FASCIA REVERSAL ISLAND GRAFT OF FOREARM IN TREATMENT OF FLEXOR TENDON INJURIES
作者：LIU Rui-jun(刘瑞军), FENG Cheng-chen(冯承臣), XU Qian-feng(徐前锋)
单位：Department of Orthopedics, LIU Rui-jun(刘瑞军), FENG Cheng-chen(冯承臣), XU Qian-feng(徐前锋) 146th Hospital of PLA, Linyi, Shandong Province, 276001
关键词：
中华创伤杂志980447 Objective To prevent or treat adhesion formation during flexor tendon healing after various degrees of tendon and peritendinous tissue injuries.
, 百拇医药
Methods From March 1989 to August 1992, 33 patients with injuries of flexor tendons were treated with fascia reversal island grafts of the forearms. The fascia graft with intact blood supply was placed circuferentially around the repaired site with microsurgical technique. Early postoperative functional rehabilitation was encouraged.
Results The improvement in postoperative flexor tendon function was evaluated according to Eaton's TAM grade, with nine as excellent, eighteen as good, three as fair and three as poor.
, 百拇医药
Conclusion The fascia reversal island graft of forearm can supply good tissue bed for tendon gliding and prevent adhesion of the tendon to the surrounding tissues. It offers a new method to obviate adhesion formation during flexor tendon healing and enables repaired tendon to achieve better functional results
In the research field of hand surgery, it remains an important problem to prevent or treat adhesion formation during flexor tendon healing after various degrees of tendon and peritendinous tissue injuries. Since March 1989, 33 patients have been treated with fascia reversal island grafts of the forearms to reconstruct the new flexor sheath. Microsurgical techniques were adopted and early postoperative functional rehabilitation was instituted, and sound functional results were achieved.
, http://www.100md.com
MATERIALS AND RESULTS
There were 20 male and 13 female patients, with age range from ten to forty-fix years. Only one flexor tendon was injured in each patient, and there were twelve index fingers, nine middle fingers, six ring and six little fingers. The operation was performed provided that there were good functional conditions of the phalanges and joints. There were seven emergency and twenty-six obstinate chronic ones. The causes of injuries were mechanical crush (14 cases), weapon wound (8 cases), glass cut (7 cases ) and knife cut (4 cases). The injury sites were located as follows: zone I in 4 patients, zone Ⅱ in 21 patients and zone Ⅲ in 8 patients. The size of grafted fascia flap was 9 cm×2.5 cm to 12 cm×2.5 cm. The fascia flap was then rotated 180 degree. Anastomosis between palmar digital artery and distal artery of the graft was performed in five of the 33 patients.
, 百拇医药
The follow-up ranging from half to five years were carried out in all 33 patients. The pre-and postoperative flexor functions were evaluated according to Eaton's TAM grade. The results were classified as excellent, good, fair and poor. Out of the 33 patients, excellent score of 260 TAM was attained in nine fingers, good score more than 190 TAM in eighteen, fair score more than 130 TAM in three, and poor score less than 130 in three fingers. The loose tendons were found during secondary operation in two of three poor cases. Stenosis anastomosis site with adhesion formation between psendosynovial fascial sheath and normal synovical sheath was found in another case.
, 百拇医药
OPERATIVE PROCEDURE
The patient was placed in the supine position. The operation was performed under blocking anesthesia of bronchial plexus with tourniquet control. The site and size of the flap and pedicle were designed according to the site and size of the flexor sheath defect. A s-shaped skin incision was made along the distal third of anterior aspect of the forearm. After incising skin and sharply separating subcutaneous tissue, superficial fascia was exposed. The fascia flap was sharply separated with scalpel from the proximal to distal of the forearm in the deep fascia space. During the procedure, care should be exercised to protect the fascial vascular network, perforating artery in the pedicle of fascia flap and muscular fibro-membranous integrity. An important principle was to maintain concordance between direction of the deep main artery and the long axis of fascia flap. The long axis of fascia flap was in the direction of radial artery when the sheath of index or middle finger was repaired, and in the direction of the ulnar artery when the sheath of ring or little finger was repaired.
