Flexor Digitorum Profundus Injuries Research Articles

What's New in Hand and Wrist Surgery.

What's New in Hand and Wrist Surgery.

A Comparison of Outcomes at Twelve Weeks of Traditional Button-Over-Nail versus Bone Anchor Repair of Zone I Flexor Digitorum Profundus Tendon Injury.

Background: The repair of zone 1 flexor tendon injury often relies on re-inserting the flexor digitorum profundus (FDP) tendon to the distal phalanx. The aim of this retrospective study is to compare outcomes at 12 weeks following traditional button-over-nail (BON) versus bone anchor (BA) repair of zone I FDP injury. Methods: Patients undergoing zone 1 FDP repair between April 2007 and September 2018 using a BON or a BA were included in the study. Patient demographics, complications, arc of flexion of distal (distal interphalangeal joint [DIPJ]) and proximal interphalangeal joint (PIPJ) and patient-rated outcomes were analysed. Results: Forty-three patients were included in the study: 21 in the BA group and 22 in the BON group. Good function was achieved by 20 patients in BA versus nine in BON. Complications occurred in five BA patients versus 10 BON patients. Patients achieved a mean active DIPJ flexion of 49° and 31° and PIPJ flexion of 92° and 57° in the BA and BON groups, respectively. Conclusion: Our study demonstrates better arc of motion, patient-rated outcomes and lower complications at 12 weeks after surgery in patients undergoing zone 1 FDP repair using a BA. Level of Evidence: Level III (Therapeutic).

Secondary Procedures following Flexor Tendon Reconstruction.

After studying this article, the participant should be able to: 1. Understand the indications and management options for secondary flexor tendon reconstruction, including tenolysis, tendon grafting, and tendon transfers. 2. Understand the reconstructive options for pulley reconstruction. 3. Understand the options for management of isolated flexor digitorum profundus injuries. Despite current advances in flexor tendon repair, complications can still occur following surgery. This article presents the spectrum of treatment options for secondary flexor tendon reconstruction ranging from tenolysis to one- and two-stage tendon grafting, and tendon transfers. In addition, an overview of pulley reconstruction and the treatment of isolated flexor digitorum profundus injuries are discussed. A management algorithm for secondary flexor tendon reconstruction is provided.

Does Digital Nerve Injury Affect Range of Motion Recovery After Zone 2 Flexor Tendon Repair?

Evidence surrounding the impact of concomitant digital nerve injury on the outcome of zone 2 flexor tendon repair is sparse and conflicting. The purpose of this study is to assess the impact of digital nerve injury on the range of motion recovery after zone 2 flexor tendon repair. We hypothesized that digital nerve injury is independently associated with decreased motion after zone 2 flexor digitorum profundus (FDP) repair. This is a single-institution, multisurgeon retrospective analysis of patients treated with primary zone 2 FDP repair. Patients with or without digital nerve injuries were included. Patients with fracture, extensor tendon injury, dysvascularity, follow-up duration of less than 10 weeks, and younger than 15 years were excluded. The primary outcome measure was Strickland percentage at the last therapy visit. Bivariate analysis was performed using simple linear regression. These results were used to guide backward stepwise multivariable analysis of qualifying exploratory variables. Forty-one patients with a total of 54 zone 2 FDP injuries qualified. Mean follow-up duration was 24 ± 10 weeks, and mean age was 38 ± 18 years. Thirty-three digits had a concomitant digital nerve injury, 26 digits had multidigit involvement, and 42 digits had combined FDP and flexor digitorum superficialis (FDS) injuries. Both older age and concomitant FDS injury exhibited independent relationships with poorer range of motion outcomes (P < .05). Digital nerve injury, follow-up duration, gender, and multidigit involvement did not influence final digital motion. In patients undergoing zone 2 FDP repair, concomitant digital nerve injury is not independently associated with poorer postoperative active range of motion.

