Complex Extensor Research Articles

Free Chimeric Superficial Circumflex Iliac Artery Perforator Flap in Reconstructing the Distal Complex Extensor Tendon Injury.

The distal complex extensor tendon injury, presenting as traumatic skin, zones 1 and 2 of extensor pollicis longus and extensor hallucis longus, and bony insertion loss, represents a challenging issue and requires a well-vascularized skin paddle, tendinous graft, and insertional reconstruction. Guided by the all-in-one-step reconstruction rule, the chimeric superficial circumflex iliac artery perforator (SCIAP) flap, generally considered as a promising multiple-type tissue provider (eg, vascularized skin paddle, fascia, iliac flap), can fulfill the reconstructive demands and has an edge over the two-stage countermeasure. The authors adopted tripartite SCIAP flaps to reconstruct distal complex thumb or toe injuries in eight cases (six thumbs and two halluces), all of which were reattached with vascularized fascia lata-iliac crest conjunctions using a pull-out technique. All SCIAP flaps survived uneventfully without donor-site complications. The remodeled interphalangeal joints regained nearly normal radiologic manifestation. The chimeric SCIAP flap may be a promising technique for distal complex extensor tendon injury; providing vascularized skin paddle and fascia lata-iliac crest graft, it also qualifies for the all-in-one-stage reconstruction concept. Therapeutic, IV.

Olecranon Tendo-Osseous Allograft Reconstruction for Complex Extensor Mechanism and Bone Loss at the Elbow

The purpose of this study was to present the results of olecranon tendo-osseous allograft (OTOA) reconstruction for patients with an irreparable extensor mechanism from prior trauma or failed total elbow arthroplasty (TEA). A retrospective review was performed of all patients with extensor mechanism loss after trauma or failed TEA who were treated with an OTOA to supplement fracture fixation or elbow arthroplasty, as indicated. Primary outcome measures were successful healing of the allograft, restoration of the extensor mechanism function, and Mayo Elbow Performance Scores (MEPS) at the most recent follow-up. Secondary outcomes included patients' active range of motion and unplanned operative interventions. Nine patients had extensor mechanism and proximal ulna loss as a result of prior TEA, acute trauma, or failed surgeries for prior trauma. All but one had undergone multiple prior surgeries. The mean follow-up was 27 months (6-60 months). At the final follow-up, patients reported MEPS of 92 (80-100). All patients regained active triceps extension (strength 3-5/5). Mean final range of motion was 16° (0° to 45°) extension, 124° (70° to 150°) flexion, 56° (45° to 80°) pronation, and 60° (40° to 80°) supination. Eight (89%) of the nine patients had a radiographically healed graft at the latest follow-up, of which four healed without notable complications or further surgical intervention. Complications included radial/ulnar nerve palsy, allograft olecranon stress fracture, deep infection, wound complications, instability, and complications related to the TEA prosthesis. In the setting of elbow reconstruction in which there is inadequate triceps tendon and/or olecranon bone stock to perform internal fixation and/or revision arthroplasty, OTOA may supplement elbow reconstruction, albeit with high rates of complications. A triceps-olecranon allograft, combined with either internal fixation or TEA, is a potentially useful salvage procedure for managing bone loss and an irreparable extensor mechanism deficit at the elbow. Therapeutic V.

Failed Extensor Tendon Repairs: Extensor Tenolysis and Reconstruction.

Extensor tendon injuries are common and require a complex treatment strategy to appropriately manage them, including initial repair, revision/reconstruction options, and postoperative protocols. Intrinsic and extrinsic components of the extensor mechanism contribute to a complex anatomic apparatus but also allow for numerous reconstructive options. Tenolysis, tendon grafting, and local tissue reconstruction are all options that can be used to treat complex extensor tendon injuries, but the type of repair is dependent on which of the eight extensor zones and accompanying structures are injured. To adequately assess and treat these injuries, a working knowledge of the anatomy, reconstructive techniques, and rehabilitation is imperative.

Efficacy evaluation of combined anterior-lateral approach for treatment of elbow triad injuries

Objective To discuss the surgical techniques and results of internal fixation supplemented with soft tissue repair of triad injury of the elbow via the combined anterior-lateral approach. Methods A retrospective analysis was done on 15 patients with triad injury of the elbow treated from January 2011 to August 2014. There were 10 males and 5 females, aged 38.4 years (range, 20-61 years). Injury resulted from traffic accidents in nine patients, high-level falls in three and ground-level falls in three. Radial head fractures were Mason type Ⅰ in five patients, type Ⅱ in eight, and type Ⅲ in two. Fractures of the coronoid process of the ulna were Regan-Morrey typeⅠ in four patients, type Ⅱ in ten and type Ⅲ in one. Time interval between injury and operation was 8.5 d. All patients were firstly operated on through the anterior approach to have Herbert screw fixation or anterior capsule suture lasso fixation of the coronoid fracture as well as Herbert screw fixation of the radial head fracture. And then, elbow lateral incision was made to repair lateral collateral ligament complex and common extensor tendon by 2-0 Ethibon suture. Elbow flexion-extension, forearm pronation-supination and Mayo elbow performance score (MEPS) were used to evaluate the clinical elbow functions. Complications were recorded after operation. Results All patients were followed up for mean 19.6 months (range, 12-30 months). All coronoid fractures healed. Radial head fractures in 14 patients healed. Comparison of preoperative to final follow-up variables presented significant differences in elbow flexion-extension [(45.1±5.6)° ∶(129.5±9.3)°], forearm pronation-supination [(55.4±8.7)° ∶(140.5±10.3)°] and MEPS [(25.1±9.6)points ∶(91.2±5.2)points] (P<0.01). Complications included heterotopic ossification in one patient and nonunion of radial head fracture in one patient. No neurovascular injury of the elbow, elbow residual instability, dislocation, elbow stiffness and active pain occurred. Conclusion Combined anterior-lateral approach with internal fixation and soft tissue repair is a simple and safe method that effectively restore the elbow joint function. Key words: Elbow joint; Ulna fractures; Radius fractures; Fracture fixation, internal