, http://www.100md.com
Both the deep and the superficial flexor tendons were repaired. The tendon suture was accomplished with Bunnell's or Kesseler's technique using 7-0 loop nylon. The repaired epitenon should be smooth and intact. The fascia flap with blood supply was transferred through a subcutaneous tunnel to the repaired site to reconstruct the flexor sheath. The smooth surface of the fascia flap was placed facing the epitenon. The pseudosynovial sheath thus constructed was sutured to normal sheath with 3-0 loop nylon. Then reconstruction of trochlea was performed, if necessary.
, http://www.100md.com
The subcutaneous tissue sheath vincula and superficial flexor tendon were thoroughly excised, if the adhesion formation was located in the injured site of flexor tendon. The defective sheath was reconstructed with fascia flap after a whole-range passive motion of the deep flexor tendon was entirely restored.
Clinically, obstinate lacerated tendon was usually accompanied by defective tendon and sheath with wide fibrous adhesions. After fibrous adhesion was excised, the defective tendon and sheath were repaired in the meantime with palmaris longus tendon together with fascia flap of forearm.
, http://www.100md.com
In all the patients, the operated fingers were immobilized in semiflexion with plaster splint. From twenty-four hours postoperatively, passive flexion and active extension rehabilitation of gradually increasing range of the digit was carried out everyday under medical direction. The fixation was removed and free active motion of the operated digit was allowed from the third week onwards.
DISCUSSION
Clinically every lacerated tendon heals by a combination of both intrinsic and extrinsic capacity.1，2 In both experiments in vivo and clinical practice, the extrinsic and intrinsic tendon healing exist consistently. So far, it is impossible to create an entirely intrinsic healing of lacerated tendon in vivo, even in well-designed experiment. However, the extrinsic healing does not necessarily bring about adhesion formation. Our experiment suggests that many factors, such as lack of local blood supply, compromised integrity of the sheath, contact with subcutaneous tissue, bony injury and immobilization, may influence the final results of the tendon repair, and that reliable healing the lacerated flexor tendon can be achieved with no or only slight membranous adhesion when the synovial nutrition and blood supply are well preserved.3
, http://www.100md.com
Both fascia and synovium originate from mesoderm of embryo.4 Connective tissues originating from mesoderm of embryo can transform mutually with the change of circumstances. The deep fascia of the palm merges proximally into the antebrachial fascia. It is thick in the palm where it forms the palmar aponeurosis and in the fingers where it forms the fibrous flexor sheaths. The transferred fascial sheath can transform into synovial sheath under the irritation induced by sliding tendon. When the antebrachial fascia is transferred with its blood supply to reconstruct the flexor sheath and to restore integrity of the synovial sheath, the pseudosynovial sheath supplies good tissue bed for tendon gliding and can prevent adhesion formation of the tendon from the surrounding tissue, thereby increasing intrinsic healing and decreasing extrinsic healing capacity. We postulate that compression irritation produced by early flexor tendon movement can accelerate transformation of fascia tissue into synovial tissue after the antebrachial fascia is transferred with blood supply to reconstruct the tendon sheath. At the same time, gradual maturation of new intact synovial sheath can offer synovial nutrition for tendon healing. So early functional rehabilitation has dual purpose, and is an important measure to prevent adhesion formation between fascia sheath and tendon. This study offers a new method to treat adhesion formation during flexor tendon healing and to enable repaired tendons to achieve better functional results.
, 百拇医药
REFERENCES
[1] Lundborg G. Experimental flexor tendon healing without adhesion formation, a new concept of tendon nutrition and intrinsic healing mechanism. Hand 1976; 8∶235.
[2] Manske PR. Intrinsic flexor tendon repair: A morphological study in vitro. J Bone Joint Surg(Am) 1984; 66∶385.
[3] Liu RJ, Feng CC, Chen YM. Fascia reversal island graft of forearm in treatment of injury of the flexor digital tendon. Chin J Microsurg 1995; 18∶60.
