Flexor tendon repair : rehabilitation adherence, outcome and complications

Flexor tendon injuries in the finger (zones 1 and 2) are problematic due to high rates of both rupture of the repair and of soft tissue adhesions resulting in poor range of motion. Both complications often result in reoperations and worse outcome of the injury. Rehabilitation after flexor tendon repair is a balancing act for the patient. The exercise and daily activities of the hand need to be at enough force to avoid soft tissue adhesion forming which restrict finger motion but still with low enough force to avoid rupture of the repaired tendon. This creates high demands on patient’s adherence while coping with the injury in everyday life. The literature describes the importance of adherence but, there is little evidence in terms of how to improve and understand patient adherence to flexor tendon rehabilitation. Risk factors for the two most common reasons for reoperations have been studied but there is a lack of studies including detailed variables about the repair, the injury and the patient. The outcome after flexor tendon repair is often reported as a classification into a category; poor, fair, good or excellent based on the finger range of motion. This classification could be criticized as being too simplistic for a complex injury, but still there is little known about how the patients´ perceptions of their outcome corresponds to these classifications. The overall aim of this thesis was to improve and explore rehabilitation adherence and outcome, including a smartphone intervention and patients´ perspectives, and to explore complications after flexor tendon repair and rehabilitation. In paper 1, a total of 101 patients were included at the start of early active motion rehabilitation after their flexor tendon repair. Patient were randomised to rehabilitation with the aid of a smartphone application or according to standard rehabilitation. Patients adherence, self-efficacy and range of motion were then assessed at baseline, and two, six and 12 weeks after repair. There were no overall differences between the groups in range of motion, adherence, or self-efficacy. In paper 2, Seventeen patients with flexor tendon repairs were interviewed after three months of early active motion rehabilitation. The interviews were then transcribed and analysed according to deductive content analysis based on the health belief theory. The results are described in six categories: perceived susceptibility to loss of hand function; perceived severity of the injury; perceived relationship between cost, benefits and efficacy of rehabilitation; perceived self-efficacy; relationship between patient and practitioner; and external factors. In paper 3 data was collected from the Swedish national hand surgery registry (HAKIR) and Statistics Sweden (SCB) on a cohort of patients with flexor tendon repair between 2010 and 2019. A total of 1375 patients were identified and followed for at least one year to assess reoperation due to rupture or tenolysis. The result showed that 5% of patients had been reoperated due to rupture and 4.8% due to tenolysis. There was an increased risk of rupture in male patient, age above 25 and in patients where the FPL tendon had been repaired. If both the FDP and FDS tendons were repaired, it increased the risk for both tenolysis and rupture. With increasing income, the frequency of tenolysis increased. In paper 4 we collected data from HAKIR on patient with flexor tendon repair between 2010 and 2020. We then used data on patients with a complete set of data from the patient questionnaires and functional assessments of range of motion at three and 12 months after repair. The patient questionnaire included the HQ-8, Quick-DASH and perceived satisfaction with results. We assessed 215 patients at three months after repair, and 150 patients at 12 months. We calculated the association between patient reported outcome and the Original Strickland classification. As perceived stiffness increased the OR of being in a higher Strickland level decreased, although perceived stiffness could only discriminate between the independent levels of fair and good. An increased Quick-DASH score decreased the OR of being in a higher Strickland level, although only between fair and poor results at three months. As perceived satisfaction with result increased, the OR of being in a higher Strickland level also increased. But perceived satisfaction could only discriminate between the levels of fair and good at twelve months. In conclusion, the smartphone application did not increase the adherence, self-efficacy or range of motion during the first three months of rehabilitation. Patients’ perceptions of the injury, the rehabilitation, and the context and support during rehabilitation affects adherence. Several risk factors were associated with reoperation due to rupture or tenolysis, namely male sex, age above 25, injury to FPL or both FDP and FDS. Patient-reported outcome only corresponded with some independent levels of Strickland and the classification of range of motion into poor, fair, good and excellent may thus add little value to the patients. Understanding the risk factors, the constructs related to adherence and patient-reported outcome may give important knowledge to surgeons and therapists when treating patients with flexor tendon injuries

Regenerative Medicine Applied to Musculoskeletal Diseases in Equines: A Systematic Review

[EN] Musculoskeletal injuries in horses have a great economic impact, predominantly affecting tendons, ligaments, and cartilage, which have limited natural regeneration. Cell therapy, which uses mesenchymal stem cells due to their tissue differentiation properties and anti-inflammatory and immunoregulatory effects, aims to restore damaged tissue. In this manuscript, we performed a systematic review using the Parsifal tool, searching the PubMed and Web of Science databases for articles on regenerative medicine for equine musculoskeletal injuries. Our review covers 17 experimental clinical studies categorized by the therapeutic approach used: platelet-rich plasma, conditioned autologous serum, mesenchymal stem cells, and secretome. These therapies reduce healing time, promote regeneration of fibrocartilaginous tissue, improve cellular organization, and improve joint functionality and sustainability. In conclusion, regenerative therapies using platelet-rich plasma, conditioned autologous serum, equine mesenchymal stem cells, and the emerging field of the secretome represent a promising and highly effective approach for the treatment of joint pathologies in horses, implying a valuable advance in equine healthcare.SIThis research received no external funding

