屈肌腱损伤-康复科讲课-英文课件

FLEXORTENDONINJURIESOFTHEHAND

MichaelZlowodzkiMDUniversityofMinnesotaDepartmentofOrthopaedicSurgeryOUTLINEAnatomyClinicalassessmentTreatmentdependingonZoneofinjuryTendonhealingbiology RepairtechniquesPost-opmotionprotocolsDelayedgraftingANATOMYFDSOrigin(2musclebellies)MedialepicondyleRadialshaft

TendonsarisefromseparatemusclebundlesACTINDEPENDANTLYFDPOrigin:ulna&interosseousmembraneFDP:CommonmuscleoriginforseveraltendonsSIMULTANEOUSFLEXIONOFMULTIPLEDIGITSFDPFDSFDPFPLLumbricalsoriginfromradialsideofFDPCAMPER’sCHIASMAFDSdividesandpassesaroundtheFDPtendon,thetwoportionsoftheFDSreuniteat“Camper’sChiasma”TENDONSHEETSPreserveA2andA4pulleytopreventbowstringing.NOTE:Thereisamistakeinthisdiagram:TheC1pulleyisDISTALtotheA2pulley!PULLEYSTENDONEXCURSION

9cmofflexortendonexcursionwithwristanddigitalflexiononly2.5cmofexcursionisrequiredforfulldigitalflexionwiththewriststabilizedinneutralpositionTENDONEXCURSIONMPmotion=noflexortendonexcursion1.5mmofexcursionper10degreesofjointmotionforDIP(FDP)andPIP(FDS,FDP)BLOODSUPPLYSegmentalbranchesofdigitalarterieswhichenterthetendonthrough:vinculaosseousinsertionsSynovialfluiddiffusionVINCULAECLINICALEXAMFDS:ClinicalExamTENODESISEFFECTPassiveextensionofthewristdoesnotproducethenormal“tenodesis”flexionofthefingersifflexorsareinjuredFDS:ClinicalExamFDP:ClinicalExamFDPRUPTURENoactiveDIPmotion(presentpassiveDIPmotion)ZONESREPAIRALLCOMPLETETEARSATALLLEVELS!ZONE1INJURIES:

JerseyFingerJERSEYFINGERJERSEYFINGERLEDDYCLASSIFICATIONType1:RetractionintopalmType2:RetractiontoPIPlevelType3:Bonyavulsion(tendonattached)Type4:Bonyavulsion(tendonattachednotattachedtobonyfragment)REPAIRWITHIN7-10DAYSTYPESOFREPAIRDirectrepair:iflacerationismorethan1cmfromFDPinsertionTendonadvancement:ifthelacerationislessthen1cmfrominsertion.TENDONADVANCEMENTBUTTONSTRONGERTHANSUTUREANCHORSTendonAdvancementPreviouslyadvocatedforzone1repairs,asmovingtherepairsiteoutofthesheathwasfelttodecreaseadhesionformationDisadvantagesShorteningofflexorsystemContractureQuadrigaeffectQUADRIGAEFFECTIfFDPtendonadvancedtoodistallyEntiremusclebellsgetspulleddistallyTendonexcursionofFDPofotherdigitsislimitedLossofgripstrengthZONE2INJURIESZONE2INJURIESZone2:DeepandsuperficialflexorglidinginsidetendonsheetsTraditionally“Noman’sland”:StiffnessafterrepairINJURY:TendonsretractZONE2:

PARTIALLACERATIONSPartiallacerationNorepairif40%ofthetendonintactPotentialcomplications:TriggeringTendonentrapmentEvalfortheriskoftriggering;debrideifnecessarydorsalblocksplintingfor6to8weeksN=15patientswithzoneIIpartialflexortendonlacerationsofthewidthofthetendon(Avg.71%)Conservativetreatment:Dorsalblockingsplintwithwristin10°offlexionImmediateguardedactiveROMSplintremoved@4wNorestriction@6wexcellentresultsin93%andgoodin7%WhynotfixapartiallacerationwhenyoustaringatitintheORanyway?Becausethedissectionnecessarytofixitmightcausetoomuchscarring,whichmightoutweighthebenefitZONE2:

COMPLETELACERATIONSMORESTRANDS:STRONGER&STIFFERREPAIRUltimateStrengthandRepairTechniqueProportionaltonumberofstrands6and8strandrepairsstrongestSteeplearningcurveIncreasedbulkandresistancetoglideIncreasedtendonhandlingandadhesionformationMaynotbenecessaryforforcesofearlyactivemotion4-STRANDREPAIRADEQUATESTRENGTHWITHOUTCOMPLEXITYOF6-8STRANDSFixFDPandFDSorjustFDP?Why?BecausethebloodsupplytotheFDPtendonisjeopardizediftheFDSisnotalsofixed(duetothevinculaeanatomy)

