Hand Surgery Tendon Future

Loading...

Flash Player 9 (or above) is needed to view presentations.
We have detected that you do not have it on your computer. To install it, go here.

4 comments

Comments 1 - 4 of 4 previous next Post a comment

  • + lynnepringle Lynne Pringle 4 months ago
    Michael Tonkin visited SA in 2007 - his input on flexor tendons was great!
  • + lynnepringle Lynne Pringle 4 months ago
    Thank you - very clear.
    Early range of motion is my first choice - specifically due to adhesion formation in zone 2. Problem is that in my practice I mostly can only see patients once a week, and often one cannot trust them with active ROM. I usually start with a passive regime, and add a few AROM repetitions as we go along.
  • + guest4fbdf guest4fbdf 9 months ago
    glad to know tissue engineered tendons are on the horizon
    thank you for posting
    a cht
    we too would like to see a multicentered research done for zone 2 post op care
  • + guille100 guille100 2 years ago
    excelent!!!
Post a comment
Embed Video
Edit your comment Cancel

2 Favorites

Hand Surgery Tendon Future - Presentation Transcript

  1. Current and Future Treatment of Flexor Tendon Injuries James Chang MD Chief of Plastic & Reconstructive Surgery Professor of Surgery & Orthopedic Surgery Robert A. Chase Hand Center Stanford University Medical Center
  2. 40th Anniversary 1967 ASSH Presentation: Kleinert HE, Kutz JE, Ashbell TS, Martinez E. “Primary Repair of Lacerated Flexor Tendons in No Man’s Land” Manske PR. History of Flexor Tendon Repair, Hand Clinics, 2005
  3. Specific Problem: Zone II Flexor Tendon Laceration
    • Current Best Treatment Based on Available Evidence
    • Future Solutions for Current Needs
  4. Research in the past 10 years: Thought leaders
    • Gelberman
    • Manske
    • Trumble
    • Boyer
    • Amadio
    • Tang
    • Strickland
    • Mass
    • Nagle
    • Taras
    • Wolfe
    • Tomaino
    • Tonkin
    • Diao
    • McGrouther
    • Hagberg
    • Elliot
    • Seiler
  5. Flexor Tendon Repair: Challenges for Research
    • Margin for error is small
    • Many repair techniques exist
    • Biomechanical studies may not be relevant clinically
      • Cadaver studies: no healing
      • Animal studies: no therapy
    • Clinical studies limited by
      • Differences in surgical skill
      • Patient compliance with therapy
      • Differences in follow-up & outcomes criteria
  6. Current Best Treatment Based on Available Evidence: Four Key Papers, Four Key Points
  7. Point #1: 4 Strands or more are necessary for early active motion
    • Strickland. J Hand Surg 2000; 25A:214-235
    • “ Development of Flexor Tendon Surgery: Twenty-five Years of Progress”
            • Two strand repairs are at risk for rupture if early active motion is applied
            • Four strand repairs are strong enough to withstand light active motion
  8. Point #2: Grasping vs. locking sutures
    • Miller et al. J Hand Surg 2007; 32A:591-96 (Trumble)
    • “ Flexor Tendon Repairs: The Impact of Fiberwire on Grasping and Locking Core Sutures ”
        • Grasping repairs failed by suture pull-out in 74%
        • Locking repairs failed by suture breakage in 99%
        • Fiberwire suture provided significant tensile strength in locking MGH repairs
        • Increased suture strength is only important in locking repairs
  9. Point #3: Rehabilitation force
    • Boyer et al. JBJS 2001; 83:891-899 (Gelberman)
    • “ Intrasynovial Flexor Tendon Repair: An Experimental Study Comparing Low and High Levels of In vivo Force During Rehabilitation in Canines”
