Extensor Tendon Reconstruction Research Articles

Extensor Tendon Reconstruction in Vaughan–Jackson Syndrome: Surgical Technique and a Case Illustration

Background and Aims: Vaughan–Jackson syndrome, a complication of rheumatoid arthritis, presents with extensor tendon rupture, dorsal tenosynovitis, distal radioulnar synovitis, dorsal subluxation of the distal ulna, and wrist arthritis. This article aimed to present a surgical approach for Vaughan–Jackson syndrome, focusing on dorsal tenosynovectomy, distal ulnar resection and extensor tendon reconstruction. Case Description: A detailed case study is presented, highlighting the surgical technique employed for managing Vaughan–Jackson syndrome. Technical nuances and considerations are discussed. Results: The surgical technique described resulted in successful management of the patient’s Vaughan–Jackson syndrome, with restoration of hand and wrist function. Conclusion: Surgical intervention involving dorsal tenosynovectomy, distal ulnar resection, and extensor tendon reconstruction is a viable option for managing Vaughan–Jackson syndrome. This article provides insights into the surgical management of this complex condition, offering guidance for clinicians encountering similar cases.

Using Free Chimeric Anterolateral Thigh Flap For Reconstruction Of Composite Dorsal Hand Defect

Simultaneous repair of the extensor tendons and soft tissues in hand injuries remains challenging. The free chimeric anterolateral thigh (ALT) flap with fascia lata (FL) flap represents an alternative for hand reconstruction. This report describes the reconstruction of the extensor tendon and skin defects using free chimeric ALT flaps with FL. Eight patients (one female and seven male) underwent reconstruction of complex hand defects with free chimeric ALT and FL flaps. The defects were caused by crushing injuries, burns, snakebite scars, and animal bite wounds. The average skin defect was 116 cm2. Perforators were selected for the skin paddle and the FL flap. The thinning procedure was performed microsurgically. The skin paddle size ranged from 12 to 23cm in length and 6 to 11cm in width, and the FL flaps ranged from 3×5 to 12×5cm. The mean pedicle length was 7.88cm. Nine extensor tendons were repaired with FL flaps. The flap thickness after thinning was only 3-6mm. The donor site was closed primarily in six patients, and skin grafts were used in two cases. All flaps survived without complications. The follow-up period lasted from 17 to 80 months. Range of motion was achieved with satisfaction. The chimeric-thinned ALT and FL flap is a valuable material, and it should be considered a reconstructive option for hand soft tissue and extensor tendon reconstruction. This technique allows us to achieve a good appearance and extensor function without donor-site morbidity.

A novel finger brace for preventing finger stiffness after trauma or surgery: a preliminary report with a case series

Purpose: Finger stiffness is a common complication following hand trauma or surgery. Early finger range-of-motion (ROM) exercises have proven to be the most effective method for preventing finger stiffness. In this paper, we introduce a novel finger brace designed for safe and early active exercises and present preliminary results from a small case series.Methods: Our innovative brace is designed for direct insertion into the finger, ensuring enhanced comfort during use. This brace features hinges that facilitate unrestricted movement in the proximal and distal interphalangeal joints, with each phalangeal component having a rounded shape to prevent rotation. Furthermore, grooves are integrated at the top of the phalangeal components for inserting bars; a straight bar to immobilize and a silicone band to provide elastic resistance exercises within a limited range.Results: Among 26 patients, 17 presented with fractures, five had extensor tendon injuries, and three had dislocations. For patients not requiring surgery, we applied the brace as early as possible. In cases involving surgery, the brace was applied step by step. When fixation was necessary for the first time, a straight bar was applied, and when starting finger movement, a silicone band was applied. The silicone band was then released to allow free finger movement. Except for one patient necessitating extensor tendon reconstruction due to a neglected rupture, all patients achieved full ROM without any complications.Conclusion: Our novel ROM finger brace represents a safe and user-friendly option for effectively initiating finger ROM exercises.