Avance tendinoso no convencional para lesiones en las zonas I y II de Verdan. Nueva técnica quirúrgica

Objetivo: Presentar una nueva técnica quirúrgica y los resultados clínicos comparativos de pacientes con roturas de tenorrafia primaria o lesiones crónicas del flexor profundo en las zonas I y II de Verdan, tratados con avance tendinoso no convencional. Materiales y Métodos: Se incluyó a pacientes &gt;18 años, con antecedente de lesiones en las zonas I y II de Verdan y un seguimiento mínimo de 36 meses. La serie estaba formada por 13 pacientes (edad promedio 29 años) que fueron divididos en dos grupos según el tipo de lesión (7 con roturas de tenorrafia primaria y 6 con lesiones crónicas del flexor profundo) y la técnica quirúrgica utilizada (alargamiento en Z más sutura término-terminal y sutura lateral del tendón alargado a un flexor vecino indemne en la zona V, respectivamente). Se empleó la Clasificación de Strickland para la evaluación. Resultados: El seguimiento promedio fue de 51 meses. El intervalo promedio entre la lesión y la cirugía fue de 11.7 semanas. Según la Clasificación de Strickland, 8 pacientes tuvieron resultados excelentes; 4, buenos y uno, pobre. El avance tendinoso promedio fue de 20,5 mm en ambos grupos. Conclusiones: El avance tendinoso no convencional para lesiones en las zonas I y II de Verdan, sea en roturas de tenorrafia primaria o lesiones crónicas del flexor profundo, resultó un tratamiento reproducible y eficaz. Palabras clave: Tendón flexor; alargamiento; zetaplastia.Nivel de Evidencia: III

Complications Following Transosseous Repair of Zone I Flexor Tendon Injuries

Multiple techniques are described for repair of zone I flexor tendon injuries, many of which are fraught with complications. This study evaluated the clinical complications after a transosseous repair technique. A retrospective review of a single institutional database identified all zone I flexor digitorum profundus (FDP) injuries repaired using a transosseous technique. In this technique, 2 nonabsorbable sutures were passed from volar to dorsal through transosseous tunnels and tied dorsally over the distal phalanx proximal to the germinal matrix. Demographics, injury characteristics, operative details, and complications were reviewed. Eight patients met the inclusion criteria. Average age was 31 years (range, 15-66 years) and all patients were male. Eight fingers were included: ring (4), small (3), and middle (1). Seven injuries were closed and one was open. Average time between injury and surgery was 13 days (range, 4-34 days). Five patients experienced complications, including osteomyelitis, chronic draining granuloma, and abnormal nail growth. Three patients required an additional operative procedure for management of complications. Transosseous repair of zone I flexor digitorum profundus injuries with a buried dorsal suture is associated with a high rate of clinical complications. Therapeutic V.

Prognostic factors for digital range of motion after intrasynovial flexor tendon injury and repair: Long-term follow-up on 273 patients treated with active extension-passive flexion with rubber bands

Study DesignObservational cohort study. IntroductionInvestigating prognostic factors using population-based data may be used to improve functional outcome after flexor tendon injury and repair. Purpose of the StudyThe aim of this study is to investigate the effect of concomitant nerve transection, combined flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) tendon transection and the age of the patient, on digital range of motion (ROM) more than 1 year after FDP tendon transection and repair in zone I and II. MethodsTwo hundred seventy-three patients with a total of 311 fingers admitted for FDP injury in zone I and II were treated with active extension-passive flexion with rubber bands and followed for at least 1 year. We compared outcome by evaluating digital mobility using Strickland's evaluation system. ResultsAt 12 months 72% of patients aged > 50 had fair or poor ROM compared to 17% of patients aged 0-25 years. At 24 months the results for patients aged > 50 had improved to 33% with fair or poor ROM, whereas no improvement had occurred for patients aged 0-25 (17% with fair or poor ROM). Concomitant nerve transection and FDS tendon transection had no negative effects on digital mobility. DiscussionAge above 50 was significantly associated with impaired digital ROM during the first year after flexor tendon injury and repair but not at 2 years follow-up. Concomitant nerve transection and combined transection of FDP and FDS do not affect digital mobility. ConclusionsOlder patients are likely to have a slower healing process and impaired digital ROM during the first year after surgery.

