Superficial Flexor Tendon Research Articles

Surgical treatment of a bilateral superficial flexor tendon luxation

A two-year-old, male, neutered, crossbreed dog was presented to Anderson Moores Veterinary Specialists with a history of bilateral pelvic limb lameness. Right pelvic limb lameness was first noted 3 months prior to presentation. Right superficial digital flexor tendon tendinopathy and associated bursitis were diagnosed based on computed tomography scans performed by the referring veterinarian. Conservative management, consisting of analgesia and exercise restriction, did not resolve the clinical signs and referral was sought. At the time of presentation, left pelvic limb lameness of 1 week's duration was reported additionally by the owner. Clinical examination and imaging findings were consistent with bilateral superficial digital flexor tendon luxation. Surgical management consisting of relocation of the superficial digital flexor tendon into the central position of the calcaneal groove alongside a retinaculoplasty and calcaneoplasty was performed bilaterally. Half-cast dressings were placed on both pelvic limbs and were removed after 3 weeks due to mild soft tissue complications. The patient was cage rested for 5 weeks in total. The re-examination 8 weeks after surgical treatment revealed that the tendons remained stable and could not be manually luxated.

Comparative study of trimming and resection of diseased finger superficial flexor tendons in gouty carpal tunnel syndrome

BackgroundHyperuricemia can lead to synovial hyperplasia in the wrist. In severe cases, it can lead to the deposition of gouty stone in the carpal tunnel, resulting in increased pressure in the carpal tunnel and compression of the median nerve to cause carpal tunnel syndrome (CTS), which is called gouty carpal tunnel syndrome (GCTS). As for the surgical treatment of gouty carpal tunnel syndrome, scholars have different opinions on whether it is necessary to remove the superficial flexor tendon. The purpose of this study was to compare the clinical efficacy of trimming and resection of the diseased superficial flexor tendon in the treatment of gouty carpal tunnel syndrome.MethodsClinical data were collected from May 2016 to July 2021 from 10 patients (13 affected wrists) diagnosed with gouty carpal tunnel syndrome and classified into two groups according to the surgical modality: the diseased portion of the gout-eroded superficial finger tendon was trimmed in 9 wrists, and the diseased superficial finger flexor tendon was excised in 4 wrists. Values related to flexion and extension functions, 2-PD, DASH, BCTQ, VAS and recurrence in the affected fingers were compared between the two groups as well as before and after surgery in each group.ResultsAll affected limbs used were cleared of gouty stones, finger numbness improved, no skin necrosis occurred, and all incisions healed at stage I. At follow-up (13.58 ± 5.53 months), there was no significant difference between groups in flexion and extension function, 2-PD, DASH, BCTQ, and VAS with respect to the affected fingers, and patients in both groups improved significantly before and after surgery. Treatment of only one wrist involved trimming to remove lesion-affected portions of tendon, which reappeared 1 year after surgery, and there was one case of poor recovery from greater piriformis muscle atrophy in both procedures.ConclusionRegarding surgical treatment of patients with gouty carpal tunnel syndrome in which the gouty stone has invaded the superficial flexor tendons of the fingers, the diseased superficial flexor tendons can be selectively excised, and the postoperative mobility of the affected fingers may not be impaired.

Median nerve versus flexor tendons: visualization of median nerve level changes in the proximal carpal tunnel during wrist movement with dynamic high-resolution ultrasound.