Wide-Awake Local Anesthesia No Tourniquet Surgery for Zone VII Extensor Tendon Reconstruction: Stages in Active Range of Motion From Intraoperative to Final Recovery

We investigated chronological changes in active range of motion (ROM) of the metacarpophalangeal (MCP) joint after zone VII extensor tendon reconstruction with wide-awake local anesthesia no tourniquet (WALANT) surgery. Reconstruction of the extensor tendons ruptured in zone VII of 82 fingers in 40 patients was performed using WALANT techniques. The mean patient age was 71.3 years. During surgery, we evaluated passive stretch distance and active contraction distance of the ruptured musculocutaneous unit. The sum of passive stretch distance and active contraction distance was defined as total excursion. In cases with total excursion ≥30 mm, we selected bridge tendon grafting for tendon reconstruction. In cases with total excursion <30 mm, end-to-side tendon transfer was performed. Active ROM of the MCP joint was measured before surgery; during surgery; 1, 3, and 5 months after surgery, and at the final follow-up. Extension lag of the MCP joint was 49.2° before surgery, improving to 2.9° during surgery, deteriorating to 18.7° at 1-month, and improving again to 15.6° at 3-months, 13.6° at 5-months, and 10.5° at the final follow-up. Meanwhile, the active flexion angle of the MCP was 87.9° before surgery, 87.3° during surgery, 67.6° at 1-month, 76.0° at 3-months, 79.7° at 5-months, and 81.0° at the final follow-up. Extension and flexion angles at each time point remained nearly constant regardless of whether tendon grafting or tendon transfer was used. Extensor tendon reconstruction using WALANT surgery allowed intraoperative measurement of active ROM, confirming near-complete extension and flexion after reconstruction. The changes in ROM of the MCP joint during follow-up are an approximate indication of the progression of postoperative recovery. Therapeutic Ⅳ.

Relative Motion Extension Splint after Extensor Tendon Reconstruction

Recently, the wide-awake local anesthesia no tourniquet (WALANT) technique and relative motion extension (RME) splint changed practice in extensor tendon reconstruction and therapy. We wanted to share our approach for zones 5 to 8 extensor tendon management following the up-to-date developments. The impacts of surgery under WALANT and early active motion therapy with RME splinting were explained frankly and shown in several videos throughout the article.

EARLY ACTIVE MOBILIZATION AFTER RECONSTRUCTION OF RUPTURED FINGER EXTENSOR TENDONS AT THE WRIST JOINT

Background: Subcutaneous spontaneous ruptures of the finger extensor tendons at the wrist frequently occur. This study aims to evaluate the outcomes of patients with extensor tendon ruptures treated by our operative methods and postoperative early active mobilization. Methods: A total of 38 patients with 68 extensor tendon ruptures were included in this study. In the reconstruction of extensor tendon ruptures, tendon transfers (extensor indicis proprius (EIP) tendon transfer and/or interlacing end-to-side suture) and/or free tendon bridge graftings were performed. Immediately after operation in all patients, early active mobilization began by wearing a specially designed bandage or splint. Results: There was no reoccurrence of re-rupture of a tendon post surgery. A patient satisfaction survey revealed that 29 patients rated their results as “excellent” and 9 were “good.” Postoperatively, the active range of motion of the finger metacarpophalangeal (MP) joint averaged +3∘(range:- 14[Formula: see text]+20∘) in extension and 69∘(range: 60–80∘) in flexion. Conclusions: We treated finger extensor tendon ruptures by tendon transfer (EIP tendon transfer to the ruptured extensor tendon and/or interlacing end-to-side suture) and/or bridge tendon grafting. We employed early active mobilization with patients wearing a specially designed bandage or splint immediately after reconstructing surgery. There was no case with re-rupture postoperatively. Our operative techniques and postoperative physiotherapy as early active mobilization in this study led to excellent results after finger extensor tendon ruptures.

Delayed reconstruction of a missed Extensor Pollicis Brevis and Abductor Pollicis Longus injury using tendon transfers and an onlay tendon graft: a case report