Sports Injury-Related Fingers and Thumb Deformity Due to Tendon or Ligament Rupture.

Background:Hand injuries are very common in sports, such as skiing and ball sports. One of the major reasons causing hand and finger deformity is due to ligament and tendon injury. The aim of this study was to investigate if the high-resolution 3T magnetic resonance imaging (MRI) can demonstrate the complex anatomy of the fingers and thumb, especially the tendons and ligaments, and provide the accurate diagnosis of clinically important fingers and thumbs deformity due to ligamentous and tendinous injuries during sport activities.Methods:Sixteen fresh un-embalmed cadaveric hands were harvested from eight cadavers. A total of 20 healthy volunteers' hands and 44 patients with fingers or thumb deformity due to sports-related injuries were included in this study. All subjects had MR examination with T1-weighted images and proton density-weighted imaging with fat suppression (PD FS) in axial, coronal, and sagittal plane, respectively. Subsequently, all 16 cadaveric hands were sliced into 2-mm thick slab with a band saw (six in coronal plane, six in sagittal plane, and four in axial plane). The correlation of anatomic sections and the MRI characteristics of tendons of fingers and the ulnar collateral ligament (UCL) at the metacarpal phalangeal joint (MCPJ) of thumb between 20 healthy volunteers and 44 patients (confirmed by surgery) were analyzed.Results:The normal ligaments and tendons in 16 cadaveric hands and 20 volunteers' hands showed uniform low-signal intensity on all the sequences of the MRI. Among 44 patients with tendinous and ligamentous injuries in the fingers or thumb, 12 cases with UCL injury at MCPJ of the thumb (Stener lesion = 8 and non-Stener lesion = 4), 6 cases with the central slip injury, 12 cases with terminal tendon injury, and 14 cases with flexor digitorum profundus injury. The ligaments and tendons disruption manifested as increased signal intensity and poor definition, discontinuity, and heterogeneous signal intensity of the involved ligaments and tendons.Conclusions:Sports injury-related fingers and thumb deformity are relatively common. MRI is an accurate method for evaluation of the anatomy and pathologic conditions of the fingers and thumb. It is a useful tool for accurate diagnosis of the sports-related ligaments and tendons injuries in hand.

Flexor pollicis longus reconstruction using the “demi-tendon” technique

We report the case of a delayed flexor pollicis longus tendon rupture post distal radius fracture and its reconstruction using the “demi-tendon” technique. This technique has been well described in relation to delayed closed flexor digitorum profundus injuries as a method to facilitate primary repair. In this instance, it is a novel application of the technique which, to date, has not been described as a method of primary tennorrhaphy for a closed rupture of the flexor pollicis longus tendon. Level of Evidence: Level V, therapeutic study.

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To describe in a cadaveric model a tenodesis procedure for restoring distal interphalangeal joint flexion in patients with unrepairable isolated flexor digitorum profundus (FDP) injuries.In 16 fresh-frozen cadaveric fingers, the FDP tendon was transected 1 cm proximal to its insertion to simulate an isolated zone I laceration. The injury was reconstructed using a palmaris longus tendon graft to create a mechanical linkage between the interphalangeal joints, which restored coordinated interphalangeal joint flexion. Joint motion and the force required to flex and extend the fingers were tested before and after the tenodesis.After FDP zone I laceration, distal interphalangeal joint flexion with load applied to the flexor digitorum superficialis tendon averaged 2°. The FDP flexion increased to a mean of 57° after the tenodesis. The sum of metacarpophalangeal, proximal interphalangeal and distal interphalangeal joint flexion averaged 186° before the tenodesis and increased to 233° after the tenodesis. The force required to achieve fingertip to palm contact and the force required to fully extend the proximal interphalangeal joint were not altered.In this cadaveric model, this tenodesis successfully restored coordinated interphalangeal joint flexion after a simulated zone I FDP laceration with improvements in distal interphalangeal joint flexion and composite finger flexion. Critical factors such as the effects of inflammation, edema, soft tissue healing, and scar formation could not be evaluated and would likely affect the outcomes of this procedure. The in vivo results of this procedure are not known.The potential use of this tenodesis for treating unrepairable isolated zone I FDP injuries was demonstrated in a cadaveric model. Further investigation of the outcomes and complications in vivo would be required before routine clinical use.