The purpose of this prospective ultrasound study was to document dorso-palmar (vertical) displacement of the median nerve in relation to the superficial flexor tendons at the level of the carpal tunnel. Furthermore, the gliding patterns of the median nerve were characterized. The presence of vertical gliding was intended to serve as an additional bio-kinematic parameter of median nerve movement, and will be referred to as a 'level change'. In this study, a total of 32 healthy young individuals underwent dynamic high-resolution ultrasound examinations of both wrists. The neutral position, and maximum flexion and extension of the wrist had to be reached in active and passive movement. The gliding patterns were determined in relation to the superficial flexor tendons. When no vertical nerve gliding was observed, it was characterized as 'no level change'. The presence of a level change prevailed in the healthy young cohort and was observed in 84% (27/32) of individuals during wrist flexion. The following gliding pattern was distinctively the most common: gliding of the entire nerve in between the flexor tendons in active but not in passive movement of the right and left wrists (13/27; 48%). The extent of vertical displacement was found to be associated with the gliding pattern (Kruskal-Wallis test). Movement in the carpal tunnel allows the median nerve to adapt to biomechanical stress. Dynamic ultrasound can demonstrate median nerve level changes in response to wrist movements. Furthermore, a typical gliding pattern was characterized. The presence of level change and gliding patterns were proposed as additional movement parameters during wrist flexion in healthy individuals.

Ultrasound-guided percutaneous opening of the A1 pulley with surgical knife on anterograde versus retrograde approach: A comparative cadaver study (40 fingers)

ObjectiveTrigger finger is one of the most common pathologies of the finger flexor mechanism. Previous studies have shown the value of ultrasound-guided percutaneous tenolysis. The aim of this study was to compare the efficacy and safety of anterograde versus retrograde percutaneous ultrasound-guided tenolysis. Materials and methodsThis was a comparative cadaver study performed between December 2021 and April 2022 in France, with 40 fresh cadaver fingers. Thumbs were excluded. A single surgeon performed 20 ultrasound-guided anterograde releases and 20 ultrasound-guided retrograde releases, using a second-generation minimally invasive surgical knife, and a multipurpose linear ultrasound transducer. The primary endpoint was the success of ultrasound-guided release, defined as complete opening of the A1 pulley along its entire length. ResultsThe success rate was 90% in the retrograde group and 95% in the anterograde group (non-significant difference: p = 0.56). There was no significant difference in superficial flexor tendon slip injuries or partial A2 pulley injuries. There were no neurovascular pedicle lesions. ConclusionThe choice of anterograde or retrograde ultrasound-guided tenolysis should be left to the surgeon's discretion.

Giant Lipoma of the Hand: An Exceedingly Rare Condition!

Lipomas are the most common benign form of soft tissue tumor in the body. Although they are commonly found on the upper extremity, their occurrence in the hand is rare. Giant lipomas of the hand, defined as >5 cm in diameter, are extremely rare. This manuscript reports a very rare case of giant lipoma on the palmar side of the hand in order to study the diagnostic, theurapeutic and prognostic aspects. A 61 year-old female had a large asymptomatic thenar swelling since 10 years. The clinical examination showed a subcutaneous tumor spreading the 1st commissure and making opposition of the thumb very limited. There were no inflammatory signs and no pain. The patient didn’t report any sensory deficit and the neurological examination was normal. The standard X-ray showed a tissue image without bone lesions. MRI demonstrated a large, well-limited T1, T2 hypersignal tissue formation, which developed in the subcutaneous fat of the first commissure, insinuated itself in front of the last three metacarpals, and included the deep and superficial flexor tendons. The patient was operated on under local anesthesia and pneumatic tourniquet at the root of the limb. The approach allowed a satisfactory exposure of the entire palm of the hand and revealed a lipomatous mass, encapsulated, pushing back the vascular and neural pedicles of the long fingers without invading them and remaining in front of the flexor tendons. The tumor was carefully dissected, which allowed it to be removed totally. Histology confirmed the diagnosis of benign lipoma. Complete recovery was achieved without any sign of recurrence during a follow up period of 5 years. Lipomas of the hand represent a rare benign tumor pathology; giant lipomas represent an exceedingly rare condition. The proximity of the relationships with the vascular and neural structures must lead to the greatest caution during surgical dissection. Only anatomopathological examinations confirm the histological nature of the lesion.

