Arthrodesis of the wrist for post-traumatic disorders.

We retrospectively reviewed the records of eighty-nine consecutive patients (ninety wrists) who had had a total arthrodesis of the wrist for the treatment of a post-traumatic disorder at one center. Fifty-six patients (fifty-seven wrists) had the arthrodesis with plate fixation, and thirty-three patients (thirty-three wrists) had the arthrodesis with a variety of other techniques. The average age of the patients at the time of the arthrodesis was forty-two years, and the dominant wrist was treated in forty-two patients. Fifty-six (98 per cent) of the fifty-seven wrists that had been fixed with a plate had a successful union at an average of 10.3 weeks postoperatively. Twenty-seven (82 per cent) of the thirty-three wrists that had been treated with other methods had a successful union at an average of 12.2 weeks postoperatively. The difference in the rates of union between the wrists fixed with a plate and those treated with alternative techniques was significant (p = 0.009; Fisher exact test). A total of thirty-nine complications were associated with twenty-nine (51 per cent) of the fifty-seven arthrodeses with plate fixation. Sixteen (41 per cent) of the complications (thirteen wrists) resolved with non-operative treatment. Twenty-six (79 per cent) of the thirty-three arthrodeses with alternative methods of fixation were associated with a total of twenty-nine complications. Twenty-three (79 per cent) of those complications (twenty wrists) resolved with non-operative treatment. The difference between the rate of complications associated with the arthrodeses with plate fixation and that associated with the arthrodeses with alternative methods of fixation was significant (p = 0.03; Fisher exact test).

Management of acute flexor tendon injuries.

Primary or delayed primary flexor tendon repair of both the profundus and superficialis tendons should be carried out in almost all patients. The use of nonabsorbable sutures with a modified Kessler or Tajima repair technique has proved to be effective. Whenever possible, repair of the flexor tendon sheath is appropriate. A well-supervised program of early motion using either active or passive techniques is also beneficial.

Safe carpal tunnel release via a limited palmar incision.

Despite its demonstrated advantages in postoperative recovery, endoscopic carpal tunnel release has not been adopted by most surgeons because of the associated complications of neurovascular injury. A technique of carpal tunnel release is presented that utilizes a 1.0 to 1.5-cm palmar incision and a specially designed carpal tunnel "tome." Any aberrant anatomy of adjacent neurovascular structures may be identified under direct vision. Anatomic dissection in 28 cadaveric specimens following the procedure showed complete decompression of carpal tunnel and preservation with safe margins of the palmar cutaneous branch and thenar motor branch of median nerve, ulnar artery and nerve, and superficial palmar arch. Clinical experience with the technique in two centers consisted of 525 patients and 694 hands over a 29-month period. The great majority of patients derived complete (72.6 percent) or near-complete (19.6 percent) symptomatic relief from the procedure, and two complications (0.29 percent) of median nerve lacerations occurred. Postoperative incisional and pillar tenderness and grip, key pinch, and three-point pinch strengths were comparable with those in published series of endoscopic carpal tunnel release. We conclude that this technique of carpal tunnel release combines the simplicity and safety of traditional open release and the reduced tissue trauma and improved postoperative recovery of the endoscopic modality.

Flexor tendon surgery. Part 2: Free tendon grafts and tenolysis.

We have attempted to review the development and current status of flexor tendon surgery. The methods of acute flexor tendon repair, conventional free tendon grafting, staged flexor tendon reconstruction, tenolysis and pulley restoration have been discussed, with the published results included for each procedure. The role of rehabilitation has also been reviewed and the ongoing quest for an active flexor tendon prosthetic implant has been briefly mentioned. It may be seen that flexor tendon surgery is a complex and difficult art which requires a thorough appreciation of the normal flexor tendon system, the exact status of that system following injury and surgery and a strong understanding of the techniques which may be best utilised to restore tendon gliding and digital joint motion. The procedures described require both technical skill and experience and the post-operative therapy programmes must be carefully chosen for each patient. With the important laboratory and clinical advancements occurring in many areas of flexor tendon surgery, it is realistic to believe that in the future the techniques described here will be substantially altered and modified and to hope that results will continue to improve until the patient and surgeon can expect to restore most digits to nearly full function after flexor tendon interruption.

Strength and functional recovery following repair of flexor digitorum superficialis in zone 2.

