Tendon Flap Research Articles

Extensor Tendon Reconstruction for Zones II and IV Using Local Tendon Flap: A Cadaver Study

To assess the feasibility of reconstructing extensor tendon segmental defects in zones II (over the middle phalanx) and IV (over the proximal phalanx) using local tendon flaps (LTFs), explore in these 2 zones the anatomical constraints that limit the use of the LTF as regards the maximum defect that could be reconstructed, and compare this flap with distant tendon grafts (DTG) reconstruction for similar size defects. We dissected 33 fresh-frozen cadaver extensor tendons from the fingers of 9 fresh-frozen cadaver forearms. A 0.5-cm defect was created in each extensor tendon of 21 fingers: 12 in zone II and 9 in zone IV. In each of 12 additional fingers, we created a 1.0-cm defect in zone IV. In 25 fingers, LTFs measuring 0.5 and 1.0 cm in length were harvested from the extensor tendon proximal to each defect and were turned distally to reconstruct the respective 0.5- and 1.0-cm defects. In 8 fingers, palmaris longus tendon grafts measuring 0.5 and 1.0 cm in length were used to reconstruct the respective 0.5- and 1.0-cm defects. Limited kinematic analysis was performed on the repaired fingers by maximally flexing the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints in sequential fashion. In zone II, repair was technically feasible using LTFs in all 9 of the 0.5-cm extensor tendon defects. Likewise, LTFs were feasible for zone IV to repair 6 of 8 and all 9 of the respective 0.5- and 1.0-cm extensor tendon defects. Two failed repairs occurred early in the study by suture gapping following LTF of 0.5 cm to repair extensor tendon defects in zone IV of a long and small finger during maximal flexion. We determined the anatomical constraints for the use of the LTFs. The maximum length of repairable defect using the LTF was 0.5 cm in zone II of the index, long, ring, and small fingers, and zone IV of the small finger. In zone IV of the index, long, and ring fingers, the largest defect that could be repaired was 1.0 cm. Similarly, DTGs were feasible in zone II to repair all 4 of the 0.5-cm defects and in zone IV to repair all 4 of the 0.5- and 1.0-cm extensor tendon defects. In a cadaver model, both the LTF and the DTG are anatomically feasible and technically easy to perform. However, the LTF avoids a distant donor site, provides morphologically similar donor tendon that is readily accessible, and avoids morbidity that may be associated with the use of DTG. In this study, however, the LTF was limited in its use to zones II and IV of the extensor tendon.

Free Vascularized Fibula Flap Reconstruction of the Clavicle Combined with Biceps Tendon Repair of the Conoid Ligament and Customized Plate Stabilization of the Acromioclavicular Joint