Clinical application of dorsal metacarpal artery composite flap for coverage of tendon and skin defects of the fingers

Objective To discuss the surgical techniques and treatment outcomes of one-stage repair of complex soft tissue and extensor tendon defect of the fingers by transferring dorsal metacarpal artery flap that includes extensor indicis proprius (extensor digiti minimi proprius) tendon and dorsal cutaneous nerve. Methods From April 2013 to September 2015, 6 cases of middle finger dorsal complex tissue defect were managed with dorsal metacarpal artery composite flap transfer for skin coverage, extensor tendon repair and sensory restoration. The flap size that covered these defects ranged from 6.0 cm×2.0 cm to 7.0 cm×3.0 cm.The donor site was directly closed.Passive functional exercise was initiate done one week postoperatively and lasted for 4 to 6 weeks. Results All 6 flaps survived completely. All the patients were follow-up for 3 to 13 months with an average of 8.2 months. Sensation of the flaps recovered to S3 level. Two-point discrimination was 7 to 10 mm while the mean value was 8.6 mm. The color, texture and contour of the flaps were good. Mobility of the hand was satisfactory. Conclusion Dorsal metacarpal artery composite flap transfer is a reliable way to cover complex tissue defects on the dorsum of fingers. It has consistent vascular anatomy, affords extensor tendon and cutaneous nerve reconstruction along with skin coverage, shortens treatment time, and improves outcomes without added risks. Key words: Surgical flaps; Finger injuries; Metacarpal artery; Compound tissue flap

Complex Extensor Tendon Injuries: Early Active Motion Following Single-Stage Reconstruction

This study presents a retrospective evaluation of patients managed with single-stage repair following complex extensor tendon injuries. Over a 2-year period, 21 extensor tendons were reconstructed in 18 patients with complex hand injuries in zones V-VII. All eight patients needed soft tissue cover. Active mobilisation was started in the first week. Total active motion (TAM) at 4 weeks was a mean of 159 degrees (SD 21.57) and at 6 weeks it was 202.6 degrees (SD 13.26). Average TAM at 8 weeks was 223.8 degrees (SD 16.46) and 249.5 degrees (SD 14.38) at 12 weeks. Grip strength at 12 weeks and 6 months was around 75% and 90% of the contralateral normal hand in most of the patients. Single-stage reconstruction of complex extensor tendon injuries seems to reduce morbidity in terms of hospitalisation, and reduced cost of treatment. It also helps to achieve better functional outcome in the early postoperative period.

Biomechanics of patellofemoral instability

The patellofemoral joint functions as a complex extensor apparatus with important biomechanical contributions provided by both articular contact and the surrounding soft tissues. The patella must remain relatively stable while tracking along the anterior and distal surfaces of the femur. If there is instability in the coronal plane (subluxation or dislocation) or around the caudocranial axis (tilt), then pain may result. Stability is maintained through the precise interaction of the patellofemoral articulating surfaces, passive and active soft-tissue restraints, and the alignment of the lower extremity. The purpose of this article is to review these biomechanical variables and how they relate to the treatment of patellofemoral instability.

Comparison of immobilization and early passive motion in the treatment of complex extensor tendon injuries

Objectives: This study was designed to evaluate the functional results in patients who underwent surgery for complex extensor tendon lacerations in zones V to VII and treated either by immobilization or early passive motion (EPM). Methods: Eleven patients (31 fingers) were treated by immobilization and nine patients (18 fingers) were treated by the EPM protocol. In the immobilization group, static palmar splints (wrist extension 30-40°; metacarpophalangeal and interphalangeal joints 0°) were used for four weeks. In the EPM group, dynamic splints and an outtrigger splint were applied to hold the wrist 30-40° extended and the metacarpophalangeal and interphalangeal joints in neutral and rubber band-assisted extension and active flexion was started three to five days postoperatively. After a mean follow-up of 22 months, total active motion and extensor lag of each involved finger, grip strength, and duration for return to pre-injury activity were evaluated. Results: No tendon ruptures occurred. Total active motion of the involved fingers (215°±39.6° vs 241°±36.6°) and duration for return to pre-injury activity (17.8 weeks vs 14.7 weeks) differed significantly in favor of the EPM group (p 0.05). According to the Miller classification, good and/or excellent results accounted for 32.2% and 61% in the immobilization and EPM groups, respectively. Conclusion: The study showed that EPM was more effective than the immobilization method in the treatment of complex extensor tendon injuries in zones V to VII.