            • Increasing post-op rehabilitation force from 5 to 17 N did not accelerate acrual of stiffness or strength
            • Some motion is good (2 mm excursion); more forceful motion may not be better
  10. Point # 4: The Effect of Gap
    • Gelberman. JBJS 1999; 81:975-82
    • “ The Effect of Gap Formation at the Repair Site on the Strength and Excursion of Intrasynovial Flexor Tendons”
          • What happens if a significant gap forms?
          • Repair site gap of greater than 3 mm:
            • No increase in adhesions
            • Weaker, with increased risk of rupture
  11. Flexor tendon repair: what we know in 2007
    • Core suture: 3-0 or 4-0
    • Epitendinous suture
    • Gaps significantly weaken the repair
      • Locking techniques prevent pullout and reduce gapping
    • Some early active motion is beneficial
      • 4 strands or more will allow early active motion
  12. The “Optimal” Repair Technique
    • Should incorporate the concepts of multi-strand repair with early motion
    • Surgeons are still influenced by their training and anecdotal experience
    • Michael Tonkin: “One’s chosen repair technique should be simple to learn, with the goal of being able to be performed safely by all trainees”
  13. Great strides have been made in suture techniques and post-operative rehabilitation. What now?!?
  14. Flexor Tendon Repair: Future Solutions for Current Needs 2007 ASSH Papers: Biomolecular Strategies
  15. Four Current Needs
    • Increase early strength of repair
    • Decrease adhesion formation
    • Shortage of tendon material in mutilating injuries
    • True outcomes data for best methods of repair and rehabilitation
    • Strategies to increase early strength of repair focus on delivery of growth factors or stem cells to the repair site
    • Gelberman et al. - Sustained delivery of PDGF-BB with a bioactive fibrin-based delivery system
    • Tang et al. - Delivery of bFGF gene with adenoviral vectors
    • Lou et al. - Delivery of BMP-12 with adenoviral vectors
    • Chong et al. - Mesenchymal stem cells in a fibrin carrier
    • Yao et al. - Mesenchymal stem cell-coated sutures
    • Strategies to decrease adhesion formation focus creating an interface or blocking known factors that cause fibrosis
    • Amadio, An et al. - Surface modification with hyaluronic acid
    • Khan et al. - 5-Fluorouracil
    • Chang et al. - Inhibitors of TGF-Beta
  16. Transforming Growth Factor - Beta
    • Family of growth factors - 3 isoforms
    • Expressed in cells active in wound healing
    • Implicated in the pathogenesis of fibrosis
      • Inflammation
      • Excessive collagen deposition
    • Natural inhibitors of TGF-Beta
      • Decorin: 40,000 MW naturally occurring proteoglycan in extracellular matrix
      • Mannose-6-phosphate (M-6-P): Naturally occurring 6 carbon sugar
  17. In Situ Hybridization Control: IL-2 mRNA TGF-  1 mRNA
  18. Rabbit Postoperative Range of Motion
  19. Rabbit Postoperative Breaking Strength
  20. Anti-TGF-Beta Therapy
      • Rabbit model of flexor tendon repair
      • Intra-operative addition of M6P significantly improved post-operative range of motion without decreasing strength of repair
        • Bates SJ, Morrow E, Zhang AY, Pham H, Longaker MT, Chang J.
        • Mannose-6-Phosphate, An Inhibitor of TGF-Beta, Improves Flexor
        • Tendon Repair. Journal of Bone and Joint Surgery (Am), 88:2465-72, 2006.
  21. 3. Strategies to replace tendon material in mutilating injuries
    • Goal of Tissue Engineering:
      • Produce construct similar to intrasynovial flexor tendon
    • Scaffold:
      • Acellularized intrasynovial tendon
    • Seeding Cells:
      • Epitenon & Endotenon