[4] Liu AM, Lu SB, Li XH. Experimental study of sheath reconstruction to repair injury of flexor digitorum tendon. Chin Orthop Surg 1990; 10∶445., http://www.100md.com
单位：Department of Orthopedics, LIU Rui-jun(刘瑞军), FENG Cheng-chen(冯承臣), XU Qian-feng(徐前锋) 146th Hospital of PLA, Linyi, Shandong Province, 276001
关键词：
中华创伤杂志980447 Objective To prevent or treat adhesion formation during flexor tendon healing after various degrees of tendon and peritendinous tissue injuries.
, 百拇医药
Methods From March 1989 to August 1992, 33 patients with injuries of flexor tendons were treated with fascia reversal island grafts of the forearms. The fascia graft with intact blood supply was placed circuferentially around the repaired site with microsurgical technique. Early postoperative functional rehabilitation was encouraged.
Results The improvement in postoperative flexor tendon function was evaluated according to Eaton's TAM grade, with nine as excellent, eighteen as good, three as fair and three as poor.
, 百拇医药
Conclusion The fascia reversal island graft of forearm can supply good tissue bed for tendon gliding and prevent adhesion of the tendon to the surrounding tissues. It offers a new method to obviate adhesion formation during flexor tendon healing and enables repaired tendon to achieve better functional results
In the research field of hand surgery, it remains an important problem to prevent or treat adhesion formation during flexor tendon healing after various degrees of tendon and peritendinous tissue injuries. Since March 1989, 33 patients have been treated with fascia reversal island grafts of the forearms to reconstruct the new flexor sheath. Microsurgical techniques were adopted and early postoperative functional rehabilitation was instituted, and sound functional results were achieved.
, http://www.100md.com
MATERIALS AND RESULTS
There were 20 male and 13 female patients, with age range from ten to forty-fix years. Only one flexor tendon was injured in each patient, and there were twelve index fingers, nine middle fingers, six ring and six little fingers. The operation was performed provided that there were good functional conditions of the phalanges and joints. There were seven emergency and twenty-six obstinate chronic ones. The causes of injuries were mechanical crush (14 cases), weapon wound (8 cases), glass cut (7 cases ) and knife cut (4 cases). The injury sites were located as follows: zone I in 4 patients, zone Ⅱ in 21 patients and zone Ⅲ in 8 patients. The size of grafted fascia flap was 9 cm×2.5 cm to 12 cm×2.5 cm. The fascia flap was then rotated 180 degree. Anastomosis between palmar digital artery and distal artery of the graft was performed in five of the 33 patients.
, 百拇医药
The follow-up ranging from half to five years were carried out in all 33 patients. The pre-and postoperative flexor functions were evaluated according to Eaton's TAM grade. The results were classified as excellent, good, fair and poor. Out of the 33 patients, excellent score of 260 TAM was attained in nine fingers, good score more than 190 TAM in eighteen, fair score more than 130 TAM in three, and poor score less than 130 in three fingers. The loose tendons were found during secondary operation in two of three poor cases. Stenosis anastomosis site with adhesion formation between psendosynovial fascial sheath and normal synovical sheath was found in another case.
, 百拇医药
OPERATIVE PROCEDURE
The patient was placed in the supine position. The operation was performed under blocking anesthesia of bronchial plexus with tourniquet control. The site and size of the flap and pedicle were designed according to the site and size of the flexor sheath defect. A s-shaped skin incision was made along the distal third of anterior aspect of the forearm. After incising skin and sharply separating subcutaneous tissue, superficial fascia was exposed. The fascia flap was sharply separated with scalpel from the proximal to distal of the forearm in the deep fascia space. During the procedure, care should be exercised to protect the fascial vascular network, perforating artery in the pedicle of fascia flap and muscular fibro-membranous integrity. An important principle was to maintain concordance between direction of the deep main artery and the long axis of fascia flap. The long axis of fascia flap was in the direction of radial artery when the sheath of index or middle finger was repaired, and in the direction of the ulnar artery when the sheath of ring or little finger was repaired.