Delayed presentation of extensor tendon injury comes with unique challenges due to retraction of tendons, adhesions and problems of disuse of the muscles. We present a case report of tendon reconstruction eight months after a sharp injury to the Extensor Pollicis Brevis (EPB) and Abductor Pollicis Longus (APL) tendon in zone VIII. The EPB was reconstructed by using an Extensor Indicis Proprius (EIP) to EPB transfer. The APL was found slack due to a large section of pseudotendon. After tenolysis the proximal tendon stump of the EPB was sutured to the APL, thus combining the impaired EPB and APL muscles for APL function. The slack section of pseudotendon of the APL was plicated to restore tension and reinforced with an onlay tendon graft (left-over from the EIP transfer). Outcomes were excellent. This is the first publication to discuss delayed repair of a combined EPB and APL injury and gives insights into the anatomical and biomechanical balance of the thumb extensors. • Delayed reconstruction of tendons is challenging due to retraction of tendons, adhesions and problems of disuse of muscles. • This is the first case report published on delayed repair of a combined APL and EPB injury. • EIP to EPB transfer is a good option for EPB reconstruction. • EIP transfer for extensor tendon reconstruction in zone VII/VIII offers surplus tendon to be used as a separate tendon graft.

An overview of mallet finger injuries.

Mallet finger describes a fingertip deformity where the distal interphalangeal joint (DIPJ) of the affected digit is held in flexion, unable to extend the distal phalanx actively. The deformity is typically a consequence of traumatic disruption to the terminal extensor tendon at its insertion at the proximal portion of the distal phalanx or slightly proximally at the level of the DIPJ. Patients typically present with a history describing the event of injury with a typical mallet deformity. Common mechanisms include sport activities causing a direct blow to the finger, low energy trauma while performing simple tasks such as pulling up socks or crush injuries from getting the finger trapped in a door. The DIPJ can be passively extended, but this extension of the joint cannot be maintained once the passive extension is stopped. The Doyle classification can be used to categorise and dictate treatment. The extensor lag associated with the deformity does not improve spontaneously without treatment. Inappropriate management can lead to chronic functional loss and stiffness of the finger. The majority of closed mallet splints are Doyle type I, which can be managed non-surgically with external splints, worn full-time to keep the fingertip straight until the tendon injury or fracture heals. Surgical techniques is considered for other types of mallet injuries. Techniques used include closed reduction and Kirschner wire fixation, open reduction and internal fixation, reconstruction of the terminal extensor tendon and correction of swan neck deformity. (www.actabiomedica.it)

Closed percutaneous reduction and minimally invasive treatment of spastic hammery deformity

Objective: To investigate the efficacy of percutaneous extensor tendon reconstruction in treating spastic hammery deformity. Methods: From February 2009 to July 2018, the clinicaldata of 36 patients with fresh sputum hammer fingers treated in Jinan People's Hospital were analyzed retrospectively. The tendon was percutaneously sutured with PDS Ⅱmonofilament suture and the distal end of the tendon was fixed to the base of the distal phalanx through the bone hole. Removal of the K-wire 6 weeks after the operation, the brace was used to fix the affected finger in the dorsal extension. For 8-10 weeks, only the brace was worn at night and the flexion and extension of the affected finger was gradually strengthened.The extension and flexion function of the interphalangeal joint of the finger was compared pre and post the operation with t test. Results: A total of 36 patients were enrolled but only 33 patientswere followed up for 6 to 15 months. The hammer-shaped deformity was corrected and there was no pain when moving fingers after the operation.The straightening angle of the interphalangeal joint of the finger improved from 46.2°±6.3° before surgery to 7.5°±0.6° after (t=35.12, P<0.05). The passive straightening angle decreased from 3.2°±0.3° before surgery to 0.9°±0.2° after (t=37.11, P<0.05). According to the Crawford functional assessment: excellent in 19 fingers, good in 10 fingers, can be in 4 fingers. The excellent rate was 87.9%. There was no knot exposure, skin necrosis and other complications. Conclusions: Percutaneous resection of the extensor tendon is fixed in the basal phalanx. It is a simple and feasible minimally invasive surgery for hammer-shaped deformity. It can obviously correct the hammer-shaped deformity and has fewer complications.

Surgical solution and clinical outcome for an initially undertreated vaughan-jackson syndrome

Vaughan-Jackson syndrome was described as a progressive rupture of the hand's extensor tendons due to tendon attrition at the wrist. It is frequently associated with osteoarthritis and rheumatoid arthritis. We present a 75-year-old male patient with a painless limitation of the extension of the little finger of the left hand. Initially, he presented a palmar displacement of the left carpus while lifting a heavy object. Vaughan-Jackson syndrome was diagnosed. At first, an end-to-side repair of the affected tendons was performed. Four months later, the patient returned with spontaneous extension lag of the left little and ring fingers. A second surgery was performed with the transfer and reconstruction of extensor tendons with a favorable outcome. Vaughan-Jackson syndrome causes functional impairment and detriment to the quality of life; thus, it is imperative to make an accurate and early diagnosis. Surgical treatment must be done in a timely and appropriate manner. We aim to report the outcome of a patient with an initially undertreated Vaughan-Jackson syndrome, highlighting the necessity of comprehensive treatment of the underlying pathophysiology, to obtain a desirable outcome.