Anatomical observation and CT three-dimensional reconstruction of Five-shu acupoints of Shaoyin Heart Meridian in rabbit's forelimb

To investigate the location and anatomical structure of "Shaochong"(HT9), "Shaofu"(HT8), "Shenmen"(HT7), "Lingdao"(HT4) and "Shaohai"(HT3) in the rabbit's forelimb. Sixteen rabbits (half male and half female) were used in the present study. By referring to the national standards on the location of acupoints in the human body and the literature about the location of acupoints in the rabbit, and by using the method of comparative anatomy, the location and needling operation of the Five-shu acupoints of Shaoyin Heart Meridian on the rabbit's forelimb were defined, and these acupoints were needled and CT three-dimensional reconstruction were conducted. Then, the rabbits were killed, and intravascular perfusion was performed, followed by inserting acupuncture needles into these five acupoints for observing the anatomical relationship between the inserted acupuncture needle and the structure of surrounding tissues. HT9 is located at the medial side of the little finger of forelimb, about 1 mm beside the nail root, and is adjacent to the superficial flexor tendon of the finger, the dorsal branches of the proper palmar digital artery and vein, and the endings of dorsal branch of palmar digital proper nerve of the ulnar nerve on the fifth finger side. HT8 is located at the palm side of the forelimb, horizontally parallel to the proximal end of the 5th metacarpophalangeal joint and between the 4th and 5th metacarpal bones, and is adjacent to the lumbricalis, the 4th and 5th interossei, and common palmar digital artery and vein and the palmar digital proper nerve of the ulnar nerve. HT7 is located at the medial margin of the extensor carpal tendon on the ulnar side, between the distal end of the ulna and the ulnar carpal bone, and is adjacent to the tendons of flexor carpi ulnaris and extensor carpi ulnaris, ulnar artery, ulnar vein and ulnar nerve. HT4 is located at the medial border of the ulnar flexor tendon, about 1.5 cun superior to HT7, and is adjacent to extensor carpi ulnaris, flexor carpi ulnaris, flexor digitorum superficialis, flexor digitorum profundus, ulnar artery, vein and ulnar nerve. HT3 is located at the depression, medial to the condyle of humerus when the elbow is bent at 90°, its neighbor structure is composed of pronator teres, biceps brachii, brachial artery and vein, radial collateral artery, radial collateral vein, medial antebrachial cutaneous nerve and median nerve. In the rabbit, there is a close relationship between HT9, HT8, HT7, HT4 and HT3 regions and brachial vascular and its branches, cephalic vein and its branches, medial antebrachial cutaneous nerve, median nerve and ulnar nerve, which is the morphological basis of the Five-shu acupoints of Shaoyin Heart Meridian for treating some related clinical disorders.

A Novel Low Air Pressure-Assisted Approach for the Construction of Cells-Decellularized Tendon Scaffold Complex.

The goal of this study was to develop a decellularized tendon scaffold (DTS) and repopulate it with adipose-derived stem cells (ADSCs) assisted by low air pressure (LP). The porcine superficial flexor tendons were processed into the DTSs using a combination of physical, chemical, and enzymatic treatments. The effectiveness of decellularization was verified by histological analysis and DNA quantification. The properties of the DTSs were evaluated by quantitative analysis of biochemical characterization, porosimetry, in vitro biocompatibility assessment, and biomechanical testing. Subsequently, the ADSCs-DTS complexes were constructed via cell injection assisted by LP or under atmospheric pressure. The differences in cell distribution, biomechanical properties, and the total DNA content were compared by histological analysis, biomechanical testing, and DNA quantification, respectively. Histological analysis confirmed that no cells or condensed nuclear materials were retained within the DTSs with widened interfibrillar space. The decellularization treatment resulted in a significant decrease in the content of DNA and glycosaminoglycans, and a significant increase in the porosity. The DTSs were cytocompatible in vitro and did not show reduced collagen content and inferior biomechanical properties compared with the fresh-frozen tendons. The assistance of LP promoted the broader distribution of cells into the adjacent interfibrillar space and cell proliferation in DTSs. The biomechanical properties of the scaffolds were not significantly affected by the recellularization treatments. A novel LP-assisted approach for the construction of cells-DTS complex was established, which could be a methodological foundation for further bioreactor and in vitro studies.