Revolutionizing PIP joint fracture treatment: A case of surgical precision and rapid recovery

Introduction: Proximal interphalangeal joint (PIPj) fractures are a common yet challenging injury, particularly in athletes. This case study explores innovative surgical techniques combined with targeted rehabilitation to optimize recovery and functionality. Case presentation: A 20-year-old male soccer goalkeeper sustained a severe Proximal Interphalangeal Joint fracture-dislocation of the third finger during a game. He was treated using the wide awake local anesthesia no tourniquet (WALANT) technique and a Medartis TriLock plate, originally designed for the proximal phalanx but adapted for use on the middle phalanx. Clinical discussion: Immediate postoperative mobilization was facilitated by the WALANT technique, enhancing pain management and functional recovery. The adaptation of the TriLock plate, typically not used in this context, proved crucial for stabilizing the complex fracture. Follow-up included regular physiotherapy, focusing on mobility exercises and strength training, which were instrumental in the patient's quick return to sport. Conclusions: This case underscores the effectiveness of combining innovative surgical adaptations with early rehabilitation in treating complex hand injuries. Such approaches can lead to successful outcomes, significantly improving recovery times and functional results in athletic populations. This strategy may set a precedent for future treatment protocols in sports-related hand injuries

Anatomical and histomorphometric observations on nerve transfer in the distal forearm for the reconstruction of hand function

In the past century, significant understanding in the field of peripheral nerve surgery has been made with the increasing advances of microsurgical techniques and knowledge of topography of peripheral nerves as well as the cellular and molecular events. As our understanding of nerve injury and repair increases, new techniques of nerve repair including nerve autograft, nerve allograft, tendon transfers and nerve transfers have been performed in the clinic. Although autografting is still the gold standard of nerve repair when possible, nerve transfers have gained great popularity among surgeons especially in the distal forearm for wrist and hand functional reconstruction. The most frequently distal nerve transfer is the transfer of the AIN to the DBUN for intrinsic hand reconstruction. Specific successful nerve transfer of the AIN to the DBUN has stimulated us to transfer the AIN to the TBMN to reconstruct the thenar muscle function and transfer the DBCUN to the SBRN or the SMN for sensory reconstruction. As previously reported, the AIN can be sacrificed because the loss of pronation function in the forearm can be compensated by the pronator teres muscle and the DCBUN can be cut because the medial dorsal side of the hand is a non-critical area. This feature of the AIN and the DCBUN allows us to use them as donor nerves which meet the technical point of nerve transfer in the upper extremity ‘donor distal, recipient proximal’. Therefore we cut the AIN at the proximal border of the pronator quadratus muscle and the DCBUN before the first bifurcation in order to maximize the axon number and decrease the regeneration distance. For the recipient nerve, we transected the SMN and the TBMN proximally enough so that they can be mobilized to allow a tension-free coaptation. Moreover, divided proximally can avoid necessity for nerve grafting as well as axon misdirection, which could substantially downgrade the functional recovery. There are two sides for everything and that certainly is time for nerve transfers as well. The major drawback of nerve transfers is sacrificing a viable nerve for an injured one, losing or diminishing the function of a muscle for more important functions, or to sacrifice a non-critical area’s sensation for critical area’s sensation. For surgeons, we need to take a risk-to-benefit ratio into consideration before we perform the operation. Therefore the anatomic and histomorphomoetric data of the nerves are crucial for us when we tailor the plan for the patient individually. In keeping with this, anatomical and histomorphometric data of nerve transfers including the motor nerve transfer from the AIN to the TBMN and sensory transfer from the DCBUN to the SBRN and the SMN were tested and documented in our study, which provided a basis for managing the peripheral nerve lesions in the hand. The nerve transfers were performed in 15 fresh cadaver specimens.The overall length of the forearm was documented 252 ± 6.0 mm from the lateral epicondyle of the humerus to the styloid process of the radius. Nerve samples were transected from the distal side of the donor nerve and proximal side of the recipient nerve at coaptation site for histomorphometric observation. The tension-free coapation sites were measured with relation to the anatomical landmarks. In the motor nerve transfer study, our anatomic data indicate that the AIN is a suitable donor nerve for the TBMN. Donor nerve and recipient nerve can be coapated in a tension-free manner after the SMN and the TBMN were proximally divided and mobilized over a length of 97 ± 4.0 mm to reach the coaptation site. It appears that an optimal site for coaptation of the AIN and the TBMN is at the proximal edge of the PQ which was recorded as 202 ± 4 mm distal from the lateral epicondyle of the humerus. Comparison of the AIN to the TBMN, the AIN has significantly less density, smaller diameter, fascicle and nerve cross-sectional area, but a comparable fascicle number. The axon ratio of the AIN to the TBMN is 1:3.7 which was slightly less than the commonly accepted successful threshold 1:3, but multivariate analyses have shown that 3-4 collaterals can be developed by one axon; hence we think that the AIN is a suitable donor nerve for the TBMN. In addition to the directly end-to-end suture, the SETS AIN-to-DBUN transfer has been described with excellent result in an incomplete injury of the ulnar nerve. This clinical scenario provides us a new choice for the reconstruction of thenar muscle by the SETS AIN-to-TBMN transfer. In the sensory nerve transfer, our anatomic data show that the DCBUN was a suitable donor nerve for the SMN and the SBRN. In order to maximize the axon number of the donor nerve, the DCBUN was cut prior to its first bifurcation.The SBRN was transected prior to its first bifurcation, which made the donor nerve axons grow into the whole recipient to supply the lateral dorsal hand. The SMN was separated from the TBMN over a distance of 82 ± 6 mm which ensured a tension-free copatation with the DCBUN. Histomorphometric data indicate that there were no significant differences (p < 0.05) between donor and recipient in terms of total fascicle number, fascicle area, nerve diameter, nerve area and axons. Based on these results, the DCBUN can be accepted as a suitable donor nerve for sensation restoration in the hand. In the past decade, accompanying with the development of nerve reconstruction from nerve grafts to nerve transfers, the difficulties and possibilities of motor or sensory nerve transfers were concern by many peripheral nerve surgeons. One of the greatest concerns of surgeons was the nerve reeducation after operation. Clinically, many transfers are performed with little or even with no training. But it is known that rehabilitation is helpful by recruiting the donor muscle groups preoperatively and repeating these activities until reinnervation is recognized. In keeping with this, early rehabilitation of the motor and sensory functions should be encouraged for the patient. With the increasing understanding of the nerve topography and redundancy as well as the advances of the basic science and clinical research, potential nerve reconstructions with end-to-end, end-to-side and reverse end-to-side transfers will continue to be expanded and become available

