R. Savage

In Vitro Studies of a New Method of Flexor Tendon Repair

The mechanical factors in tendon repair have been studied and physical principles applied to this unsolved problem. A new technique of tendon repair has been derived and tested in the laboratory. Compared to several well known techniques it has been shown to have three times the tensile strength and to allow one tenth the gap to form between the tendon ends under load. It has been designed not to constrict the blood supply of the tendon and the tests indicate that it will be strong enough to allow early active mobilisation even after inflammation has caused the tendon to soften.

Free latissimus dorsi muscle flap with skin graft for treatment of traumatic chronic bony wounds.

Based on this review of 35 cases of chronic bony wounds, it would appear that the free-muscle flap method of wound closure and nourishment after thorough dead bone debridement is an attractive and successful alternative to local skin flaps, staged skin flaps, or extend skin-muscle flaps in areas where reliable muscle flaps are not available. It would also seem that the latissimus dorsi muscle flap with skin graft is an ideal donor-muscle transfer with features allowing a favorable and contoured surface in the recipient site and minimal aesthetic and functional deformity in the donor site.

Current Practice of Primary Flexor Tendon Repair: A Global View

In this article, a group of international leaders in tendon surgery of the hand provide details of their current methods of primary flexor tendon repair. They are from recognized hand centers around the world, from which major contributions to the development of methods for flexor tendon repair have come over the past 2 decades. Changes made since the early 1990s regarding surgical methods and postoperative care for the flexor tendon repair are also discussed. Current practice methods used in the leading hand centers are summarized, and key points in providing the best possible clinical outcomes are outlined.

The search for the ideal tendon repair in zone 2: strand number, anchor points and suture thickness

This review article examines the mechanical factors involved in tendon repair by sutures. The repair strength, repair stiffness and gap resistance can be increased by increasing the number of core strands and anchor points, by increased anchor point efficiency and the use of peripheral sutures, and by using thicker sutures. In the future, laboratory tests could be standardized to a specific animal model and to a defined cyclic motion programme. Clinical studies support the use of multi-strand core and peripheral sutures, but two-strand core sutures are not adequate to ensure consistently good clinical results. Training surgeons in complex tendon repair techniques is essential.

Elective cross-hand transfer: A case report with a five-year follow-up

The elective free microvascular cross-hand transfer of the right hand to the left distal carpus was successfully performed in a 35-year old professional photographer. Traumatic loss of the left hand with preservation of a useful thumb and concomitant right upper extremity injury leaving the right hand with an amputated thumb, but paralyzed and insensate from a brachial plexus palsy 5 years before transfer, set the stage for such a reconstruction. Multiple immediate tendon transfers and primary nerve grafting provided for finger flexion and extension plus functional sensibility in this first reported case of an elective cross-hand microvascular transfer. Five years follow-up demonstrates useful and powerful flexion, and functional extension of digits in the reconstructed left hand and right upper extremity function has been improved with a below-elbow prosthesis.

Experience of the early use of technetium 99 bone scintigraphy in wrist injury

In a retrospective study, patients with suspected scaphoid fracture had an average of three sets of scaphoid radiographs prior to scintigraphy. Scans were performed an average of 3 months after injury and many were inconclusive because of disuse changes. A prospective analysis of early scintigraphy in 35 cases over 18 months was carried out. Scans were performed at an average of 15.5 days after injury in selected cases. Patients had an average of 1.28 sets of negative radiographs prior to scanning. There were no false negative scans and in 13 with focal uptake a wrist fracture was demonstrated. Diffuse uptake was thought to be indicative of ligamentous damage or reflex sympathetic dystrophy. Early scintigraphy was found to be a sensitive, reliable and cost-effective examination in cases of suspected significant wrist injury.

MRI ASSESSMENT OF THE PROXIMAL POLE OF THE SCAPHOID AFTER INTERNAL FIXATION WITH A TITANIUM ALLOY HERBERT SCREW

We report a series of scaphoid fractures fixed with titanium alloy Herbert screws in which postoperative Magnetic Resonance Imaging (MRI) was used to assess the marrow signal in the proximal pole of the scaphoid and thus detect the presence of avascular necrosis. The artefact produced by the titanium alloy Herbert screw did not preclude this assessment.

History and Nomenclature of Multistrand Repairs in Digital Flexor Tendons

Multistrand core suture repairs have become the mainstay of digital flexor tendon repair in recent decades. Here we briefly describe the history of the development of these multistrand repair methods and their correct nomenclature. A historical account, their evolution, the correct use of nomenclature, and some technical points are reviewed.

INTRAMUSCULAR TENOTOMY OF FLEXOR DIGITORUM SUPERFICIALIS IN THE DISTAL FOREARM AFTER SURGICAL EXCISION OF DUPUYTREN'S DISEASE

Contracture of the proximal interphalangeal joint after surgery to excise Dupuytren’s disease, despite release of the contributory structures within the finger, can be caused by flexor digitorum superficialis (FDS) contracture. We describe five cases where FDS contracture was released by intramuscular tenotomy in the distal forearm. Standard postoperative therapy for Dupuytren’s fasciectomy was used and clinical review showed improved finger extension with no loss of strength. We suggest that intramuscular tenotomy of FDS in the forearm can be used safely where indicated after excision of the Dupuytren’s disease.

Angular correction related to excision of specific cords in fasciectomy for Dupuytren's disease.

Named cords were excised sequentially at fasciectomy for Dupuytren’s disease and the resultant correction in the joint angle was measured intra-operatively in 99 fingers. Eighty-two metacarpophalangeal and 59 proximal interphalangeal joints were affected. At the metacarpophalangeal joint, excision of the central cord resulted in 82% correction in 69 joints, and spiral/lateral cord excision resulted in an additional 12% correction in 10 joints. At the proximal interphalangeal joint, excision of the central cord resulted in 44% correction in 36 joints, spiral/lateral cord excision resulted in an additional 19% correction in 16 joints, and retrovascular cord excision resulted in a further 23% correction in 27 joints. Subsequent division of the accessory collateral ligament resulted in a further 14% correction in 14 joints. Larger pre-operative angles of the proximal interphalangeal joint were associated with a retrovascular cord, and larger combined angles were associated with an increasing number of pathological structures involved. The data explain the complexity of surgery at the proximal interphalangeal joint, where four structures are implicated in causing flexion deformity.