Culture and characterization of various porcine integumentary-connective tissue-derived mesenchymal stromal cells to facilitate tissue adhesion to percutaneous metal implants

BackgroundTransdermal osseointegrated prosthesis have relatively high infection rates leading to implant revision or failure. A principle cause for this complication is the absence of a durable impervious biomechanical seal at the interface of the hard structure (implant) and adjacent soft tissues. This study explores the possibility of recapitulating an analogous cellular musculoskeletal-connective tissue interface, which is present at naturally occurring integumentary tissues where a hard structure exits the skin, such as the nail bed, hoof, and tooth.MethodsPorcine mesenchymal stromal cells (pMSCs) were derived from nine different porcine integumentary and connective tissues: hoof-associated superficial flexor tendon, molar-associated periodontal ligament, Achilles tendon, adipose tissue and skin dermis from the hind limb and abdominal regions, bone marrow and muscle. For all nine pMSCs, the phenotype, multi-lineage differentiation potential and their adhesiveness to clinical grade titanium was characterized. Transcriptomic analysis of 11 common genes encoding cytoskeletal proteins VIM (Vimentin), cell–cell and cell–matrix adhesion genes (Vinculin, Integrin β1, Integrin β2, CD9, CD151), and for ECM genes (Collagen-1a1, Collagen-4a1, Fibronectin, Laminin-α5, Contactin-3) in early passaged cells was performed using qRT-PCR.ResultsAll tissue-derived pMSCs were characterized as mesenchymal origin by adherence to plastic, expression of cell surface markers including CD29, CD44, CD90, and CD105, and lack of hematopoietic (CD11b) and endothelial (CD31) markers. All pMSCs differentiated into osteoblasts, adipocytes and chondrocytes, albeit at varying degrees, under specific culture conditions. Among the eleven adhesion genes evaluated, the cytoskeletal intermediate filament vimentin was found highly expressed in pMSC isolated from all tissues, followed by genes for the extracellular matrix proteins Fibronectin and Collagen-1a1. Expression of Vimentin was the highest in Achilles tendon, while Fibronectin and Col1agen-1a1 were highest in molar and hoof-associated superficial flexor tendon bone marrow, respectively. Achilles tendon ranked the highest in both multilineage differentiation and adhesion assessments to titanium metal.ConclusionsThese findings support further preclinical research of these tissue specific-derived MSCs in vivo in a transdermal osseointegration implant model.

The Impact of Digital Nerve Injury on the Outcome of Flexor Tendon Tenolysis: A Retrospective Case-Control Study.

Tenolysis is an established treatment for flexor tendon adhesions at the hand. Concomitant finger nerve injuries with incomplete reinnervation may negatively influence outcomes. This study investigates the impact of finger nerve injuries on outcomes of flexor tendon tenolysis. A retrospective pair-matched study was conducted, including patients undergoing tenolysis for flexor tendon adhesion after primary repair of isolated superficial and deep flexor tendon injury and both finger nerves (test group [TG]). These were compared with patients (control group [CG]) with similar injuries without affection of nerves and pair-matched in age, zone of injury and follow-up. Patients' demographics, finger sensitivity, total active range of motion (TAM) before and after tenolysis and complications were retrieved. For both study groups, 10 patients each were included in this study. There were no significant differences regarding patients' demographics and follow-up. Mean follow-up was 37 (CG) and 41 (TG) months. Total active range of motion was preoperatively 81 ± 47° (CG) and 68 ± 54° (TG) and reached postoperatively 125 ± 57° (CG) and 79 ± 43° (TG). Hence, TAM improvement was significantly higher in patients without nerve damage (58 ± 16 vs 21 ± 11%; P > 0.05). Tendon ruptures occurred significantly more frequent in patients with nerve injury (n = 0.4 ± 0.52) compared with patients of the CG (n = 0; P < 0.05). This study shows that finger nerve injury with incomplete recovery after combined flexor tendon and nerve injuries of the finger negatively influences the outcomes of flexor tendon tenolysis.