The Physiological Mechanisms of Effect of Vitamins and Amino Acids on Tendon and Muscle Healing: A Systematic Review

© 2018 Human Kinetics, Inc.To evaluate the current literature via systematic review to ascertain whether amino acids/vitamins provide any influence on musculotendinous healing and if so, by which physiological mechanisms. Methods: EBSCO, PubMed, ScienceDirect, Embase Classic/Embase, and MEDLINE were searched using terms including "vitamins," "amino acids," "healing," "muscle," and "tendon." The primary search had 479 citations, of which 466 were excluded predominantly due to nonrandomized design. Randomized human and animal studies investigating all supplement types/forms of administration were included. Critical appraisal of internal validity was assessed using the Cochrane risk of Bias Tool or the Systematic Review Centre for Laboratory Animal Experimentation Risk of Bias Tool for human and animal studies, respectively. Two reviewers performed duel data extraction. Results: Twelve studies met criteria for inclusion: eight examined tendon healing and four examined muscle healing. All studies used animal models, except two human trials using a combined integrator. Narrative synthesis was performed via content analysis of demonstrated statistically significant effects and thematic analysis of proposed physiological mechanisms of intervention. Vitamin C/taurine demonstrated indirect effects on tendon healing through antioxidant activity. Vitamin A/glycine showed direct effects on extracellular matrix tissue synthesis. Vitamin E shows an antiproliferative influence on collagen deposition. Leucine directly influences signaling pathways to promote muscle protein synthesis. Discussion: Preliminary evidence exists, demonstrating that vitamins and amino acids may facilitate multilevel changes in musculotendinous healing; however, recommendations on clinical utility should be made with caution. All animal studies and one human study showed high risk of bias with moderate interobserver agreement (k = 0.46). Currently, there is limited evidence to support the use of vitamins and amino acids for musculotendinous injury. Both high-quality animal experimentation of the proposed mechanisms confirming the physiological influence of supplementation and human studies evaluating effects on tissue morphology and biochemistry are required before practical application.Peer reviewe

Prevalence, diagnosis and management of musculoskeletal disorders in elite athletes: A mini-review

[Abstract] Musculoskeletal injuries in elite sports are ones of the most impact issue because their remarkable impact on performance caused by drastic absence of training and competition and a progressive deterioration in physical health, emotional and social athletes’ dimen- sions. Also, the prevalence of epidemiologic research found an incidence of musculoskeletal disorders vary within sports and in elite athletes which is even higher as a consequence of higher demand physical performance. This way, the loss of physical performance due to an sport injury impacts not only the individual economic sphere of the professional but also that of sports entities, reaching, according to some studies, a loss estimated in the range of 74.7 million pounds. Thus, the purpose of this article is to review and to pro- vide an overview of the most common musculoskeletal injuries in elite sports precipitating factors, clinical presentation, evidence-based diagnostic evaluation, and treatment recom- mendations with a view to preventing medical conditions or musculoskeletal injuries that may alter performance and general health in the elite athletes