Common Flexor Research Articles

Applying the V.E.R.A. method to entheses of the humerus: An assessment of repeatability and reproducibility

AbstractThe “Validated Entheses‐based Reconstruction of Activity” (V.E.R.A.) method has proven to be a reliable method for the quantification and analysis of entheses. However, this method has only been successfully applied to human hand bones and animal long bones. This study tests the general applicability of the V.E.R.A. method to the human humerus, focusing on evaluating its reliability and repeatability. The sample included 23 humeri of unknown origin and background. The V.E.R.A. method was applied to six entheses of the humerus, comprising the subscapularis, supraspinatus, infraspinatus, teres minor, common extensor origin, and common flexor origin. Lin's concordance correlation coefficient (CCC) and percentage of error statistics were used to measure intraobserver error. Interobserver error was assessed through analysis of variance (ANOVA) tests, the intraclass correlation coefficient (ICC), and Lin's CCC. Intraobserver rates were between 1.83% and 3.23%. Interobserver error values were excellent, with no significant differences found in the ANOVA tests; Lin's CCC values were all above 0.90, with only the common extensor origin being 0.87; and ICC values were all above 0.97. Our results showed that the V.E.R.A. method is highly reliable and reproducible for the six entheses of the human humerus selected for this study. These results demonstrate the vast potential for the V.E.R.A. method to be applied to other parts of the human skeleton.

Minimally invasive needle tenotomy vs. platelet rich plasma injection in the treatment of chronic elbow epicondylitis

BackgroundMedial and lateral epicondylitis, characterized by repetitive microtraumas to common flexor and extensor tendons respectively, are common causes of elbow pain in adults. Though symptoms generally are self-limiting, 10% of cases are refractory to conservative management, persisting for greater than 18 months and leading to surgery, which can have increased risk of complications. There is minimal data on sustained pain relief and functional benefit for newer non-surgical management options such as minimally invasive needle tenotomy (MINT) via Tenjet and platelet-rich plasma (PRP) for chronic elbow epicondylitis. Additionally, no previously established correlation exists between MRI severity of chronic epicondylitis with pain and functional improvement in MINT and PRP-treated patients. MethodsA retrospective review of 51 adults (n=23 for Tenjet; n=28 for PRP) was conducted to investigate long-term outcomes in pain relief (via Visual Analog Scale or VAS) and improvements in upper extremity function (via Quick Disability of the Arm, Shoulder, and Hand questionnaire or qDASH). These outcomes were correlated with radiographic evidence of epicondylitis severity, assessed by grade of epicondylitis and percentage thickness of tendon tears. ResultsThere were significant improvements in pain (VAS) but no significant differences in function (qDASH) following MINT and PRP. On average, VAS score improved by 2.6 (p<0.001) post-Tenjet and by 3.8 (p<0.001) post-PRP, combined for all follow-up time points. No adverse events were reported over the entire study. A significantly higher percentage of patient-reported pain relief was noted post-Tenjet at all follow-up time points. VAS and qDASH outcomes post-Tenjet and post-PRP were not correlated with initial MRI severity of epicondylitis. ConclusionsThere are multifactorial benefits of both Tenjet and PRP as safe, non-open surgical modalities that can be used, despite MRI severity, to provide sustained pain relief for patients with refractory elbow epicondylitis.

Mapping Origins of Tendons on the Medial Epicondyle to Improve Treatment of Medial Epicondylitis: Anatomical Study