A cadaveric assessment of percutaneous trigger finger release with 15\xb0 stab knife: its effectiveness and complications

Percutaneous release of the A1 pulley has been introduced as a therapeutic approach for trigger fingers and is suggested as an effective and safe alternative, where conservative treatments fail. The aim of the current study was to determine if percutaneous release with a 15° stab knife can effectively result in acceptable efficacy and lower complication rate.MethodsIn the present study, the percutaneous release of the A1 pulley was evaluated by percutaneous release using a 15° stab knife in 20 fresh-frozen cadaver hands (10 cadavers). One hundred fingers were finally included in the present study. The success rate of A1 pulley release as well as the complications of this method including digital vascular injury, A2 pulley injury, and superficial flexor tendon injury was evaluated, and finally, the data were analyzed by the SPSS software.ResultsThe results showed a success rate of 75% for A1 pulley release in four fingers, followed by eleven fingers (90%) and eighty-five fingers (100%). Therefore, the A1 pulley was found to be completely released in eighty-five fingers (100%). Overall, the mean of A1 pulley release for these fingers was determined as 97.9%, indicating that percutaneous trigger finger release can be an effective technique using a 15° stab knife. Furthermore, our findings revealed no significant difference in the amount of A1 pulley release in each of the fingers in the right and left hands. Additionally, 17 fingers developed superficial scrape in flexor tendons, while 83 fingers showed no flexor tendons injuries and no other injuries (i.e., vascular, digital nerve, and A2 pulley injuries).ConclusionsPercutaneous release of the A1 pulley using a 15° stab knife was contributed to acceptable efficacy and a relatively good safety in the cadaveric model.

RADIOSCAPHOLUNATE (RSL) FUSION ON SECONDARY OA WRIST WITH NEGLECTED DISLOCATION RADIOCARPAL JOINT AND CONTRACTURE DUE TO ENTRAPMENT OF SUPERFICIAL FLEXOR TENDON INDEX FINGER OF LEFT HAND

ABSTRACT&#x0D; &#x0D; Background: When pain, deformity and instability compromise wrist function, wrist stabilization by means of fusion is a procedure of recognized validity. The goal of wrist arthrodesis is to provide the patient with a stable wrist for power grip and the predictable relief of pain while sacrificing wrist motion. The radioscapholunate (RSL) fusion is one of salvage procedure indicated in the case of traumatic or degenerative osteoarthritis of the radiocarpal joint, involving the lunate facet of the radius. RSL-fusion reduced total wrist motion (3 MC/Rad) in the F/E axis to an average of 49% of F/E in the unfused wrist but preserves midcarpal joint motion while alleviating pain.&#x0D; Case Report: We report a 43-year-old male patient with pain on his left wrist. 10 months before admission, he felt down from stairs with his left hand bear his body weight. He broke his wrist and got surgery at that time. Because still feel pain and his index finger can’t fully extensed, he brought to Soeharso orthopaedic hospital. Here, we have done RSL-fusion using cross pinning K-Wire to reduce pain, distal scapoid excision to optimizing radial angulation and release superficial flexor tendon index finger of left hand.&#x0D; Discussion: With Secondary OA of left wrist post traumatic with neglected radiocarpal dislocation and superficial flexor tendon contracture due to entrapment index finger of left hand post RSL-fusion, distal scapoid excision and release contracture can reduce pain at radiocarpal joint and improve range of movement.&#x0D; Conclusion: The goal of Radioscapholunate (RSL) fusion is to optimizing wrist motion and strength while minimizing or eliminating pain&#x0D; &#x0D; Keywords: Radioscapholunate fusion, partial wrist arthrodesis, limited wrist fusion, reduce pain

Unusual rupture of the middle finger flexor digitorum superficialis tendon in a climber: Biomechanical analysis