Representation of flat Lagrangian $H$-umbilical submanifolds in complex Euclidean spaces

The author proved earlier that, a Lagrangian //-umbilical submanifold in complex Euclidean «-space with n>2 is either a complex extensor, a Lagrangian pseudo-sphere, or a flat Lagrangian //-umbilical submanifold. Explicit descriptions of complex extensors and of Lagrangian pseudo-spheres are given earlier. The purpose of this article is to complete the investigation of Lagrangian //-umbilical submanifolds in complex Euclidean spaces by establishing the explicit description of flat Lagrangian //-umbilical submanifolds in complex Euclidean spaces. 1. Statements of theorems. We follow the notation and definitions given in (2). In order to establish the complete classification of Lagrangian //-umbilical submanifolds in Cn we need to introduce the notion of special Legendre curves as follows. Let z: I^S2n~ι cCbeaunit speed Legendre curve in the unit hypersphere S2n~1 (centered at the origin), i.e., — z(s) is a unit speed curve in S2n~1 satisfying the condition: (z'(s iz(s)) = 0 identically. Since = z(s) is a spherical unit speed curve, = 0 identically. Hence, z(s), iz(s% z'(s iz'(s) are orthonormal vector fields defined along the Legendre curve. Thus, there exist normal vector fields P 3, ...,/> along the Legendre curve such that (1.1) Φ), ι'Φ), z'(s iz\s PM iPsis), > Pn(s), iPn(s) form an orthonormal frame field along the Legendre curve. By taking the derivatives of = 0 and of =0, we obtain =0 and = — 1, respectively. Therefore, with respect to an orthonormal frame field chosen above, z can be expressed as

Complex extensors and Lagrangian submanifolds in complex Euclidean spaces

Lagrangian //-umbilical submanifolds are the simplest Lagrangian submanifolds next to totally geodesic ones in complex-space-forms. The class of Lagrangian //-umbilical submanifolds in complex Euclidean spaces includes Whitney's spheres and Lagrangian pseudo-spheres. For each submanifold M of Euclidean «-space and each unit speed curve F in the complex plane, we introduce the notion of the complex extensor of M in the complex Euclidean «-space via F. The main purpose of this paper is to classify Lagrangian //-umbilical submanifolds of the complex Euclidean «-space by utilizing complex extensors. We prove that, except the flat ones, Lagrangian //-umbilical submanifolds of complex Euclidean «-space with n greater than 2 are Lagrangian pseudo-spheres and complex extensors of the unit hypersphere of the Euclidean w-space. For completeness we also include in the last section the classification of flat Lagrangian //-umbilical submanifolds of complex Euclidean spaces.

IMMEDIATE ACTIVE SHORT ARC MOTION FOLLOWING EXTENSOR TENDON REPAIR

Postoperative management of the extensor tendon injury has been altered over the past 15 years from treatment with 4 to 6 weeks of immobilization to controlled passive motion and, now, to active SAM with minimal tension and wrist tenodesis programs. The concepts of immediate motion are supported biochemically in experimental studies, and biomechanically through excursion studies, mathematical analysis of tendon excursion and force application, and study of repair tensile strengths. The results cited in this article and those reported by others demonstrate that early motion for extensor tendons in zones III, IV, V, VI, VII, T IV, and T V is safe and effective if force application is precise. Early referral to therapy, meticulous care in the control of edema, precise positions of postoperative splinting, and controlled motion programs will greatly improve the results of both simple and complex extensor tendon injuries, both in terms of function achieved and in terms of time and expense.

Clinical application of controlled stress to the healing extensor tendon: a review of 112 cases.

The purposes of this article are to describe an early passive motion program for the healing extensor tendon and to report the results and trends noted in a review of 112 complex extensor tendon injuries treated with this therapeutic technique. The rationale for this technique is based on a review of the physiologic response of healing tendon to controlled stress. Clinical application is dependent on a biomechanical study of extensor tendon excursion, which allows the therapist to apply controlled stress to the healing tendon with precision. The early passive motion technique is considered in terms of physiology, biomechanics, clinical application, and results. The author concludes that early controlled passive motion for the complex extensor tendon injury in zones V, VI, VII, T IV, and TV is a safe and effective rehabilitation technique that reduces complications associated with extensor tendon injury and repair.

Extensor tendon repair in the emergency department

Extensor tendon lacerations of the hand are commonly seen in the emergency department. These injuries can often be definitively managed by the emergency physician who has a working knowledge of the complex extensor mechanism anatomy plus basic surgical skills. A thorough initial assessment including a tourniquet examination for adequate exposure is the key to making the complete diagnosis. Surgical indications, materials, techniques, complications, and postoperative management involved in extensor tendon repair are reviewed. The emergency physician's decision to treat or refer these injuries will depend greatly on the clinical setting, familiarity with the procedure, and the availability of and relationship with appropriate consultants.