Medial epicondylitis is a tendinosis found commonly in throwing and golfing athletes. Although there are choices for nonsurgical treatments, when these fail, surgical intervention can be considered. When surgical treatment is performed, the objective is to debride the diseased tissue from the epicondyle. The purpose of this study was to clarify the locations and size of the common flexor tendons and medial collateral ligament (MCL) relative to each other and to the posterior ridge of the medial epicondyle. The common flexor tendons and MCL were dissected and reflected their origin on the medial epicondyle in six cadaver elbows. Measurements were taken from the posterior and distal ridges of the medial epicondyle with respect to the humerus. Each origin was also measured for its height and width. The flexor carpi ulnaris origin starts at a mean of 4.2 mm from the posterior ridge of the medial epicondyle and extends anteriorly an average of 4.8 mm. The flexor carpi radialis starts at a mean of 4.2 mm from the posterior ridge and extends anteriorly an average of 7.4 mm. The pronator teres begins at a mean of 4.6 mm from the posterior ridge and extends an average of 5.7 mm anteriorly. The MCL starts at an average of 10.4 mm from the posterior ridge and extends 5.2 mm anteriorly. The measurements found have allowed the creation of a map of the specific common flexor tendon origins and their sizes on the medial epicondyle, as well as their position relative to the MCL. A surgeon may debride 1 cm anteriorly from the posterior ridge of the medial epicondyle to safely address the affected tissues and ensure the safety and integrity of the MCL.

Tendinous Signal Alterations on MRI in the Asymptomatic Elbow: A Retrospective Cross-Sectional Study.

It is clinically relevant to prevent overtreatment of tendinopathy diagnosed solely on imaging. Therefore, the prevalence of presumable asymptomatic signal changes in the common flexor origin, biceps insertion, brachialis insertion, and triceps insertion were assessed. Two hundred and five magnetic resonance imaging (MRI) exams of the elbow with coronal and axial fat-saturated fluid-sensitive sequences between January 1, 2018 and July 31, 2022 were retrospectively identified in our center.Two radiology residents reviewed the exams independently. The elbow tendons were given a score from 0 to 4. Score 0: no signal abnormality; score 1: increased T2-weighted signal around the tendon; score 2: increased T2-weighted signal compared to muscle within the tendon; score 3: partial tear; and score 4: complete tear. The common flexor tendon showed signal alterations in 8% of patients; nine patients had an increased signal around the tendon, and eight patients had an increased signal within the tendon. Three patients (1.5%) had an altered signal intensity in the biceps tendon. All triceps tendons showed a linear hyperintense signal, suggesting that it is physiological. There were no partial or complete tears. No signal abnormalities were noted in the brachialis tendon among all patients. The prevalence of presumable asymptomatic signal alterations seen in the common flexor origin on MRI is not negligible; therefore, clinical correlation is advised to prevent overtreatment of tendinopathy in these cases. No partial or complete tears were seen.

Gluteal Tendon Tear Healing on Ultrasound 10 Weeks Following a Single Platelet-Rich Plasma Injection: A Case Report

Tendinosis with or without tendon tear is a common form of tendon pathology and should be managed differently from inflammatory tendinitis although both are termed tendinopathy. The current tendinopathy management involves rest, icing, a brace, oral anti-inflammatory medicine, and physiotherapy. Should that fail a trial of Corticosteroid (CS) injection allow surgery as a last resort. This article presents a middle-aged male, a human resources manager who suffered two occasions of tendinopathy with the first one being a gradual development of symptomatic right common flexor origin calcific tendinosis (golfer’s elbow) on ultrasound (USS) secondary to competitive squash that failed conservative management and USS-guided CS injection. He had a long-term symptomatic recovery after six weeks following a single autologous platelet-rich plasma (PRP) therapy. Three years later he injured his right hip following a twisting injury to the right hip/gluteal area resulted in debilitating symptoms, USS scan revealed gluteus minimus/ medius calcific tendinosis, a partial split tear of the gluteus minimus, and trochanteric bursitis. He failed physiotherapy and anti-inflammatory medicine. He elected PRP therapy over CS injection, he became symptoms free six weeks after the injection. Teen weeks post-injection USS revealed a complete resolution of gluteus minimus tendon tear and no trochanteric bursitis, no clear tendinosis features but calcifications present. This case demonstrates the use of relatively safe affordable clinic-based PRP therapy for long-term symptomatic control of tendinopathy with/without a tear. This is superior to oral anti-inflammatory and CS injections. Additionally, the healing of the tendon tear could save people from avoiding invasive surgery with its complications and long recovery time. Thanks to the regenerative healing power of the growth factors and signaling proteins in platelets that stimulate the internal mesenchymal stem cells. We recommend a large-scale randomized control trial to confirm those findings and standardization of the PRP technique, hoping regenerative medicine to become the mainstream therapy in several musculoskeletal pathologies, particularly in resistant injuries.

