations and no residual instability of the first ray. The only observation was a minimal stiffness of the metatarsophalangeal joint with no tendency to degeneration.

Adult↗

PubMed1985

Attritional flexor tendon rupture due to a scaphoid non union imitating an anterior interosseous nerve syndrome: a case report.

A case is presented of acute loss of function of flexor pollicis longus and profundus tendon to the index finger. Although the aetiology was obscure, the acute onset suggested a mechanical cause rather than a nerve compression disorder such as anterior interosseous nerve palsy. X-rays showed an ununited scaphoid fracture related to an injury many years previously. Surgical exploration revealed attritional rupture of flexor pollicis longus and partial division of profundus tendon to index finger by a spicule of ununited scaphoid which had eroded through the volar capsule. Removal of the spicule and tenodesis of flexor pollicis longus gave a good long term result.

Aged↗

PubMed1995

Avascular necrosis of the scaphoid treated by total excision and radial advancement osteotomy.

Total scaphoid excision and radial advancement osteotomy has been investigated in a cadaveric and clinical study. In three below-elbow fresh amputation specimens, the technique was utilized and stability was checked by radiographs. Instability on ulnar deviation was prevented by extensor carpi radialis longus tenodesis. Four patients were treated in this way. The wrist was immobilized in a below-elbow splint for 45 days, then active motion was encouraged. After 10 months, three patients had excellent results and one patient had good result using the criteria of Cooney et al (1987).

Adult↗

PubMed1996

Diagnosis of closed central slip injuries. A cadaveric analysis of non-invasive tests.

Four non-invasive tests for central slip integrity were analysed using 20 fresh frozen cadaver fingers. A pre-boutonnière deformity was simulated by dividing the central slip. A passively correctable boutonnière was simulated by dividing the central slip, triangular ligament and oblique fibres of the extensor expansion. The test described by Boyes, which evaluates distal interphalangeal joint flexion, was found not to be reliable for the diagnosis of either injury. The test described by Elson, which evaluates distal interphalangeal joint rigidity while actively extending the flexed proximal interphalangeal joint, was the only manoeuvre which was able to discern central slip integrity in both simulated injuries. The central slip tenodesis test and testing resistance of active proximal interphalangeal joint extension should be performed with the proximal interphalangeal joint in flexion to weaken the effectiveness of the lateral bands.

Biomechanical Phenomena↗

PubMed2001

Biceps tendinitis and subluxation.

Since the 17th century, the long head of the biceps tendon as a source of shoulder pain and its functional significance has been a source of debate. Although the term tendinitis is commonly used, overuse tendon injuries infrequently demonstrate inflammatory cells; instead, degenerative changes resulting from the failure of self-repair usually are found. Bicipital tendinitis or bicipital tenosynovitis is most often secondary to impingement beneath the coracoacromical arch. Primary bicipital tendinitis and tendinitis secondary to instability are possible, however. Through a careful history, physical examination, and appropriate imaging studies, the clinician can establish the diagnosis of disorders of the biceps tendon Arthroscopic evaluation greatly improves the diagnosis and treatment of biceps tendon and related shoulder pathology. Although the exact functional role of the biceps tendon remains incompletely defined, a growing body of evidence supports its role as a stabilizer of the glenohumeral joint. This stabilizing function should be incorporated into the treatment of biceps tendon disorders. Routine tenodesis has been replaced by a more individualized approach, taking into consideration physiologic age, activity level, expectations, and exact shoulder pathology present. New repair techniques are under development, and preservation of the biceps-labral complex is now preferred when possible.

Cumulative Trauma Disorders↗

PubMed1995

Salvage of the failed Darrach procedure.

Six patients (5 post-traumatic, 1 rheumatoid) underwent a three-component reconstruction for correction of dorsal instability and radioulnar impingement following failure of a Darrach resection of the entire distal end of the ulna. The technique was devised to prevent simultaneous coronal and sagittal instability. The procedure used longitudinal intramedullary tenodesis of the extensor carpi ulnaris tendon, dorsal transfer of the pronator quadratus through the interosseous space, and temporary percutaneous pinning to maintain corrected distal radioulnar relationship. The were evaluated for 11 to 39 months (average, 20 months) following reconstruction. The preoperative wrist extension-flexion arc was preserved following surgery; there was a minimal loss of radial and ulnar deviation. The arc of forearm rotation increased 24 degrees to a range equal to 95% of the rotational arc of the opposite, unoperated wrist. Postoperative grip strength improved to an average value of 65 lb., two and one half times the preoperative value, representing 80% of the value for the opposite extremity. Four patients were able to return to their previous employment. All patients achieved pain-free forearm rotation and relief of their preoperative complaints of painful mechanical popping, clicking, and catching.

Adult↗