Smooth Gliding Surface Research Articles

A Simple and Inexpensive Management for Peroneus Longus Dislocation

Introduction:Peroneal longus dislocation is an uncommon sports injury and commonly misdiagnosed. Imaging measure includes plain radiography, ultrasonography, and MRI examination. Treatment strategies include controversial nonoperative treatment with a significant failure rate and several surgical procedures were reported. We reporting a chronic peroneal longus dislocation case in our hospital.Material and methods:Twenty-two years old male presented with a painful snapping lateral ankle suffered 3-month prior surgery. He played futsal and suddenly he felt popped on his ankle followed by pain and swelling. Dynamic ultrasound examination shows dislocation of peroneal longus tendon and convex shape of the retromalleolar groove. A five-centimeter long incision is made posterior to the lateral malleolus and during exploration we confirmed the ultrasound findings. We perform retromalleolar groove deepening by making bone flap medially, curette the cancellous bone and tamper back the bone flap, followed by superior peroneal retinaculum (SPR) reconstruction to the medial aspect of lateral cortex of the lateral malleolus to provide smooth gliding surface. We immobilize the ankle with a cast for six weeks for soft tissue healing.Result:After six weeks he can perform the almost full range of motion of the ankle without pain. Followed by further physiotherapy to regain full range of motion of the ankle. He returns to sport six months after surgery. Ultrasound examination shows the stability of the peroneal longus tendon.Conclusion:Dynamic ultrasound examination and retromalleolar groove deepening with SPR reconstruction are simple and inexpensive management for peroneal longus dislocation

Subcutaneous Ulnar Nerve Transposition Using Osborne's Ligament as a Ligamentodermal or Ligamentofascial Sling.

The ulnar nerve is most commonly compressed at the elbow in the cubital tunnel. Conservative and operative treatments have been applied for cubital tunnel syndrome. Surgical management options include decompression, medial epicondylectomy, and various anterior transposition techniques. We describe a novel technique of anterior transposition of the ulnar nerve by using Osborne's ligament as a sling to avoid subluxation. Osborne's ligament is incised posteriorly and medially on the olecranon to create a sling with 2 to 3 cm width. The sling is tailored to wrap around the ulnar nerve and attached to the flexor-pronator fascia or dermis to create a smooth gliding surface without causing compression. Ten patients with cubital tunnel syndrome, established by physical examination findings and electromyography/nerve conduction studies underwent ulnar nerve transposition using this technique and were able to participate in a phone survey. The average follow-up was 15.6 months (range, 4-28 months). The average time to become subjectively "better" after surgery was 4.2 weeks. The pain intensity was reduced from an average of 7.5 preoperatively to <1, on a 10-point scale, at the time of the survey. All patients had symptomatic relief without any complication. The proposed technique using Osborne's ligament as a ligamentofascial or ligamentodermal sling offers a unique way of creating a non-compressive sling with the component of the cubital tunnel itself and has an additional benefit of creating a smooth gliding surface for early return of function.

Tissue Expansion

Tissue expansion in the upper extremity is a valuable technique with expanding indications and expected outcomes. The primary indications are coverage problems after trauma, but the technique is also applicable to defects caused by treatment of hemangioma, nevi, tattoos, or hypertrophic scars as well as correction of unstable tissue or as an alternative to free tissue transfer. The advantage of expansion-specifically, match in tissue texture and retention of sensibility-may be more important in the hand and upper extremity than in other areas. The inevitable capsule that forms around the expander does provide a smooth gliding surface for tendons in the forearm and wrist. In conclusion, tissue expansion of the upper extremity offers the surgeon the ability to improve cosmesis in one location without having to sacrifice cosmesis at a second site.

Histology of the extensor retinaculum of the wrist and the ankle.

The extensor retinaculum of the wrist has been used for reconstruction of the annular pulleys of the flexor sheath. We examined the histologic structure of the extensor retinaculum and tendon sheath of the wrist and ankle in cadaveric specimens using hematoxylin-eosin and Verhoeff-van Gieson stains to detect elastin and alcian blue to detect hyaluronic acid, comparing the structure with that described previously for the annular pulleys. Three distinct layers are identified in the retinaculums of both the ankle and wrist: the inner gliding layer, with hyaluronic acid-secreting cells, shows isolated chondroid metaplasia; the thick middle layer contains collagen bundles, fibroblasts, and interspersed elastin fibers; and the outer layer consists of loose connective tissue containing vascular channels. This basic 3-layered histologic composition of the extensor retinaculum is carried in anatomic pulleys throughout the body and appears to represent an adaptive mechanism to provide both a smooth gliding surface as well as the mechanical strength to prevent tendon bowstringing. Given the same histologic structure as the annular pulleys, the extensor retinaculum is a reasonable biologic replacement for the reconstruction of deficient annular pulleys. Likewise, the extensor retinaculum of the ankle could be used to reconstruct a deficient retinaculum of the wrist.