A two-pronged study was designed to evaluate the strength in vitro and functional recovery in vivo of FDS repairs in zone 2. In part I, horizontal mattress or Tajima grasping repairs were performed on fresh-frozen cadaveric digits, using 3/0 or 4/0 braided nylon suture material. The Tajima repair was significantly stronger than the mattress suture, using either 3/0 (P = 0.0001) or 4/0 (P = 0.0027) suture material. The 3/0 Tajima repair appeared strong enough to permit gentle early active motion. Furthermore, the clinical portion of the study (part II) demonstrated restoration of FDS function following repair in relatively isolated injuries in 13 out of 15 digits (86.7%), with PIP flexion averaging 80 degrees and grip strength 89% of that in the uninjured hand.

Philosophy of the treatment of athletes.

There is a proliferation of sports medicine physicians whose training is largely in the management of such athletically debilitating conditions as knee ligament and meniscus tears. Physicians with responsibility for the management of the full spectrum of sports-related conditions, including upper extremity injuries, may actually be a disservice to the athlete who may receive less than expert care for his or her injured wrist or hand.

Considerations for the treatment of the injured athlete.

This article discusses the significance that contusions, fractures, or ligament injuries (involving the small bones, joints, and soft tissues of the forearm, wrist, or hand) can have on the athlete. The concern for proper management of upper-extremity injuries is addressed in order to decrease the possibility of long-term function consequences for the athlete.

Flexor tenolysis.

The results of thorough tenolysis of the flexor tendons in the palm and digits in selected patients can be quite gratifying. Preoperative requirements include a well-motivated patient with a supple digit and an established wide discrepancy between the active and passive ranges of digital motion. Careful preservation or reconstruction of annular pulleys and the demonstration of the adequacy of the lysis at the time of surgery are extremely important. A vigorous, protected, and closely monitored postoperative therapy course is critical to the success of the procedure. When this surgical-therapy program proceeds without complication, the improvement in digital flexion has been consistent, often with the restoration of near normal function. The incidence of tendon rupture, infection, or delayed wound healing has been low.

Results of flexor tendon surgery in zone II.

In this article we have attempted to analyze the results of Zone II flexor tendon repair, staged flexor tendon reconstruction, and tenolysis based on cases taken from a single hand surgical practice. Formulas have been offered to determine the percentage return of motion at the PIP and DIP joints utilizing the total active and passive motion measurements. Variation in the formulas for each procedure are necessitated by the preoperative active and passive motion. A common classification system based on the percentage return following each procedure has also been utilized. By employing these assessment methods on digits of our patients who underwent flexor tendon repairs, we achieved the following results: Digits undergoing primary flexor tendon repair in Zone II with postoperative controlled passive motion techniques returned 56 per cent excellent or good function, with 13 per cent in the poor category and 4 per cent experiencing tendon rupture. Staged flexor tendon reconstruction returned 40 per cent excellent or good results with 66 per cent categorized as excellent, good, or fair. Twenty-eight per cent remained in the poor classification, with 7 per cent having ruptures. These results were substantially upgraded by tenolysis of the tendon grafts following Stage II in 47 per cent of all digits. Tenolysis was an effective procedure following a repair or graft and was found to return 67 per cent excellent or good results when carried out for adherent tendon repairs, with 10 per cent in the poor category and an 8 per cent rupture rate. A 65 per cent excellent or good return followed tenolysis of flexor tendon grafts, with 12 per cent judged poor and 8 per cent incidence of rupture. An analysis of the theoretical results of 100 consecutive Zone II flexor tendon repairs following multiple procedures for those digits that had unsatisfactory initial results indicated that, under ideal circumstances, as high as 96 per cent of all digits might be expected to return flexor performance in the excellent or good categories. I acknowledge that the results of flexor tendon procedures are strongly influenced by a wide array of factors, including the patient's age and motivation, the preoperative status of the digit, surgical technique, and postoperative management. An effort has been made here to minimize the variables by including patients taken from a single hand surgical practice and managed, to a large extent, by the same surgeon.(ABSTRACT TRUNCATED AT 400 WORDS)

Opinions and preferences in flexor tendon surgery.

Responses to 378 questionnaires that were completed by members of the American Society for Surgery of the Hand are tabulated. The questionnaire was distributed in January 1984 in an attempt to determine the opinions and preferences of surgeons performing flexor surgery throughout the country. Those polled were asked to answer philosophical questions regarding their approach to flexor tendon repair, grafting, reconstruction, and lysis.