(Personalcommunication:Dr.JamesHouse)FIXFDPANDFDS!COMPLICATIONSStiffnessRe-ruptureTenolysismayberequiredinanestimated18%to25%ofpatientsNoearlierthan3monthsafterrepairIfnoROMimprovementfor1-2monthsZONE3INJURIESLumbricalmusclebelliesusuallyarenotsuturedbecausethiscanincreasethetensionofthesemusclesandresultina“lumbricalplus”finger(paradoxicalproximalinterphalangealextensiononattemptedactivefingerflexion).ZONE4INJURIESZONE4:CarpalTunnelTENDONHEALINGFlexortendonhealingIntrinsichealing:occurswithoutdirectbloodflowtothetendonExtrinsichealing:occursbyproliferationoffibroblastsfromtheperipheralepitenonadhesionsoccurandlimittendonglidingPHASESOFTENDONHEALING1.Inflammatory(0-5days):strengthoftherepairisreliantonthestrengthofthesutureitself2.Fibroblastic(5-28days):orso-calledcollagen-producingphase3.Remodelling(28days-4months)TENDONWEAKEST@10-14DAYSBRUNNERINCISIONSUTURETECHNIQUESKesslerModifiedKessler

(1suture)Advantage:Onlyonenodeinsidetherepairsite.Easiertouseamonofilamentsuturelikea4.0Prolinetore-approximatetendonedges.Kessler-Tajima

(2sutures)SUTUREMATERIALNon-absorbableMostauthorspreferasyntheticbraided3.0or4.0suture,usuallyofpolyestermaterial(Mersilene,Tycron,Tevdek)However,monofilamentsutureslikenylonandwirearealsoused(e.g.Proline)Additionalrunning,circumferential5-0or6-0nylonisusedoftenIN:InterferencewithhealingOUT:Interference

withtendonglidingSUTUREKNOTLOCATIONSUTUREKNOTLOCATIONKnotsoutsidesuperiorinoneinvitrostudy(Aoki)Statisticallysignificantincreaseintensilestrengthat6wkswithknotsinsidetechniqueincaninemodel(Pruitt)FEWSTUDIES–NOCONSENSUSSHEATREPAIRAdvantagesBarriertoextrinsicadhesionformationMorerapidreturnofsynovialnutritionDisadvantagesTechnicallydifficultIncreasedforeignmaterialatrepairsiteMaynarrowsheathandrestrictglideNOCLEARADVANTAGEESTABLISHEDPOST-OPREHABHISTORICALBunnel(1918)PostoperativeimmobilizationActivemotionbeginningat3wkspostop.Suboptimalresultsbytoday’sstandardsImprovedsuturematerial/techniqueaswellaspostoperativerehabilitationprotocolsSTIFFNESSRUPTUREToomuchmotionTolittlemotionRUPTURESTIFFNESPOST-OPPROTOCOLSKleinert:Activeextension,passiveflexionbyrubberbandsDuran:ControlledPassiveMotionMethodsStrickland:EarlyactiveROMGOAL:FULLACTIVEROM@10-12weeks

KleinertProtocolDuranprotocolDURANPROTOCOLDorsalSplintin20degwristflexionNorubberbandsPassiveflexionDesignedinresponsetonotion3-5mmoftendonglidingsufficienttopreventrestrictiveadhesionsRehabilitationStrickland(1980s-1990s)Usesa4strandrepairwithepitendinoussutureDorsalblockingsplintwithwristat20degofflexionSupervisedactiveROMstartsPOD#3UnsupervisedAROMat4weeksRarelyused,becauseitrequiresaprettyextensive“bulky”repairtoallowforearlyactiveROM.AlotofsurgeonsthinksthattoomuchsuturematerialmaybeproblematicfortendonhealingCHILDRENUsuallynotabletoreliablyparticipateinrehabilitationprogramsNobenefittoearlymobilizationinpatientsunder16yearsImmobilization>4wksmayleadtopooreroutcomesDELAYEDRECONSTRUCTIONSingleStageTendonGrafting:

IndicationsSegmentaltendonlossDelayindefinitiverepair(>3-6weeks)NeedFullPROMCompetentpulleysSingleStageTendonGrafting

Zone2InjuriesGraftdonorsPalmarislongusPlantarisLongtoeextensors(FDS)(EIP)(EDM)TwoStageReconstruction

IndicationsExtensivesofttissuescarringCrushinjuriesAssociatedfractures,nerveinjuriesLossofsignificantportionofpulleysystemTwoStageReconstruction:Stage1ExcisionoftendonremnantsHunterrodthenplacedthroughpulleysystemandfixeddistallyReconstructpulleysasneededifimplantbowstringsTwoStageReconstruction:Stage2Impl