Sport climbing is increasingly popular and consultations by climbers in hand surgery departments are on the increase. The pathologies related to this sport concern essentially the pulley system, tendons being rarely affected. We report the case of a male climber who presented an atypical rupture of the flexor superficialis tendon in his left middle finger sustained when using an atypical climbing grip technique: the “hook grip”. This consists in extension of the metacarpophalangeal joints and maximal flexion of the proximal interphalangeal joints with force exerted only on middle phalanx of the middle finger. A biomechanical analysis using finger musculoskeletal modeling was performed to compare the hook grip to other grips, and the patient’s recovery performance was assessed. Adapted functional treatment with physiotherapy seems to have been a good option for the treatment of this atypical lesion since the patient recovered normal use of his finger in daily life. He recovered maximal force in climbing holds. The biomechanical analysis confirmed that the atypical “hook grip” was likely at the origin of the rupture, since flexor digitorum superficialis tendon force for this grip is greater than in other climbing grip techniques. The “hook grip” seems to be dangerous and should be used cautiously by climbers to prevent similar pathology. Additionally, the patient should henceforth be careful when climbing, since the biomechanical model showed that the remaining flexor digitorum profundus tendon was overused.

The Effect of Gelatin Molecular Weight on Tendon Lubrication Utilizing an Extrasynovialized Turkey Flexor Tendon Model.

Flexor tendon injuries are common hand injuries among the military population often resulting in functional impairment. Flexor tendon gliding friction has been linked to adhesion formation, especially with the use of extrasynovial grafts. Carbodiimide-derivatized hyaluronic acid with gelatin (cd-HA-gelatin) can reduce gliding friction of the tendon graft; however, the effects of gelatin molecular weight (MW) have not been studied. The turkey model has been shown to better match humans, but extrasynovial tendons are unavailable. The purpose of this study was to (1) manually roughen turkey flexor digitorum profundus (FDP) tendons to simulate extrasynovial tendons and (2) investigate the effects of gelatin MW on tendon friction. The third digit of (n = 48) turkeys were dissected with the proximal pulley, and FDP tendon and the flexor superficialis tendon were preserved. Digits were randomly assigned into four groups: one saline control and three cd-HA-gelatin-treated groups of varying gelatin MW. Flexor digitorum profundus tendon friction was measured at its original condition, serving as a baseline. Tendons were roughened using a custom rig, and tendon friction was measured again. All four groups received treatment and gliding friction was measured every 100 cycles to a total of 1,000 cycles. Tendon friction significantly increased (P < 0.05) after roughening. Friction in the saline control group increased steadily over repeated cycles, whereas friction of all gelatin-treated tendons decreased significantly compared with the saline control group (P < 0.05), maintaining low friction to 1,000 cycles representing human tendons. There was no significant difference found between gelatin-treated groups. We have developed a method to roughen synovial FDP tendons to create extrasynovial-like tendons for lubrication material evaluations. Cd-HA-gelatin effectively reduces tendon friction in this model. Our data suggest medium or low MW gelatin may provide a better reduction in friction compared with high MW gelatin.

Effectiveness of nuchal ligament autograft in the healing of an experimental superficial digital flexor tendon defect in equid.

This study aimed to investigate nuchal ligament (NL) autograft on experimental tendon defect healing in donkeys. Eight healthy donkeys were used. The left forelimb’s superficial digital flexor (SDF) tendon was assigned as treatment, and the right forelimb was allocated as the control group (without surgical intervention). A 3×1.5 cm segment of the funicular part of the NL was excised. A full thickness defect created in the treatment tendon and was grafted with the excised NL. The following parameters were evaluated in 120 days postoperatively: clinical, ultrasonography, radiography, histopathology, biomechanical properties, and scanning and electronic transmission microscopy. There were no significant changes observed in the neck angle so that it was confirmed this treatment regimen preserved the head and neck situation without any considerable neck swelling. Weight-bearing in gait and trot was similar between both forelimbs at the end of the study. Mild to moderate adhesion was detected in the dorsal surface of the SDF tendon. There was no significant difference in the echogenicity and fiber alignment, respectively, on days 90 and 120 after surgery. Treatment significantly amplified the collagen diameter and enhanced the collagen fibril diameter and density considerably compared to the NL. The transplanted tissue was mostly in the remodeling or maturation phase, on day 120 postoperatively. It seems that the NL is biocompatible, almost biodegradable, and effective in tendon healing without metaplasia or tissue rejection.