Subclinical enthesitis inenthesitis-related arthritis andsacroiliitis associated with familial Mediterranean fever.

In our study, we investigated the presence of subclinical enthesitis by ultrasonography (US) in asymptomatic patients with enthesitis-related arthritis (ERA) and sacroiliitis associated with familial Mediterranean fever (FMF). A total of 50 patients, including 35 patients with ERA and 15 with sacroiliitis associated with FMF, were included in the study. All patients were evaluated with US by a paediatric radiologist. Enthesis of seven tendons (common extensor and flexor tendons, quadriceps tendon, proximal and distal patellar tendon, Achilles tendon, and plantar fascia) was examined on both sides. Subclinical enthesitis was detected in 10 ERA (28.5%) and three FMF (20%) patients. Enthesitis was radiologically diagnosed in 16 (2.3%) out of 700 evaluated entheseal sites. The most frequent sites of enthesitis were Achilles (37.5%) and quadriceps (31.3%) tendons. All patients were in clinical remission and had no active complaints, and acute phase reactants were within normal limits. Therefore, the patients were followed up without treatment change. However, disease flare-up was observed in three of these patients (23.1%) during the follow-up, and their treatments were intensified. Our results showed that the US can be particularly helpful in detecting subclinical enthesitis and predicting disease flare-ups.

Bilateral Infectious Extensor Tenosynovitis: A Case Report.

Infectious extensor tenosynovitis is a rare infection spreading along the extensor tendons of the extremities. It presents a diagnostic challenge in the emergency department (ED) given the nonspecific signs and symptoms, as opposed to the more common flexor tenosynovitis that is diagnosed by the classic Kanavel signs on physical exam. Here we present a case of bilateral extensor tenosynovitis in a 52-year-old female denying past medical history who presented to the ED with two days of bilateral dorsal hand swelling and pain. She denied any risk factors such as direct trauma to the hands or intravenous drug use. The rare diagnosis was suspected in the ED due to a very high complement reactive protein level and a concerning point-of-care ultrasound. Extensor tenosynovitis was ultimately confirmed on computed tomography and by operative irrigation and drainage of the tendon sheaths. This case demonstrates the importance of keeping extensor tenosynovitis on the differential when seeing a patient with dorsal extremity edema and pain, even if the findings occur bilaterally.

The AIUM Practice Parameter for the Performance of the Musculoskeletal Ultrasound Examination.

The AIUM Practice Parameter for the Performance of the Musculoskeletal Ultrasound Examination.

Terrible than terrible triad of elbow

The brachial artery is rarely injured in closed posterior dislocation, despite the anatomical proximity.Most cases of brachial artery injury after dislocation of the elbow are associated with fracture. The neurovascular examination that comprises checking for the distal pulse is mandatory, and the absence of the same is considered a warning sign. Investigations like doppler and arteriography should be done to prevent potential complications. Our study is about a patient with closed posterior dislocation with vascular insufficiency in the left ulnar and Radial artery due to following self-fall from a 2-wheeler. We treated her with Tissue reconstruction on the medial and lateral sides, including UCL and Common Flexor Origin and repaired LCL and Common extensor origin with Thrombectomy. At six months follow-up, no complications of vascular injury were noted.

Polygastric flexor muscle of the index finger and its clinical implications

Although muscle variations in the forearm have been widely reported, the presence of supernumerary muscles in this compartment may be associated with compressive disorders of the nerves of the upper limb. The purpose of this study was to report the finding of a polygastric flexor muscle of the index finger (PFID), a supernumerary muscle associated with the anterior compartment of the forearm, the morphology and pathway of which are closely related to the median nerve. The PFID was found in a routine dissection of an upper right limb. Following a dissection methodology by planes, a narrow, polygastric muscle was identified, formed sequentially and interspersed by four tendons and three muscle bellies, that extended between the common flexor muscle mass of the anterior compartment of the forearm and the index finger. The sixth part of the PFID was partially in the carpal tunnel and established close relation with the median nerve, which was displaced superficially. Knowledge of this and other muscle variations that appear in the forearm and carpal tunnel are relevant when performing a differential diagnosis of carpal tunnel syndrome or in planning surgery on this canal.