Microsurgical salvage of complex dorsal shearing injuries of the hand and wrist

Dorsal shearing injuries of the hand and wrist can be seen with high-energy motor vehicle accidents and present challenging problems to the reconstructive surgeon. At the time of initial injury, care must be taken to adequately debride the mangled extremity and extensive wounds. Following debridement, a series of decisions must be made regarding bony stabilization, extensor tendon reconstruction, and soft tissue coverage. These reconstructions often require staged procedures, and appropriate planning is warranted from the start. Reasonable function of the hand can be expected from the patient following such injuries.

Physiotherapy Following Extensor Tendon Reconstruction in Zone 5-A Case Study

Background: Extensor tendon attrition in Rheumatoid arthritis is very common and if not treated properly, can lead to substantial loss of hand function. Here we present the rehabilitation of a 45 years female patient following extensor tendon reconstruction in zone 5. Materials and Method: The motor assessment included examination of active range of motion, grip and pinch strength and hand function was done during first visit and at the end of 3rd week, 6th week and 12th week. The patient received physiotherapy (immobilization method) and the program was divided into three phases. Results: The test results were used to find the efficacy of immobilisation method, author’s modification of the program and home based exercises. There was 60 to 80 percentile of ROM improvement in wrist joint, 50 to 90 percentile of ROM improvement in digits .By comparing 6th week and 12th week DASH there was about 47% improvement in upper limb functional activities The results show that the management combined with a comprehensive rehabilitation programme and commitment on the part of the patient makes it possible to achieve satisfactory treatment out comes enabling a return to normal daily functioning Conclusion: The functional recovery achieved indicates the advisability of using immobilisation method in post-operative rehabilitation of patients with extensor tendon injury.

Practical Tips to Improve Efficiency and Success in Upper Limb Replantation.

After reading this article, participant should be able to: 1. Describe the technique of replantation for very distal amputation of the digit and salvage procedures for venous drainage. 2. Perform single-digit replantation after viewing the videos. 3. Recognize appropriate cases for joint salvage techniques in periarticular amputation at each joint of the digit and wrist. 4. Outline the methods of flexor and extensor tendon reconstruction in an avulsed amputation of the digit or thumb. 5. Understand the order of digital replantation and transpositional replantation for a restoration of pinch or grip in multiple-digit amputation. This article provides practical tips and caveats for the latest replantation surgical techniques for digit, hand, and upper extremity amputation. Four videos, clinical photographs, and drawings highlight important points of operative technique and outcomes of replantation.

Review of the optimal timing and technique for extensor tendon reconstruction in composite dorsal hand wounds

Aim: The management of complex dorsal hand wounds with extensor tendon loss is controversial. Treatment has focused on soft tissue coverage, but there is limited evidence comparing immediate vs. staged tendon reconstruction. This review evaluates existing literature to determine the optimal management of composite hand defects.

Clinical Results of Autogenous Palmaris Longus Tendon Graft for Ruptures of Multiple Extensors in Rheumatoid Hands

The purpose of this study was to evaluate the clinical outcome of autogenous palmaris longus grafting for extensor tendon ruptures of 2 or more fingers in rheumatoid hands and to identify the factors related to the clinical outcome. Between 2000 and 2013, a total 41 patients with advanced rheumatoid arthritis and multiple extensor tendon ruptures reconstructed with autogenous palmaris longus tendon grafts were reviewed. Extension lag at the metacarpophalangeal (MCP) joint, total active motion (TAM), and fingertip-to-palm (TTP) distance were evaluated at final follow-up. Simple regression analysis was done to determine the factors predictive of clinical outcome. The mean extension lag at the MCP joint of the reconstructed finger was 9° (range, 0°-90°; median, 0°). The mean TAM was 239° (range, 85°-280°; median, 260°), and the mean TTP distance was 5 mm (range, 0-50 mm; median, 0 mm). Simple regression analysis showed that only age was related to extension lag at the MCP joint and only arthritis of the MCP joint was related to TAM. In rheumatoid arthritis, extensor tendon reconstruction of multiple extensor tendon ruptures using autogenous palmaris longus tendon graft is a viable option to achieve a favorable clinical result. Therapeutic IV.

