Extensor tendons: can we design a simpler classification zone system?

We summarize the attention that has been drawn to and the thought process about the complexity of current classification zones of extensor tendons. A possible new, simpler classification was proposed by the lead author and discussed with the co-author. A simplified classification is presented with rationale, mainly based on the simplified treatment strategies used by the authors. We also discuss the possible drawbacks and call for investigations on this topic to make the current treatment strategies less complex. An updated system should be based on improved understandings of clinical treatment, including an increasing trend of using conservative treatment for closed injuries and strong surgical repair methods for open injuries of extensor tendons.

Artificial dermal repair for larger finger pulp defects: Satisfactory coverage with limitations in sensation and inevitable scar formation.

BACKGROUND: This prospective study aimed to evaluate the outcomes of the use of dermal templates for lengthy volar soft tissue defects (1.5-4 cm) in the fingers. METHODS: The volar soft tissue defects of 15 patients (19 fingers) were treated with Lando dermal template coverage between June 2022 and November 2022. We evaluated sensory recovery, scar formation, and overall appearance of the repair site at an average of 13 months (range, 12-17 months) of follow-up. RESULTS: The defect healed in all cases. We found an average static 2-point discrimination of 7 mm (range 4 to 14 mm). Scar formation was evident in all cases. The repair did not restore the bulkiness of the volar finger, especially in the finger with the bony exposure. Nail deformities and joint contracture were observed in some cases. CONCLUSION: Dermal template repair does not restore normal sensation and inevitably leads to scar formation when the defect is longer (>1.5 cm). Bulkiness of the volar finger is not restored in most patients, especially when there was bone or tendon exposure in the initial wound site.

Complications of flexor tendon repair.

This article reviews and highlights complications of flexor tendon repairs. Although the outcomes of flexor tendon repairs have improved over the years, fair or poor functional outcomes are seen, especially in patients whose trauma involves multiple structures of the hand and in zone 5 with multiple tendon lacerations. Rupture of the flexor tendon after repair is no longer a major problem if current repair principles are carefully adhered to. Different degrees of adhesion formations and interphalangeal (IP) joint stiffness still occur in a few patients. Early active postoperative mobilization and use of a shorter splint with sparing of the wrist are effective measures to prevent adhesion formation and IP joint stiffness. Given the overall poor results and high rate of complications with flexor digitorum profundus (FDP) repairs in zone 1, a direct repair of the FDP tendon to any short remnant of the distal insertion with 10-strand or even stronger core suture repair is adopted by many units.

Diagnostic and treatment recommendations for recurrent or persistent symptoms after trapeziectomy: a Delphi study.

The aim of this Delphi study was to provide a diagnostic and treatment algorithm for patients with persistent or recurrent symptoms after trapeziometacarpal joint resection arthroplasty. Three Delphi rounds were conducted in which surveys were sent to 182 experienced hand surgeons worldwide. Responses were received from 140 participants. A consensus threshold was set at 67% agreement. Diagnostic tools and treatment approaches for six common revision scenarios achieved consensus. Radiographs are appropriate as primary (97%) and CT scans as secondary (76%) diagnostic tools. For scaphometacarpal impingement, 67% of respondents agreed that revision interposition is appropriate, with 93% recommending autologous tendon for the interposition. Additional suspension was considered appropriate by 68% of the participants. The diagnostic and treatment algorithm can help the surgeon to identify the reason for persistent symptoms after trapeziometacarpal joint resection arthroplasty and to choose an appropriate treatment strategy.Level of evidence: V.

Healing strength of tendon repair with or without knots between two tendon ends and histological changes in a chicken model.

We studied the healing strength and histological changes of digital flexor tendons repaired using Kessler (core suture knots placed over the tendon surface) and modified Kessler (core suture knots placed between two tendon ends) in 31 long toes of chicken. Four weeks after surgery, the healing tendons were measured in a tensile testing machine, and the adhesion formation and histological changes were observed. The strength of the Kessler repairs was significantly greater than that of the modified Kessler repairs with a 35% mean difference. No significant difference was found between the adhesion scores of the tendons repaired with both techniques. In histological sections, the arrangement of collagen fibers in the modified Kessler repair group was more disordered. We conclude that the tendons repaired with the Kessler method are stronger than those with the modified Kessler technique. The knots between tendon ends are detrimental to the early healing strength of digital flexor tendons.

What to Retain and What to Change in Asian Hand Surgery.