Suturing of the flexor digitorum profundus tendon to the entire volar plate in distal zone I injuries

Purpose: The author conducted an anatomical and a prospective clinical study to address the technique and complications of using the entire volar plate (VP) as a distally-based flap for distal Zone I flexor digitorum profundus (FDP) tendon repair. Methods: In the anatomical study, eight fresh finger specimens were dissected to study the anatomy of the VP as well as the stability of the distal interphalangeal joint (DIPJ) after raising the entire VP as a distally-based flap. In the clinical series, six patients underwent repair of distal Zone I FDP lacerations using the VP flap technique and were assessed at a mean of 9 months for range of motion as well as DIPJ deformities. Results: The results of the anatomical study showed that the intact collateral ligaments can still maintain the stability of the DIPJ after loss of joint support from the VP. In the clinical series, none of the patients showed joint hyper-extension or flexion contracture at the DIPJ. Using Moiemen-Elliot criteria, the post-operative active range of motion at the DIPJ was rated as excellent in one, good in three, and fair in two patients. Conclusion: It was concluded that the use of the entire VP as a distally based flap is an acceptable technique to repair distal FDP injuries and the technique does not result in DIPJ instability or flexion contracture.

Flexor Digitorum Profundus Injury in a Newborn

Injuries of flexor digitorum profundus tendons in children are rare (Nietosvaara at all.), certainly in newborns. In this case report, we discuss the presentation, treatment and outcome of a profundus tendon injury of the fifth finger of a ten days old baby. The tendon injury in this case was caused by a knife cut, unrelated to cesarean sectio. To our knowledge, this is the first report about a flexor digitorum profundus injury and repair in a newborn of this age.

Tenodesis for Restoration of Distal Interphalangeal Joint Flexion in Unrepairable Flexor Digitorum Profundus Injuries

To describe in a cadaveric model a tenodesis procedure for restoring distal interphalangeal joint flexion in patients with unrepairable isolated flexor digitorum profundus (FDP) injuries. In 16 fresh-frozen cadaveric fingers, the FDP tendon was transected 1 cm proximal to its insertion to simulate an isolated zone I laceration. The injury was reconstructed using a palmaris longus tendon graft to create a mechanical linkage between the interphalangeal joints, which restored coordinated interphalangeal joint flexion. Joint motion and the force required to flex and extend the fingers were tested before and after the tenodesis. After FDP zone I laceration, distal interphalangeal joint flexion with load applied to the flexor digitorum superficialis tendon averaged 2°. The FDP flexion increased to a mean of 57° after the tenodesis. The sum of metacarpophalangeal, proximal interphalangeal and distal interphalangeal joint flexion averaged 186° before the tenodesis and increased to 233° after the tenodesis. The force required to achieve fingertip to palm contact and the force required to fully extend the proximal interphalangeal joint were not altered. In this cadaveric model, this tenodesis successfully restored coordinated interphalangeal joint flexion after a simulated zone I FDP laceration with improvements in distal interphalangeal joint flexion and composite finger flexion. Critical factors such as the effects of inflammation, edema, soft tissue healing, and scar formation could not be evaluated and would likely affect the outcomes of this procedure. The in vivo results of this procedure are not known. The potential use of this tenodesis for treating unrepairable isolated zone I FDP injuries was demonstrated in a cadaveric model. Further investigation of the outcomes and complications in vivo would be required before routine clinical use.