Common flexor plane block: A novel approach to median and ulnar nerve block at elbow.

Common flexor plane block: A novel approach to median and ulnar nerve block at elbow.

Anteromedial coronoid fractures: technical description of an extensile surgical approach and outcomes from a small series using this technique

Varus posteromedial rotatory instability is a difficult clinical problem to diagnose and treat. Fixation of the anteromedial coronoid fracture is often necessary to achieve elbow stability. We describe an extensile surgical approach to the anteromedial coronoid. A retrospective review was performed of all patients at our institution who had anteromedial coronoid fracture fixed with this approach between 2012 and2020. Six patients were identified. They all achieved a stable elbow. Four of 6 developed heterotopic ossification and 2/6 required further surgery for this. Only 1 patient had a transient ulnar sensory loss. We describe an approach to the coronoid that allows great visualization of the joint and access to large coronoid fractures. The approach is extensile and does not require extensive dissection or work around the ulnar nerve. Access to fracture and for fixation can be improved by release of the common flexor pronator origin and the medial collateral ligament.

A Meta-Analysis of Biomechanical Studies for Suture Button Pullout Versus Suture Anchor Repair of Flexor Digitorum Profundus Avulsions.

There is no current consensus on which of the two most common flexor digitorum profundus (FDP) avulsion repair constructs, via suture button pullout (SBP) or suture anchor (SA), is biomechanically superior. Our purpose was to compare these repair methods via systematic review and meta-analysis of available literature. We performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-guided systematic review of PubMed, the Cochrane library, and Embase. We only included studies with direct comparison data for both techniques. We performed a meta-analysis comparing the reported biomechanical results using pooled data for initial repair stiffness (N/mm), gap formation (mm), and ultimate load to failure (N). Seven studies met inclusion criteria, including a total of 201 cadaveric specimens. Four studies reported initial construct stiffness, with pooled analysis showing superiority for SA repairs (P < .05). Four studies evaluated gap formation, with pooled analysis demonstrating less gapping with SA repair (P < .05). Mean gap formation was 2.4 (±1.4) mm and 3.9 (±2.0) mm for the SA and SBP groups, respectively. All 7 studies assessed load to failure, with pooled analysis revealing no significant difference between groups (P > .05). We lacked statistical power to determine equivalence between techniques for load to failure. Both groups had failure values significantly lower than the native FDP. Via meta-analysis, there was increased initial construct stiffness and less gap formation for SA compared to SBP for FDP reinsertion, with no significant differences for ultimate failure load.

Medial Elbow Pain Syndrome: Current Treatment Strategies.

Medial elbow pain is a common presentation that can be a challenge to appropriately treat for the orthopedic surgeon. Causes include medial epicondylitis, ulnar neuritis, ulnar collateral ligament injury, flexor pronator strain, or snapping medial triceps. A good outcome is typically achieved with adequate treatment of tendon degeneration at the common flexor tendon origin. Mainstay treatment is nonoperative modalities such as stretching, rest, activity modification, therapy, and injections. If nonoperative management fails, intermediate interventions such as extracorporeal shockwave therapy, platelet-rich plasma injections, prolotherapy, and ultrasound-guided percutaneous tenotomy can be attempted. Surgical treatments are dictated based on the severity of the pathology, involvement of soft tissues, and concomitant pathology. Medial elbow complaints can be multifactorial and require a broad differential diagnosis. [Orthopedics. 2023;46(2):e81-e88.].

A Survey of Zone II Flexor Tendon Repair Techniques and Rehabilitation Protocols Preferred by Malaysian Orthopaedic Practitioners.