Flexor Tendon Injuries: II. Operative Technique.

The repair of flexor tendons (zones I and II) is a technique-intensive surgical undertaking. It requires a strong understanding of the anatomy of the tendon sheath and the normal relationship between the pulleys and the flexor digitorum superficialis and flexor digitorum profundus tendons in the digit. Meticulous exposure, careful tendon retrieval, and atraumatic repair are extremely important, and the repair should be of sufficient strength to resist gapping and permit the early postrepair application of motion forces. Whenever possible, the tendon sheath should be preserved or repaired, and a smooth gliding surface should be reestablished. The author describes an effective method of tendon retrieval and a simplified technique for a four-strand tendon repair with a supplementary peripheral running-lock suture. The repair is considered to maintain sufficient strength throughout healing to allow a postrepair rehabilitation protocol that will impart passive and modest active stress forces to the repaired tendons. Complications include tendon rupture, digital joint flexion contractures, and adhesions that restrict tendon gliding and ultimately necessitate tenolysis.

Fetal Tendon Healing

An experimental model was developed to study the process of fetal tendon healing. The flexor digitorum profundus tendons of the right hindlimb of 14 fetal lambs were partially lacerated at 100 days' gestation (term 145 days) and then studied macroscopically and histologically at several postinjury intervals (2, 4, 7, 14, 28, 42, and 56 days); two lambs were studied at each interval. A similar procedure was done in 14 adult sheep, who served as a control group. The fetal lambs showed no subcutaneous scarring, the digital sheath and tendon healed 2 weeks after injury, and a smooth, gliding surface was reconstituted. Collagen fibers were randomly arranged at 1 week but became organized along the tendon axis by 2 weeks. No adhesions, ruptures, or triggering was noted in the healing fetal tendons. Normal morphology was restored by 6 weeks. In the adult, dense subcutaneous scarring was noted, the digital sheath healed by 4 weeks and the tendon gap by 6 weeks, but a smooth gliding surface was not restored. Collagen fibers were randomly arranged at 2 weeks and became organized along the tendon axis by 4 weeks after injury. There were no dense adhesions or ruptures, but 25 percent of the tendons showed triggering.

Fibrin sealant in prevention of flexor tendon adhesions: An experimental study in the rabbit

The effect of fibrin sealant on the development of adhesions in flexor tendon surgery was studied in both immobilized and active weight-bearing paws of rabbits. A partial laceration was produced and was treated with sutures alone or with both sutures and glue. Immobilized tendons treated in these ways showed no difference in adhesion formation, but in mobile tendons there was a difference at 6 weeks in gross appearance, scanning electron micrographic appearance, and strength of adhesions as measured when the distally cut tendon was pulled out of its sheath. These observations indicate that, after repair, a mobile flexor tendon heals with a smooth gliding surface and without formation of restricting adhesions when treated with fibrin glue around the suture site.

Flexor tendon healing.

Significant changes in the concepts of tendon physiology and tendon healing have occurred in the last decade. Nevertheless, they reflect questions and controversies which date back many hundreds of years. Investigators and clinicians of today must recognise that, like their predecessors with an interest in flexor tendon surgery, they will contribute to the understanding of this very important structure, but they also will leave unanswered questions for future generations. The current interest in methods to prevent or modify adhesions is based on the presumption that the tendon can participate in the repair process. In this regard, it would be inappropriate to ignore the potential contribution by peripheral cellular elements as well. Surgeons may have moved on from the concept that pricking the tendon causes pain, twitching, and convulsions, but they have not yet clearly defined the repair process and how to consistently obtain healing of a lacerated tendon with a smooth gliding surface.

Clinical applications of free temporoparietal flaps in hand reconstruction

Vascularized temporoparietal fascia can be used to cover deficits up to 14.0 X 12.0 cm in the hand or fingers. The tissue is thin, pliable, and has a smooth gliding surface advantageous to tendon function. Through scalp incisions, with meticulous yet straightforward dissection, this fascia can be isolated as a vascular island based on the superficial temporal artery system. Vessels are large and the anatomy is constant. Technique and clinical applications are discussed in detail.

Intrinsic restoration of the flexor tendon surface in the nonhuman primate

A pattern of restoration of the smooth gliding surface was noted in lacerated monkey flexor tendon segments maintained in a cell free tissue culture environment over a 9-week period. The epitenon fibroblasts proliferated and migrated into the laceration site, forming collagen fibers that bridged the defect. After the smooth tendon surface was restored, the epitenon cellular response diminished.