Sir: We report a new application of the free vascularized fibula1 for clavicular reconstruction, using a biceps tendon transfer to reconstruct the coracoclavicular ligament and a customized clavicular plate to prevent acromioclavicular joint dislocation. Two of three previous reports of vascularized fibula for clavicular reconstruction2,3 were for malunion and involved normal clavicular joints. The other describes whole clavicle reconstruction after oncologic resection of the clavicle.4 Although aesthetically satisfactory, wire fixation resulted in limited functional shoulder abduction. Our case epitomizes translational research collaboration between surgical and engineering specialties to produce an optimal outcome tailored to the patient. A 42-year-old man presented with a 5-cm recurrent dermatofibrosarcoma adherent to the periosteum of the lateral third of the left clavicle on magnetic resonance imaging, 9 years after his original resection. In operation 1, in October of 2006, wide tumor excision, with 3-cm skin margins and 9.5 cm (lateral two-thirds) of the clavicle, was performed, sparing adjacent neurovascular structures and a ligamentous acromioclavicular joint cuff (Fig. 1, left). A left osseocutaneous fibular flap was raised on the peroneal vessels and transferred (Fig. 1, center). The fibula was inset with reciprocal step-osteotomies in the clavicle and secured with a plate and unicortical screws. Laterally, the fibula was fixed in the acromioclavicular joint using a Kirschner wire threaded transversely through the acromion into the medulla of the fibula and by suturing the acromioclavicular joint capsule to a cuff of fibula periosteum. The coronoid (coracoclavicular) ligament was reconstructed using the short head of the biceps tendon. Left attached proximally, the tendon was split longitudinally toward the muscle belly and the medial half looped around the fibula and sutured to itself to reconstruct this ligament, critical for neoclavicular stabilization. End-to-end anastomosis of peroneal vessels to the transverse cervical artery and external jugular vein was performed to revascularize the flap. Despite satisfactory early postoperative recovery and appropriate splinting for 4 weeks, the Kirschner wire extruded, resulting in acromioclavicular joint subluxation. To resolve this, the curved Richardson clavicular dislocation hook-plate5 was customized by an engineer (Fevzi Alakus) to match the straight shape of the fibula.Fig. 1.: Diagram of the procedure. (Left) The site of bone section (arrow). (Center) The free flap and (right) in the split biceps tendon flap, the clavicular hook plate in position to prevent dislocation of the acromioclavicular joint, and revascularization of the composite flap to vessels in the neck.In operation 2, the acromioclavicular joint dislocation was reduced and held by fixing the modified clavicular plate with unicortical screws and positioning the hook beneath the acromion laterally (Fig. 1, right). The previously reconstructed coracoclavicular ligament (divided for access) was repaired and tightened. The wound healed uneventfully and the patient underwent precautionary postoperative radiotherapy. After initial stiffness, excellent shoulder contour and movement were achieved (Fig. 2), with radiographic union at 3 months and no resulting shoulder dislocation or tumor recurrence at 12 months. Although traditional teaching suggests that endosteal blood supply is critical for fibula bone flap survival, our experience suggests that this bone will survive on the periosteal supply alone, verified in this case, by sound claviculofibular union at 3 months, despite postoperative radiotherapy.Fig. 2.: The result at 6 months.The immediate clavicular reconstruction with conoid ligament repair and customized clavicular plating for acromioclavicular joint stabilization highlights the importance of multidisciplinary collaboration in optimizing outcomes for the individual patient. G. Ian Taylor, A.O., M.D. S. Seneviratne, F.R.A.C.S. I. Jones, F.R.A.C.S. D. White, F.R.A.C.S. E. Mah, M.B.B.S. R. Shayan, M.B.B.S. Department of Anatomy and Cell BiologyUniversity of MelbourneParkville, Victoria, Australia

Use of a Turndown Quadriceps Tendon Flap for Rupture of the Patellar Tendon After Total Knee Arthroplasty

Patellar tendon rupture is a devastating complication after total knee arthroplasty. The results of surgical treatment of this complication were discouraging in most of the reports. We describe a case of rupture of patellar tendon 7 weeks after total knee arthroplasty treated with a turndown quadriceps flap and circumferential wiring. Two years and 6 months after operation, the patient had no extension lag of the knee and knee flexion to 110°.

Eyelid reconstruction with a composite radial forearm palmaris longus tendon flap

We performed reconstruction with a composite radial forearm palmaris longus tendon flap in patients with wide defects of upper or lower eyelids. In one upper eyelid reconstruction, a palmaris longus tendon was fixed to the frontal muscle to make it possible to open the eye. In the lower eyelid reconstruction, the tendon was fixed to both the medial palpebral ligament and the lateral orbital rim to support the flap. In wide upper and lower eyelid reconstruction with a forearm flap, it is convenient to utilise the palmaris longus tendon to support the flap.