Морфологические изменения в ткани сухожилия поверхностного сгибателя пальца у лошадей при тендинитах

The superficial flexor tendon of the horse's toe in the middle third of the metacarpus and in the region of the joint of the second phalanx was studied. Here, the tendon tissue is hypovascular or avascular, with inclusions of fibrous cartilage. The features of the structure of tissue in health and in chronic tendinitis are shown.

Ultrasound anatomy of the fingers: flexor and extensor system with emphasis on variations and anatomical detail.

Many anatomical details and variants occur in the finger tendons and soft tissue structures. These may lead to misdiagnosis if the radiologist is not well aware of them. We discuss the midhand extensor tendons, dorsal hood, junctura tendinea, conjoint tendons, transverse retinacular ligament, triangular ligament as well as central and distal slip anatomy and ultrasound correlation. The dorsal hood is an important structure to center the tendons at the midportion of the MCP heads, and the sagittal bands are its main components. Two tendons are present at the second digit, and two or more at the fifth digit. The extensor mechanism is anatomically interrelated with the palmar lumbricals and interosseous tendons. At the palmar side, the flexor superficialis and profundus tendons show varying relationships along the finger. The flexor profundus passes through an opening in the flexor superficialis. We also discuss the chiasma crurale, ridges at the flexor superficialis insertions and bifid flexor profundus tendon. Although a typical distribution of annular pulleys can be observed, many variants may be present of which we address some. The volar plate is a midline fibro-cartilaginous meniscus attached proximally to the well-identifiable checkrein ligaments and distally to the base of the phalanges. Knowledge of these details and variations allows for better understanding of the finger and hand ultrasound.

Complication inhabituelle à 20 ans d’une arthroplastie trapézo-métacarpienne

Trapeziometacarpal joint arthroplasty is a reliable method for treating TM osteoarthritis, with the major benefit of rapid pain relief and recovery after surgery. Despite recent advances in prosthetic design, with a 90% survival rate at 10 years, there remain complication risks that cannot be ignored. The most common complications are prosthetic dislocation and trapezial cup loosening. To our knowledge, flexor tendon rupture has not been reported after TM joint arthroplasty. We report a unique case of total asymptomatic trapeziometacarpal prosthesis dislocation, accidentally discovered after the occurrence of a rupture of the index flexor tendons more than 20 years after surgery in an 82-year-old woman. Formal testing was informative and confirmed the lack of normal function of the superficial and profundus flexor tendons of her left index finger. There was no sign of carpal tunnel compression. She showed satisfactory thumb mobility with a Kapandji score of 8/10 and a grip strength of 10 kg. She had near-comparable mobility to the contralateral healthy side. X-rays showed a total dislocation of the prosthesis stem, whose proximal end was located next to the carpal tunnel. We undertook surgical exploration via a carpal tunnel approach. The prosthesis stem was located at the radial base of the carpal tunnel. Both index flexor tendons were ruptured. The stem was removed and not replaced. The reconstruction of the index profundus flexor tendon was performed by transfer of the ring finger flexor superficialis tendon using the Pulvertaft technique in zone 3. Immobilization was considered unnecessary. Active and passive rehabilitation were performed daily and initiated on postoperative day 1. Follow-up at 6 months showed satisfactory motion of the thumb without any pain, a Kapandji score of 8/10, a grip strength of 12 kg, satisfactory flexion of the index and ring fingers, and a Quick-DASH score of 29.55/100. We noticed a clinical shortening of the thumb explained by significant shortening of M1 on radiographs. This case presents a rare case of complication of trapeziometacarpal joint arthroplasty, since dislocation went unnoticed for a considerable time. Our strategy was to avoid any loss of range of motion. Prosthesis removal was efficient and ring finger superficial flexor tendon transposition allowed immobilization to be avoided. This observation adds a new clinical complication of the trapeziometacarpal prosthesis, and shows an example of how it was promptly managed.