Introduction:Flexor tendon repair is challenging mainly due to the need to balance between a strong repair technique, ease of tendon gliding and early mobilisation to prevent adhesions while preventing tendon rupture. While different countries have different preferences in repair techniques, core sutures and suture types, there is still no study in Malaysia regarding our preference and whether we are following the current evidence.Materials and methods:We performed a survey with a standard questionnaire distributed during our annual national orthopaedic meeting in 2019. The standard questionnaire consisted of 24-objective multiple-choice questions concerning the treatment of flexor tendon injury were distributed with consent. A total of 290 questionnaires that were filled out correctly were included in this study.Results:The majority of respondents preferred the Modified Kessler technique (n=96, 33.1%) followed by the Adelaide technique (n=81, 27.9%) and Double Modified Kessler (n=45, 15.5%). However, for the number of core strands in the repair, the majority utilised the 4-strand (n=203, 70%), followed by 2-strand (n=34, 11.7%) and 6-strand (n=21, 7.2%). The majority utilised Prolene sutures (n=259, 89.3%) with a suture size of 4/0 (n=157, 54.1%). For rehabilitation, 56.9% (n=165) preferred early passive motion, 27.6% (n=80) early active motion and 14.8% (n=43) would strictly immobilise.Conclusion:There is still no consensus as to the best technique; however, the aim of tendon repairs is still the same around the world. It would be helpful to know our preferences to improve our current practice and outcomes following these common flexor tendon injuries in hand.

Youth throwing athletes do not show bilateral differences in medial elbow width or flexor tendon thickness.

BackgroundMedial elbow laxity develops in throwing athletes due to valgus forces. Medial elbow instability in professional, collegiate, and high school athletes is well documented; however, the medial elbow of young throwing athletes has received less attention. This study investigated the medial elbow and common flexor tendon during applied elbow valgus stress of youth baseball players. MethodsThe study included 15 participants. The medial elbow width and thickness of the common flexor tendon were measured on ultrasound images.ResultsNo significant side differences in medial elbow width or common flexor tendon were found at rest or under applied valgus stress. At rest, the medial elbow joint width was 3.34±0.94 mm on the dominant side and 3.42±0.86 mm on the non-dominant side. The dominant side increased to 3.83±1.02 mm with applied valgus stress, and the non-dominant side increased to 3.96±1.04 mm. The mean flexor tendon thickness was 3.89±0.63 mm on the dominant side and 4.02±0.70 mm on the non-dominant side. ConclusionsThese findings differ from similar studies in older throwing athletes, likely because of the lack of accumulated stress on the medial elbow of youth throwing athletes. Maintaining elbow stability in young throwing athletes is a vital step to preventing injury later in their careers.

Surgical Techniques and Clinical Outcomes for Medial Epicondylitis: A Systematic Review

Background: Medial epicondylitis (ME) is a pathological condition that arises in laborers and athletes secondary to repetitive wrist flexion and forearm pronation causing degeneration of the common flexor tendon. Although nonoperative management has demonstrated high rates of success, no standardized surgical technique has been established for situations when operative management is indicated. Purpose/Hypothesis: The purpose of this study was to perform a systematic review of the surgical treatment options for ME and evaluate the associated patient-reported outcomes (PROs). We hypothesized that surgical management of ME would vary across studies but no technique would prove to be superior. Study Design: Systematic review; Level of evidence, 4. Methods: Searches were conducted using PubMed, EMBASE, Cumulative Index of Nursing Allied Health Literature (CINAHL), SPORTDiscus, and Cochrane databases between 1980 and April 2020. All level 1 to 4 studies were identified that focused on surgical management and PROs in the setting of ME. Description of surgical technique and PROs were required for inclusion. Investigators independently dually abstracted and reviewed the studies for eligibility. Weighted means were calculated for demographic characteristics and available PROs. Results: Overall, 851 studies were identified according to the search criteria. A total of 16 studies met the inclusion and exclusion criteria and therefore were evaluated. Three surgical techniques were found: open (13 studies), arthroscopic (2 studies), and percutaneous (1 study). Descriptions of the open technique were subdivided into those with (7 studies) and without (6 studies) common flexor tendon repair. Analysis included 479 elbows; patients were primarily male (58.3%) with a weighted mean age of 47.2 years. Weighted mean follow-up was 4.6 years. Tennis and manual laborer were the most common sport and occupation, respectively. Surgical success ranged from 63% to 100%, with a low complication rate of 4.3%. Success rates for return to sports and work were 81%-100% and 66.7%-100%, respectively, and only 1 study reported a return to work rate <90%. Conclusion: This systematic review demonstrates that surgical intervention for refractory ME often has a high success rate. Regardless of surgical technique performed, patients generally demonstrated an improvement in PROs, and an encouraging number returned to work with limited complications. Further investigation is necessary to determine superiority among open, arthroscopic, and percutaneous techniques.