Composite Anterolateral Thigh???Fascia Lata Flap: A Good Alternative to Radial Forearm???Palmaris Longus Flap for Total Lower Lip Reconstruction

Major defects of the lower lip are challenging to the reconstructive surgeon. The major goals in treating total lower lip defects are reconstruction of the external skin and mucosal lining and maintenance of oral competence and sphincter function. The authors describe reconstruction of total lower lip and larger full-thickness defects including the cheek and commissure by means of a composite anterolateral thigh-fascia lata free flap. The flap was harvested with 5-cm fascial extensions at the superior and inferior margins. The flap was folded over the fascia lata to restore the intraoral lining and cover the external skin defect. Fascia lata extensions were divided longitudinally into two fascial strips at both margins of the flap. Two strips were tunneled through the orbicularis muscle in the upper lip and sutured to each other and to the orbicularis muscle. The remaining two strips were anchored to the zygomatic bone periosteum by permanent sutures. This procedure was used in 11 patients. In all cases, disease was advanced squamosus cell carcinoma. The patients' ages ranged from 37 to 72 years. Nine patients had cancer of the lower lip and two patients had a buccal cancer involving the lip. The entire lower lip, bilateral modiolus, and part of the cheek were resected in all patients, and mandibulectomy was performed in three patients. Flap survival was 100 percent. One patient died 10 days after the operation because of cardiopulmonary arrest. At the end of the 1-year follow-up period, all patients had good oral continence at rest and had achieved sufficient oral competence when eating. Eight patients were able to resume a regular diet and two patients could eat a soft diet. This flap is a good choice for reconstruction of the extensive head and neck defects. We think that anterolateral thigh-fascia lata composite flap has maximum reconstructive capacity and minimal donor-site morbidity. This flap has many advantages over the radial forearm flap and should replace to the composite radial forearm palmaris longus tendon flap when total lower lip reconstruction is concerned.

The treatment outcome of microsurgical reconstruction of achilles tendon defects

目的 探讨跟腱缺损显微外科治疗手术方式的选择及其远期疗效.方法自1999年1月至2003年7月间,对26例跟腱缺损患者进行显微外科手术治疗,根据跟腱缺损长度及组织缺损情况分为三类9型,其中吻合血管大收肌肌腱(皮瓣)移植18例,吻合血管髂胫束(皮瓣)移植6例,吻合血管腓骨、吻合血管大收肌肌腱-骨-皮瓣联合移植1例,吻合血管背阔肌腱膜皮瓣移植1例.结果临床应用26例,皮瓣全部成活,随访2～6.5年,平均4.3年,按Thermann's功能评定:优18例,良6例,可1例,差1例,优良率92.3%.结论跟腱缺损的伤情复杂,临床分类、分型有利于显微外科手术方式的选择;跟腱缺损采用显微外科修复方法是符合跟腱解剖和生理功能重建需求的良好选择。

Single-Stage Reconstruction of the Flexor Mechanism of the Fingers with a Free Vascularized Tendon Flap: Case Report

The reconstruction of the flexor tendon in zones I and II of a ring finger in a single stage, using a free vascularized tendon graft, is reported in a single clinical case. The flexor digitorum superficialis (FDS) tendon of the same finger was freely transferred based on a vascular branch off the ulnar vessels. The ulnar artery was reconstructed with an end-to-end anastomosis, and the free flap was connected to the superficial palmar arch. The functional result was satisfactory.

TRIGGER FINGER CAUSED BY AN OLD PARTIAL FLEXOR TENDON LACERATION: A CASE REPORT

We report a rare case of trigger finger caused by an old partial laceration of the flexor digitorum superficialis. The triggering occurred five months after injury. This case was the latest presentation of triggering in the literature. The patient was managed by incising the A1 pulley and suturing the flexor tendon flap after trimming. He was relieved of triggering and there was no recurrence.

Reconstruction of Achilles tendon by transfer of the soleus tendon flap

目的 介绍比目鱼肌肌腱瓣移位重建跟腱术的方法及临床效果.方法在对参与跟腱组成的小腿浅层各肌肉的解剖特点进行仔细观察的基础上,设计了比目鱼肌肌腱瓣移位重建跟腱的术式,临床应用于12例伴有缺损的跟腱损伤患者的治疗,并进行了平均39个月的随访.结果根据Amer-Lindholm疗效评定标准,优9例,良2例,差1例,优良率达92%.结论比目鱼肌肌腱瓣移位重建跟腱术,具有损伤小、对跟腱血供的影响小、术后愈合好的优点。