A Novel Supraretinacular Endoscopic Carpal Tunnel Release: Instrumentation and Technique (Cadaveric Study)

Purpose Endoscopic carpal tunnel release has been shown to be associated with a shorter return to work compared with open carpal tunnel release in the treatment of carpal tunnel syndrome. Unfortunately, it may be associated with a higher risk for median nerve injury when the carpal tunnel is used as a portal for instrumentation. The purpose of this study was to assess safety in using a newly designed retractor through a supraretinacular approach. Methods We used 8 wrists (4 left and 4 right wrists) from 4 fresh-frozen cadavers for this study. Supraretinacular endoscopic carpal tunnel release using the supraretinacular retractor was performed by a single investigator, followed by exploration of the carpal tunnel and the structures surrounding it. Surgeries were performed using a new surgical instrument consisting of an arch-shaped blade and handle. It includes a retainer adapted to receive a 2.4- or 2.7-mm endoscope and to retain it at the apex of the arch, which can be moved in and out to visualize the entire transverse carpal ligament. The space below the blade is also used as a portal to insert scissors and instrumentation to cut the transverse carpal ligament. Results All 8 carpal tunnels were completely released with no injury to the median nerve, superficial palmar arch, flexor tendon, or violation into Guyon canal. Mean distance of the flexor retinaculum division to the recurrent motor branch, palmar cutaneous branch, and superficial palmar arch was 6.87 ± 2.80, 7.13 ± 5.33, and 9.13 ± 4.42 mm, respectively. All specimens had an extraligamentous recurrent motor branch. Conclusions The retractor and described technique were safe and effective in this cadaveric study. Further clinical trials are necessary before it can be adopted as a safe and reliable technique. Type of study/level of evidence Therapeutic IV.

Reliability of ultrasound speckle tracking with singular value decomposition for quantifying displacement in the carpal tunnel

Inhibited movement patterns of carpal tunnel structures have been found in carpal tunnel syndrome (CTS) patients. Motion analysis on ultrasound images allows us to non-invasively study the (relative) movement of carpal tunnel structures and recently a speckle tracking method using singular value decomposition (SVD) has been proposed to optimize this tracking. This study aims to assess the reliability of longitudinal speckle tracking with SVD in both healthy volunteers and patients with CTS.Images from sixteen healthy volunteers and twenty-two CTS patients were used. Ultrasound clips of the third superficial flexor tendon and surrounding subsynovial connective tissue (SSCT) were acquired during finger flexion-extension. A custom made tracking algorithm was used for the analysis. Intra-class correlation coefficients (ICCs) were calculated using a single measure, two-way random model with absolute agreement and Bland-Altman plots were added for graphical representation.ICC values varied between 0.73 and 0.95 in the control group and 0.66–0.98 in the CTS patients, with the majority of the results classified as good to excellent. Tendon tracking showed higher reliability values compared to the SSCT, but values between the control and CTS groups were comparable.Speckle tracking with SVD can reliably be used to analyze longitudinal movement of anatomical structures with different sizes and compositions within the context of the carpal tunnel in both a healthy as well as a pathological state. Based on these results, this technique also holds relevant potential for areas where ultrasound based dynamic imaging requires quantification of motion.

Key aspects of anatomy, surgical approaches and clinical examination of the hand

Knowledge of the functional anatomy of the hand is essential to be able to successfully clinically examine and operate on it. The topic of hand anatomy, clinical examination and surgical approaches is therefore closely linked and discussed in this article. The focus will be on detailed functional anatomy of the joints, tendons, and other soft tissue structures of the hand, related to the clinical examination and surgical approaches. Particular attention will be paid to the superficial and deep flexor tendons and how to examine them; the extensor mechanism and examination of the central slip; and surgical approaches to the finger. The pathoanatomy of Dupuytren's disease and fingertip infections are also discussed.