Multiple extensor tendons reconstruction with hamstring tendon grafts and flap coverage for severe dorsal hand injuries

Treatment of patients with traumatic loss of skin and multiple extensor tendons on the dorsum of the hand is a challenge. The aim of this study was to assess the outcome after reconstruction of soft tissues and multiple extensor tendons in patients who suffered traumatic loss of skin and multiple extensor tendons. Ten patients were enrolled in the study. These patients underwent single-stage reconstruction with autogenous hamstring tendon grafts for multiple extensor tendon defects and fasciocutaneous flaps for coverage of dorsal hand defects. In total, 25 tendons (2 tendons in 5 patients and 3 tendons in 5 patients) were reconstructed. The semitendinosus tendon was used in all patients and the gracilis tendon was added in five patients for tendon reconstruction. Total tendon length requiring reconstruction was between 9cm and 31cm. Free anterolateral thigh flaps were used in six patients and reverse pedicled forearm flaps were used in four patients. According to Miller's scoring system, 8 fingers had excellent results, 12 fingers had good results and 5 fingers had fair results at the final follow-up. Hamstring tendons can be used satisfactorily for primary reconstruction of multiple digital extensor tendons due to their availability and compatibility, with a fasciocutaneous flap. Level of evidenceIV.

Single stage soft tissue and extensor tendon reconstruction of upper extremity with antero-lateral thigh free flap- A case report

Soft tissue coverage for traumatic soft tissue loss of upper extremity is challenging with limited local tissues availability. Hence, free tissue transfer is indicated. A patient presented to us with degloving injury of the right dorsum hand and forearm following a road traffic accident. There was large soft tissue defect on the dorsal lateral aspect of the hand and forearm, open comminuted fracture of distal end radius with segmental loss of extensor tendons. After adequate debridement and fracture stabilization with external fixator, soft tissue and extensor tendon reconstruction were performed with conjoined flow-through anterior-lateral thigh and tensor fascia lata free flap. At postoperative three months, there was non union of the distal end of right radius. Flap was re-elevated and non union was corrected with osteotomy, non vascularized bone graft and locking plate. Subsequently, at 1 year follow up revealed limited range of movement at wrist joint (flexion-extension 15 degree), acceptable at metacarpophalangeal of all fingers (hyperextension 15 degree, flexion 60 degree) and interphalangeal joints (PIP joint extension- flexion 0-45 degree, DIP joint extension-flexion 0-15 degree). Hand grip was weak and requires further hand therapy. Anterior lateral thigh flap is a versatile and reliable option for reconstruction of large soft tissue and composite defects of upper extremity with favourable outcome.

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

Extensor Tendon and Coverage Reconstruction of Soft Tissue Defect in a Case of Trauma to Dorsal Hand

: A case of soft tissue defect of dorsal hand due to crush injury in a 37-year-old female is reported here. The reconstructive surgery was performed for the hand soft-tissue defect. Among different flaps used in the surgery, the regional flap such as radial forearm flap can be done. But usually it is not accepted by patient because of cosmetic appearance. Therefore, random pattern abdominal flap and extensor tendon reconstruction were done concurrently.

The juncturae tendinum flap: An alternative method for the reconstruction of extensor tendon defects

Extensor tendon injuries are common conditions because these tendons are located in less protected anatomical locations compared to flexor tendons. Extensor tendons are linked on the dorsum of the hand by cross-connexions, called juncturae tendinums, or intertendinous connexions. Several methods for extensor tendon reconstruction have been reported in the literature. To the best of our knowledge, tendon reconstruction incorporating the juncturae tendinum has not been previously reported. Here we describe the use of the juncturae tendinum flap for the reconstruction of extensor tendon defects on the dorsum of the hand. A simple, one stage, minimally invasive procedure is reported that preserves the option of performing other potentially necessary reconstruction methods for repairing tendon defects.