Flexor tendon repair.

In 1979 Verdan wrote, "whatever the situation may be, adhesions are until now certainly not a technically avoidable accident, but rather a consequence of the physiological healing process. As long as we have no technical solution to the problem of accurately maintaining the two cut ends in an intact synovial sheath without interfering with the blood supply, adhesions will remain a biologic inevitability." Although his admonition remains applicable, advances are occurring in our understanding of tendon healing and nourishment, the pulley system, techniques of repair, and the modification of adhesions. Armed with this information, each surgeon dealing with interruptions of flexor tendons must develop a rational, systematic approach to the management of these difficult injuries. The principles of atraumatic technique, as set down many years ago by Bunnell, remain inviolate. Repair procedures should be carried out by surgeons who are thoroughly knowledgeable and well trained in the area of flexor tendon surgery. Primary or delayed primary tendon repair of both the profundus and superficialis tendons should be carried out in almost all patients in all zones of flexor tendon interruption. The use of nonabsorbable sutures with a modified Kessler or Tajima "core suture" has proved to be effective, and, whenever possible, repair of the flexor tendon sheath seems to be appropriate. A well supervised program of early motion utilizing either active or passive techniques is also beneficial in suitable individuals. The restoration of function to a digit following flexor tendon interruption may be a long and tedious undertaking, requiring strong rapport between surgeon, therapist, and patient. When initiating the care of a patient with such an injury, the surgeon should spend considerable time explaining the problems related to the particular injury, the likelihood of achieving success, and the number of procedures that may be required. A high degree of patient motivation must be established to insure the proper participation in the demanding postoperative regimen associated with these procedures. With the important advances occurring in many areas of flexor tendon surgery, it is realistic to believe that in the future the techniques described in this article will be substantially altered and modified. Results should continue to improve until the patient and surgeon can expect all digits to return to nearly full function after flexor tendon interruption.

Therapy following flexor tendon surgery.

The emergence of therapists specifically trained in the techniques of hand rehabilitation has added immeasurably to the ability to return function following upper extremity injury or disease. Specifically, in the difficult area of flexor tendon injury, this specialized therapy has markedly elevated the anticipated level of functional recovery following repair, graft, lysis, or reconstruction. Specific protocols have been suggested for the early mobilization of flexor tendons following severance and repair. Methods of tendon and digital mobilization following grafting or reconstruction and the problems associated with flexor tenolysis have been discussed in conjunction with exercise techniques, the use of static and dynamic splints, and the importance of adjunctive modalities designed to improve the results of these procedures. The need for close cooperation and understanding between patient, surgeon, and therapist is emphasized in this article. The need to approach each patient as a separate entity with unique requirements, limitations, and goals is extremely important in the effort to return maximum function following each surgical procedure.

Anatomy and pathogenesis of the digital cords and nodules.

Current theories on the origin of the diseased tissue in Dupuytren's contracture are reviewed, and previous descriptions of the pathologic anatomy are clarified. The pathogenesis of Dupuytren's contracture is cited, with emphasis on the development of the contracture at various sites.

Carpal tunnel release with a small palmar incision.

The use of carpal tunnel tome with a small palmar incision to release the transverse carpal ligament is discussed. The technique is fully illustrated, and the authors early clinical experience is reviewed.

Recalcitrant carpal tunnel. The hypothenar fat pad flap.

Open decompression of the median nerve generally is so effective that little is mentioned of the surgical treatment options for recalcitrant or unrelieved carpal tunnel syndrome. The hypothenar fat pad flap has been shown to be a reliable local source of well-vascularized adipose tissue that can be used for coverage of the median nerve during re-exploration of recurrent or persistent idiopathic carpal tunnel syndrome. The hypothenar fat pad flap is a technically simple procedure that allows the fat pad to be mobilized easily and placed across the palm as a barrier between the nerve and the radial leaf of the transverse carpal ligament, effectively preventing median nerve readherence. This flap hopefully will improve the tissue environment for the median nerve, permitting it to have normal excursion during wrist motion. Our results to date have been better than previously described for other techniques. We believe the hypothenar fat pad flap should be considered in the hand surgeon's armamentarium for recalcitrant idiopathic carpal tunnel syndrome.