Lesser metatarsophalangeal joint capsular release utilizing the #66 mini-blade

Lesser interphalangeal and metatarsophalangeal sagittal plane deformities are common pedal pathologies. The mechanical imbalances responsible for the development of these digital deformities have received much attention (1-3), but a complete discussion of these is beyond the scope of this article. In general, when conservative measures have failed to provide long-term satisfactory relief from symptomotology, surgical intervention is undertaken. To this end, a myriad of soft-tissue and osseous procedures have been advocated (4-6). The senior author (lB.R.) utilizes a 60° angled Opthamology #66 mini-bladef (Fig. 1) in the following manner to surgically release the tendinous, capsular, and ligamentous metatarsophalangeal joint contracture component of the digital deformity. A standard longitudinal incision is performed extending from the base of the proximal phalanx to the head of the intermediate phalanx, and deepened to the extensor tendon complex at the level of the proximal interphalangeal joint (Fig. 2). The extensor tendon complex is then incised transversely at this level, with care taken to leave the medial and lateral collateral ligaments intact at the level of the proximal interphalangeal joint. Following this, the medial and lateral margins of the sling and wing components of the extensor digitorum longus tendon are incised vertically, parallel to the longitudinal axis of the proximal phalanx. The resultant extensor digitorum longus tendon flap is then grasped with atraumatic forceps and underscored through a combination of sharp and blunt dissection to the level of the corresponding metatarsal head

Covering extensive soft tissue defects in infected knee endoprostheses by gastrocnemius flap

Total knee arthroplasty has become a routine procedure in surgery. Deep infections have an incidence of 2-5%. Major risk factors are large prostheses, rheumatoid arthritis, diabetes mellitus and postoperative wound-healing complications. In large soft-tissue defects with skin necrosis, local wound care shows poor results, especially if loosening of the prosthesis and necrosis of the patellar ligament are evident. In these cases, no standard surgical therapy has been developed yet. Thus, we consider meticulous débridement with synovialectomy to be mandatory. Exchange of the prosthesis may be necessary. Soft-tissue coverage ought to be performed with a gastrocnemius muscle flap covered with a split-thickness skin graft. In the last three years, 11 patients with large soft-tissue defects and necrosis of the ligament were treated according to this concept. In all cases the muscle flap healed primarily and soft tissue coverage was excellent. Two patients who underwent single-stage removal and reimplantation of the prosthesis showed reinfections of the prosthesis. Reconstruction of the ligament was performed with the flap tendon. The patients with two-stage removal and reimplantation of the prosthesis and those who retained their implants had a good functional outcome. The gastrocnemius muscle flap provides easy and reliable soft-tissue reconstruction in large defects. In our patients a two-stage operation for reimplantation of the prosthesis was superior to a single-stage procedure. The reconstructed ligament should be reinforced with autologous material to prevent a secondary rupture. Early reconstruction with sufficient soft-tissue coverage and reconstruction of the ligament offers the patient the best chances of obtaining a good functional result and prevents arthrodesis or amputation. In addition, reconstructive surgery reduces the length of hospital stay and costs.

Dislocation of the tibialis posterior tendon: Diagnosis and treatment

Traumatic dislocation of the tibialis tendon occurred from minor ankle sprains in a 37-year-old male and a 53-year-old female. Both complained of local pain at the medial malleolus, and both walked with a limp. The diagnosis was suspected by clinical examination, in one case with 2 months' delay, and verified by ultrasound, computed tomography, and magnetic resonance imaging. The male patient was initially treated for an "uncomplicated ankle sprain." For various reasons surgery was delayed 4 months. During this interval the male patient complained of pain and severe dysfunction, requiring analgesic treatment. A medial Achilles tendon flap was used to support the repositioned tendon. The female patient was operated on within 1 week from injury, by resuturing of the retinaculum over the tendon. Postoperatively, both patients were immobilized with below-knee casts for 6 weeks, allowing full weightbearing, followed by strength and stretching exercises. They were free of symptoms 2 and 3 months, respectively, after surgery. At follow-up 1 year postoperatively, both were asymptomatic and participated in activities like those before their injuries.