      • Fibroblasts
      • Mesenchymal stem cells
        • Zhang A, Chang J. Tissue Engineering of Flexor Tendons, in Clinics in Plastic Surgery, 30: 565:72, 2003.
  22. Normal Intrasynovial Tendon
  23. Acellularization Protocol: Freeze/Thaw, Trypsin & Triton X-100 Tendons are completely acellularized
  24. Acellular Tendon Control: 3 weeks post-implantation Disordered collagen Inflammatory cell infiltration
  25. Seeded Constructs: 3 weeks post-implantation Normal collagen architecture Tenocytes repopulated
  26. Different cell lines can be used for flexor tendon tissue engineering Bone Marrow Derived MSC Adipoderived MSC Tenocytes Sheath Fibroblasts
  27. Similar collagen I & III synthesis Collagen I Immunohistochemistry Bone Marrow Derived MSC Adipoderived MSC Tenocytes Sheath Fibroblasts
  28. Cell Proliferation Can be Increased with a Cell Bioreactor (Intermittent Cyclic Strain)
  29. Intermittent Cyclic Strain Optimizes Total Collagen I Production
  30. Cyclic Strain Causes Cytoskeletal Alignment Control Cyclic Strain 200x 200x
  31. The Next Step: Tendon Bioreactor
  32. Clinical Relevance
    • Flexor tendon losses
    • Biopsy from patient
      • Intrasynovial tendon from hand or foot
      • Adipoderived stem cells
    • Expand autologous cells in culture
    • Banked allogenic acellularized scaffolds
    • Seed acellularized scaffolds to create constructs
    • Reconstruct flexor tendon losses
  33. Tissue Engineered Flexor Tendon Seeded construct prior to reimplantation
  34. 4. True outcomes data for best method of repair and rehabilitation Tang JB. Clinical outcomes associated with flexor tendon repair. Hand Clin 2005, 21:199-210.
  35. Controversies that persist
    • Suture repair technique?
    • Grasp vs. lock?
    • Fiberwire?
    • Suture caliber?
    • 4 - 6 - 8 strand repair?
    • Repair FDS and FDP?
    • Repair sheath?
    • Sacrifice A4 pulley?
    • Rehabilitation method?
  36. Repair types in the Stanford program Epi Last 4 Strand Locking 4-0FW Curtin Epi 1st/last 4 Strand Grasping 3-0FW Gutow Epi Last 2 Strand Grasping 3-0 Nguyen Epi 1st 4 Strand Grasping 4-0Pro Maser Epi Last 4 Strand Grasping 4-0FW Buncke Epi Last 4 Strand Locking 4-0FW C. Lee Epi 1st 4 Strand Grasping 4-0Pro Press Epi Last 4 Strand Locking 3-0 G. Lee Epi Last 4 Strand Locking 4-0FW Yao Epi 1st 4 Strand Locking 3-0Ethi Chang Epi Last 2 Strand Locking 4-0 Ladd Epi 1st 4 Strand Grasping 4-0 Hentz
  37. The Problem
    • Different injuries
    • Different repairs
    • Different post-op regimens
    • One Cochrane review on postoperative therapy: inconclusive
    • No multicenter trial
    • Ideal topic for the new ASSH Clinical Trials and Outcomes Committee
  38. A Plea for Support of Research
    • Basic science research for modulating flexor tendon repair and reconstruction
    • Clinical research for establishing a true multi-center trial on outcomes of Zone II flexor tendon repair
    • Flexor tendon repair -
      • All hand surgeons face this clinical problem
      • Hand surgeons are the only group who care to advance this field

+ Saba KamalSaba Kamal, 3 years ago

custom

2393 views, 2 favs, 0 embeds more stats

Tendon Future for therapists.
Future of flexor/ext more

More info about this document

© All Rights Reserved

Go to text version

  • Total Views 2393
    • 2393 on SlideShare
    • 0 from embeds
  • Comments 4
  • Favorites 2
  • Downloads 0
Most viewed embeds

more

All embeds

less

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate. If needed, use the feedback form to let us know more details.

Cancel
File a copyright complaint
Having problems? Go to our helpdesk?

Categories