Flexor Tendon surgery

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Flexor tendon surgery & it's anatomical basis

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Flexor Tendon surgery

  1. 1. 2012.4.27 서울 현대병원 정 순영
  2. 2. Anatomy of Flexor Tendon
  3. 3. *Origin 2 muscle bellies - medial epicondyle - radial shaft * tendons arise form separated muscle bundles act independently
  4. 4. * Origin ulna & interosseous membrane * commom muscle origin for several tendons act simultaneous flexion of multiple digits
  5. 5. 1. Synovial fluid :produced within tenosynovial sheath 2. Blood supply provide by vincular circulation Vascular supply to flexor tendon
  6. 6. Suprative tenosyovitis Kanavel’s 4 cardinal sign
  7. 7. system  Nutrition of tendon  Suspensory ligament of tendon  Stabilization of tendon
  8. 8. 9cm : wrist & digital flexion 2.5cm : full digital flexion with wrist neutral position DIP ( FDP ) & PIP ( FDS,FDP ) joint motion 10 degrees : 1.5mm excursion MP motion : no flexor tendon excursion
  9. 9. Welcome to Real World !
  10. 10. Is it necessary ?
  11. 11. * primary tendon repair : < 12 hrs ( 24 hrs ) * delayed primary repair : 24 hrs ~ 10 days * early secondary repair : 10 days ~ 4 weeks * late secondary repair : > 4 weeks Myofibrosis Prefer tondon graft
  12. 12. How ? ( suture technique )
  13. 13. Sourmelis and McGrouther’s Method
  14. 14. A. Conventional Bunnel stich B. Crisscross stich C. Mason-Allen( Chicago ) stich D. Kessler grasping stich E. Modified Kessler stitch with single knot at repair F. Tajima modification of Kessler stitch with double knots at repair site
  15. 15. - Tajima core sutures in place - Back wall running-lock peripheral epitendinous stitch - Mattress core suture - Completion of running-lock peripheral epitendinous suture
  16. 16. *Proportional to number of strands - 6 and 8 strand repairs strongest steep learning curve 4-strand repair adequate strength without complexity of 6 ~ 8 strands • increased bulk and resistance to glide • increased tendon healing and adhesion formation • May not be necessary for forces of early active motion
  17. 17. Inner side Outer side : interference with healing : interference with tendon gliding
  18. 18. *Providing a barrier for adhesion formation *Restoring synovial fluid nutrition *Restoring the sheath mechanics Technically difficult Increased foreign material at repair site May narrow sheath and restrict glide VS
  19. 19. *Intrinsic tendon healing : differentiation of fibroblasts from epitenon ( tenocyte ) : collagen synthesis occurred primarily within the endotenon cells : vascularity of tendon bed - important *Extrinsic tendon healing : activity of peripheral fibroblast : peripheral adhesions No Adhesion Take Home Message !!
  20. 20. * Inflammatory phase : phagocytosis 3 ~ 5 days * Fibroblastic or collagen-producing phase : neovascularization, peripheral adhesion 5 ~ 3-6 weeks * Remodeling or maturation phase : arrangement of fiber 6 ~ 9monts Tendon weakest at 10 ~ 14 days Take Home Message !!
  21. 21. Zone I : distance < 1cm  direct insertion into distal phalanx ( Advancement repair )
  22. 22. Uneven tension : too tight  lengthen of tendon at wrist tendon graft
  23. 23. • Can be advanced without disturbing its blood supply ( does not have vinculum ) • Lengthening of tendon at writ by Z plasty may be required
  24. 24. Post-Operative Rehabilitation
  25. 25. * Heal faster * Gain tensile strength faster * Have fewer adhesions * Better excursions Take Home Message !!
  26. 26. * Kleinert : Active extension, Passive flexion by rubber bands * Duran : controlled passive motion * Strickland : early active ROM Goal : Full active ROM at 10 ~ 12 weeks
  27. 27. Duran protocol Wrist 30 flexion MP joint 50~70 flexion IP joint allow to extension
  28. 28. Kleinert Protocol Wrist 35 flexion MP joint 60~70 flexion IP joint full extension Elastic band : proximal 8~10cm from wrist joint
  29. 29. The ideal treatment of flexor tendon injuries under almost every circumstance is primary repair
  30. 30. Hope the Best Prepare the Worst
  31. 31. Too little motion Too much motion Stiffness Rupture
  32. 32. *Severe injury *Make excessive amounts of scar tissue *Have not co-operated with therapy : low pain thresholds social circumstances stupidity Mostly complication of primary repair : ruptured & adherent primary repairs Healings of either “ bad injuries ” or “ bad patients ”
  33. 33. One stage
  34. 34. By 4 ~ 6 weeks, pseudosheath formation two stage
  35. 35. *The skin is pliable *Any wounds are well healed *Edema has subsided *The joints allow a full passive range of motion *Sensation in finger is normal ( at least one ) A2 & A4 pulley systems also should be intact
  36. 36. * palmaris longus * plantaris tendon * long extensors of toes
  37. 37. Take Home Message !!
  38. 38. cascading Determining tension
  39. 39. Thumb located In front of index IP joint : 30 degree flexion Wrist neutral position
  40. 40. Tendon reconstruction risks worsening finger function Tenodesis Arthrodesis
  41. 41. *Paradoxical extension of the IP joints while attempting to flex the fingers *Most commonly caused by FDP laceration distal to the origin of limbricals 3rd finger m/c involve  Tenodesis of FDP to terminal tendon  Reinsertion to distal phalanx  Lumbrical release Tx
  42. 42. * at least 3 months pass * some situations 4 ~ 6 months may be required to make an accurate assessment of patient’s progress Take Home Message !!
  43. 43. Extensive shortage of skin
  44. 44. Do you know ?
  45. 45. What I want to be

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