Repair of neglected achilles tendon ruptures with a triceps surae muscle tendon advancement

Neglected Achilles tendon ruptures, although rare, can be a surgical challenge for the lower extremity specialist. These injuries often present with large defects which require special reconstructive techniques and principles. This paper presents an overview of this problem, various treatment strategies, and two case reports utilizing a triceps surae muscle tendon flap advancement.

Conservative management of transverse partial flexor digitorum profundus tendon lacerations in zone 2

The experience with six patients managed conservatively following transverse partial flexor digitorum profundus tendon lacerations in zone 2 is presented. Four patients who were mobilized using elastic traction experienced no triggering; however, two patients who had unrestricted mobilization immediately following injury developed triggering. The mechanism of triggering and tendon flap formation in the clinical cases is discussed.

Triggering after partial tendon laceration

Triggering and tendon flap formation were studied after a transverse laceration of 50% of the width of the flexor digitorum profundus tendons of the hind limb of 14 adult sheep at various intervals after injury. The tendon laceration was not repaired and there was no post-operative immobilization. Triggering was not caused by bulbous scar formation but by the bunching of the tendon fibres proximal or distal to the laceration site. This bunched part of the tendon appeared to become incorporated into the healing process, with gradual spontaneous resolution of triggering. Failure of incorporation of this bunched part resulted in the formation of a flap in two tendons.

Vault prolapse: a new approach.

This paper discusses the successful use of rectus sheath tendon flap in 20 patients with vaginal vault prolapse.

Tendon subluxation after de Quervain's release: Treatment by brachioradialis tendon flap

Volar subluxation of the tendons of the first dorsal compartment of the wrist occurred in two patients after surgery for treatment of de Quervain's stenosing tenosynovitis. In both patients a painful tenosynovitis of the extensor pollicis brevis and abductor pollicis longus developed, which was unresponsive to conservative therapy as the tendons prolapsed over the prominence of the first dorsal compartment. A distally based flap of the brachioradialis tendon was used to prevent tendon prolapse, with both patients asymptomatic and free of subluxation one and five years after operation.

Surgical treatment of chronic Achilles tendinitis.

Between 1977 and 1985, 170 patients suffering from chronic Achilles tendinitis were treated surgically. Ninety-one patients with 143 tendons returned for followup. The duration of preoperative symptoms averaged 18 months. In all cases, conservative treatment was first attempted but failed to alleviate symptoms. Only those patients whose lesions and symptoms were confined to the Achilles tendon segment 2 to 6 cm proximal of the insertion were included in this study. All athletes who had an insertion tendinopathy or a lesion at the musculotendinous junction were excluded from this study. The surgical procedure depended on the lesion. For 93 tendons exhibiting pure peritendinitis, treatment consisted of a simple release of the fascia cruris and the peritenon. For the 50 tendons with tendinosis, a resection of diseased tendon tissue was performed. The defect could be sutured side to side in 26 cases but in the other 24 cases, reinforcement with a turned down tendon flap was necessary because of the extensive debridement. Of the 93 cases in which only dorsal release was performed, results were considered excellent in 54 cases, good in 28, fair in 8, and poor in 3 cases. Of the 26 cases in which side-to-side suture was performed, 15 cases were rated as having excellent results, 4 as good, 4 as fair, and 3 as poor. For the 24 cases in which a turned down tendon flap procedure was performed, the result was excellent in 12 cases, good in 9, fair in 2, and poor in 1 case.(ABSTRACT TRUNCATED AT 250 WORDS)

Reconstruction of the posterior cruciate ligament.

Presented is a three to eight year follow up of reefing of the posterior cruciate in 20 cases, and reconstruction of the posterior cruciate with a patellar tendon, quadriceps tendon flap as a "reversed Jones' procedure" in 10 cases. Using the reefing procedure, there were six excellent results, ten acceptable, and four poor results. The reconstruction resulted in no excellent results, six acceptable, and four unchanged. Further improvements in present techniques are necessary before satisfactory results following reconstruction of the posterior cruciate ligament can be routinely expected.