The Simple Transverse Intraosseous Phalangeal Suture for Zone 1 Flexor Digitorum Profundus Injuries

Zone 1 flexor digitorum profundus injury often precludes the use of a simple core suture as a result of a distal remnant that is too short. The aim of this study was to assess the senior author's (S.I.) simple technique for reinsertion of the flexor digitorum profundus tendon. The case series consisted of 12 patients who required a primary flexor digitorum profundus repair in zone 1, with all repairs performed by the senior author. A Bruner incision was extended to the pulp to expose the base of the distal phalanx. A two-strand repair was anchored to the distal phalanx using the author's technique, which involved passing a 3-0 polypropylene suture on a straight needle through a hypodermic needle that had been drilled through the base of the distal phalanx. This provided a stable, intraosseous, internal repair, allowing a standard early active mobilization regimen. Two patients had excellent results and 10 had good results in terms of distal interphalangeal joint range of movement (mean, 57 degrees; range, 51 to 80 degrees) and Quick Disabilities of the Arm, Shoulder and Hand questionnaire scores (mean, 12; range, 0 to 31.8). There were no reported tendon ruptures at the time of writing this article (range, 6 to 37 months after surgery). The authors present a technique for the repair of zone 1 flexor digitorum profundus injuries that is simple, can be performed quickly, is easily learned, and has results that compare favorably with other techniques in the literature. Furthermore, there is limited morbidity to surrounding fingertip structures. Therapeutic, IV.

Clinical Outcomes of Zone II Flexor Tendon Repair Depending on Mechanism of Injury

To determine whether mechanism of injury affects outcomes of Zone II flexor tendon repairs. We retrospectively analyzed patients who underwent Zone II flexor tendon repair between 2001 and 2010 with a minimum of 12-month follow-up. Exclusion criteria included fingers with fracture, pulley reconstruction, or flexor tendon bowstringing. The saw group injuries were from saws or from tearing mechanisms; the sharp group had clean transection injuries from knives or glass. At final evaluation, primary outcomes were total passive motion (TPM) and total active motion (TAM) at the proximal interphalangeal and distal interphalangeal joints. Secondary comparisons included strength, Disabilities of the Shoulder, Arm, and Hand (DASH) score, percentage of postoperative tendon rupture, and percentage of patients requiring secondary surgery. The saw group had 13 patients with 17 fingers studied. The sharp group had 21 patients with 24 fingers studied. All patients had primary flexor digitorum profundus repairs in Zone II. Operative records review confirmed for all but 1 patient that flexor digitorum profundus injuries were repaired with a minimum of a 4-strand core suture technique. In the saw group, 9 of 14 fingers with a 50% or greater laceration of flexor digitorum superficialis were repaired; in the sharp group, 15 of 18 such flexor digitorum superficialis injuries were repaired. Average follow-up was 4 years (range, 1-9 y). The saw group had significantly less TAM and TPM compared with the sharp group. There was no significant difference in DASH scores, strength measurements, or tendon rupture rates. The rate of secondary surgery was significantly higher in the saw group. Tearing types of injury, such as those caused by saws, led to poorer outcomes for Zone II flexor tendon injuries compared with sharp injuries at an average follow-up of 4 years. Our results can be useful when discussing expected outcomes. Mechanism of injury in Zone II flexor tendon lacerations may eventually help define optimal treatment.

Arthroscopic Distal Interphalangeal Joint Arthrodesis

Arthrodesis using a headless screw has been shown to be an effective surgical treatment for pain, deformity, or instability arising at the distal interphalangeal joint of the fingers or interphalangeal joint of the thumb. Previous publications have documented the utility of this treatment using open techniques. Common indications include degenerative, inflammatory, or posttraumatic arthritis and chronic mallet finger or chronic flexor digitorum profundus injury. The purpose of this study is to present an arthroscopic technique for arthrodesis of the distal interphalangeal joint of the fingers or interphalangeal joint of the thumb using the headless screw. The surgical technique is carefully outlined including surgical setup and necessary equipment. Potential technical difficulties and complications are also reviewed.