Radiologic evaluation and clinical effect of calcification in medial epicondylitis.

Although most radiologic findings of medial epicondylitis (ME) are normal, up to 25% show calcification, and little is known about the clinical relevance of soft-tissue calcification in ME. The purposes of this study were to reveal the characteristics of calcification in ME and to identify their clinical relevance. This study included 187 patients (222 elbows) with a diagnosis of ME. We classified calcification according to its anatomic location and further evaluated its distribution. Logistic regression analysis was performed to calculate the odds ratios and 95% confidence intervals for possible factors that may affect calcification in ME: age, sex, laterality, hand dominance, visual analog scale (VAS) pain score, Mayo Elbow Performance Score, symptom duration, history of steroid injection, number of steroid injections, concomitant ulnar neuropathy, and treatment method in terms of conservative treatment or surgery. Of a total of 222 elbows, 53% (118 of 222 elbows) showed calcification in radiologic findings. The VAS pain score, the number of steroid injections, and concomitant ulnar neuropathy were significantly associated with calcification in ME. Calcification was most commonly identified at the anatomic insertion site of the common flexor tendon (33%), followed by the pronator teres (18%) and the medial collateral ligament (10%). Of the total cases of calcification, 45% were distributed at multiple sites, and age was strongly associated with multiple-site distribution. Calcification in ME was more commonly identified than previously reported and was distributed over a relatively broad area. Calcification was associated with a higher VAS pain score, a history of steroid injection, and combined ulnar neuropathy. The anatomic insertion site of the common flexor tendon most commonly showed calcification, and age was a strong indicator of a broad distribution of calcification.

Detection of lesions of the DDFT and the proximal Manica flexoria of the SDFT – Comparison of ultrasonographic and tenoscopic findings in equine aseptic tenosynovitis of the common digital flexor tendon sheath

Detection of lesions of the DDFT and the proximal Manica flexoria of the SDFT – Comparison of ultrasonographic and tenoscopic findings in equine aseptic tenosynovitis of the common digital flexor tendon sheath

Biomechanical Analysis of Abductor Pollicis Longus Lasso Suspensionplasty for Trapeziectomy

Multiple methods of ligament reconstruction and tendon interposition (LRTI) or suspension have been described to prevent first metacarpal subsidence following trapeziectomy. An abductor pollicis longus (APL) lasso is a newly described technique of suspensionplasty, which aims to obviate concerns regarding previously described methods. The purpose of this study was to compare subsidence between the APL lasso and 2 other common methods, APL sling and flexor carpi radialis LRTI, after trapeziectomy in cadaveric forearms. Ten cadaveric forearms were prepared on a custom-made plinth to recreate pinch grip upon the loading of previously identified muscles. A sequence of procedures was performed, with radiographs taken after each to assess the subsidence. The APL lasso was superior to simple trapeziectomy and flexor carpi radialis LRTI in preventing subsidence. The APL lasso was superior to simple trapeziectomy and flexor carpi radialis LRTI in preventing subsidence, and it may be a viable alternative when considering suspension methods after trapeziectomy. The APL lasso may be considered when trying to prevent subsidence after trapeziectomy.