Notice of Editorial Error - Tang JB. What to Retain and What to Change in Asian Hand Surgery. J Hand Surg Asian Pac Vol. 2023 May 5. doi: 10.1142/S2424835523300013. The Journal of Hand Surgery Asian-Pacific Volume (JHS-AP) has rescinded the above paper from journal's website. An edited version of this article has been previously published in the February 2023 issue (Tang JB. Towards Better Hand Surgery. J Hand Surg Asian Pac Vol. 2023 Feb;28(1):1-4. doi: 10.1142/S2424835523400015). It was accidentally given a new DOI number in the article production process due to an editorial error. The online version of the above paper (Tang JB. What to Retain and What to Change in Asian Hand Surgery. J Hand Surg Asian Pac Vol. 2023 May 5. doi: 10.1142/S2424835523300013) has been removed from the JHS-AP webpage and all hosting service providers have been informed of this move. The editors apologise for this error.

Flexor Tendon Repair Techniques: M-Tang Repair.

The authors present the methods and outcomes from six institutes where M-Tang repairs with early active flexion exercise are used for zone 2 digital flexor tendon repair. The authors had close to zero repair ruptures, and few digits needed tenolysis. The excellent to good results are generally between 80% and 90%. In the pandemic period, less stringent therapy supervision might have allowed some patients to move too aggressively, with repair ruptures not seen before the pandemic in one institute. In Nantong, Yixing, and Saint John, the rupture incidence is zero to 1%. In Florence and Heidelberg, the rupture incidence was 3%.

Debris flow characteristics of the compound channels with vegetated floodplains.

Compound cross-sections with vegetated floodplains are a common type of cross-section in debris-flow gullies. Floodplain vegetation participates in large-scale debris flow events and regulates debris-flow discharge. Extensive research has been conducted on the water flow characteristics of compound rivers. However, few studies have investigated the debris flow characteristics of compound channels in mountainous areas, particularly those of debris flow and flash flood inundation areas with vegetation. This study discusses the section characteristics of debris flow gullies with vegetated floodplains, gully evolution processes, and their influence on debris flow. The results show that the compound debris flow gully with a vegetated floodplain is formed in the gully from the mature stage to the old-mature stage. The compound sections are developed in flow areas with a gentle slope, which can be bilateral floodplain, unilateral floodplain, and multi-main gully floodplain types. Owing to the vegetation of the floodplain, the roughness of the channel increases, which makes the beach roughness coefficient much larger than that for the main channel. In the integrated Manning coefficient method, the error in resolving the flow velocity and discharge is large and cannot reflect the difference in velocities of the floodplain and main channel, therefore the sectional splitting method is most applicable. Influencing debris flow movement, limiting channel migration, and retaining debris flow to the main channel were the main contributions of the riparian forest zone.

Some Misconceptions in the Treatment of Cubital Tunnel Syndrome, Radial Tunnel Syndrome, and Median Nerve Compression in the Forearm.

This article discusses ulnar, median, and radial nerve compression in the proximal forearm and elbow and some possible common misconceptions. In particular, the ligament of Struthers extremely rarely causes ulnar neuropathy. Lacertus syndrome and flexor superficialis-pronator syndrome can be diagnosed separately. Surgical release can be through a small incision. Acronyms for compression to radial nerve in proximal forearm can be simplified to radial tunnel syndrome, which includes a mild type (classical radial tunnel syndrome) and a severe type (posterior interosseous nerve (PIN) compression).

Direct Repair of Flexor Tendons Close to Bony Insertion and Ruptured Collateral Ligaments.

Lacerated flexor tendons close to bony junction are commonly repaired using a pullout suture. However, these injuries very close to the tendon-bone junction can be repaired with robust direct suture repair of the proximal tendon stump with the short residual tendon stump and any local tissues such as periosteum and joint volar plate. Subacute or chronic traumatic rupture at the midpart of the collateral ligaments can also be repaired by "refreshing" the divided ligament ends and repairing the ligament stumps to local tissues with multiple sutures often combined with tightening the elongated joint capsule.

10 Hypotheses in Hand Surgery.

I have put together 10 topics and labeled them as hypotheses, which outline my preferred practices. The topics relate to questionable nerve compression, double crush syndrome of nerves, motion therapy after surgery, delayed primary tendon repair, proximal pole fracture of the scaphoid, short splint, and indications for postoperative hand elevation. I found no proof whether my preferred methods are better than or inferior to alternative methods that others use. The 10 hypotheses are presented to stimulate thinking, clinical observation, or investigations and highlight several areas of research. Investigation into these hypotheses may avoid unnecessary treatment or improve postsurgical comfort for patients and long-term outcomes of treatment.