, http://www.100md.com
Both the deep and the superficial flexor tendons were repaired. The tendon suture was accomplished with Bunnell's or Kesseler's technique using 7-0 loop nylon. The repaired epitenon should be smooth and intact. The fascia flap with blood supply was transferred through a subcutaneous tunnel to the repaired site to reconstruct the flexor sheath. The smooth surface of the fascia flap was placed facing the epitenon. The pseudosynovial sheath thus constructed was sutured to normal sheath with 3-0 loop nylon. Then reconstruction of trochlea was performed, if necessary.
, http://www.100md.com
The subcutaneous tissue sheath vincula and superficial flexor tendon were thoroughly excised, if the adhesion formation was located in the injured site of flexor tendon. The defective sheath was reconstructed with fascia flap after a whole-range passive motion of the deep flexor tendon was entirely restored.
Clinically, obstinate lacerated tendon was usually accompanied by defective tendon and sheath with wide fibrous adhesions. After fibrous adhesion was excised, the defective tendon and sheath were repaired in the meantime with palmaris longus tendon together with fascia flap of forearm.
, http://www.100md.com
In all the patients, the operated fingers were immobilized in semiflexion with plaster splint. From twenty-four hours postoperatively, passive flexion and active extension rehabilitation of gradually increasing range of the digit was carried out everyday under medical direction. The fixation was removed and free active motion of the operated digit was allowed from the third week onwards.
DISCUSSION
Clinically every lacerated tendon heals by a combination of both intrinsic and extrinsic capacity.1，2 In both experiments in vivo and clinical practice, the extrinsic and intrinsic tendon healing exist consistently. So far, it is impossible to create an entirely intrinsic healing of lacerated tendon in vivo, even in well-designed experiment. However, the extrinsic healing does not necessarily bring about adhesion formation. Our experiment suggests that many factors, such as lack of local blood supply, compromised integrity of the sheath, contact with subcutaneous tissue, bony injury and immobilization, may influence the final results of the tendon repair, and that reliable healing the lacerated flexor tendon can be achieved with no or only slight membranous adhesion when the synovial nutrition and blood supply are well preserved.3
, http://www.100md.com
Both fascia and synovium originate from mesoderm of embryo.4 Connective tissues originating from mesoderm of embryo can transform mutually with the change of circumstances. The deep fascia of the palm merges proximally into the antebrachial fascia. It is thick in the palm where it forms the palmar aponeurosis and in the fingers where it forms the fibrous flexor sheaths. The transferred fascial sheath can transform into synovial sheath under the irritation induced by sliding tendon. When the antebrachial fascia is transferred with its blood supply to reconstruct the flexor sheath and to restore integrity of the synovial sheath, the pseudosynovial sheath supplies good tissue bed for tendon gliding and can prevent adhesion formation of the tendon from the surrounding tissue, thereby increasing intrinsic healing and decreasing extrinsic healing capacity. We postulate that compression irritation produced by early flexor tendon movement can accelerate transformation of fascia tissue into synovial tissue after the antebrachial fascia is transferred with blood supply to reconstruct the tendon sheath. At the same time, gradual maturation of new intact synovial sheath can offer synovial nutrition for tendon healing. So early functional rehabilitation has dual purpose, and is an important measure to prevent adhesion formation between fascia sheath and tendon. This study offers a new method to treat adhesion formation during flexor tendon healing and to enable repaired tendons to achieve better functional results.
, 百拇医药
REFERENCES
[1] Lundborg G. Experimental flexor tendon healing without adhesion formation, a new concept of tendon nutrition and intrinsic healing mechanism. Hand 1976; 8∶235.
[2] Manske PR. Intrinsic flexor tendon repair: A morphological study in vitro. J Bone Joint Surg(Am) 1984; 66∶385.
[3] Liu RJ, Feng CC, Chen YM. Fascia reversal island graft of forearm in treatment of injury of the flexor digital tendon. Chin J Microsurg 1995; 18∶60.
[4] Liu AM, Lu SB, Li XH. Experimental study of sheath reconstruction to repair injury of flexor digitorum tendon. Chin Orthop Surg 1990; 10∶445., http://www.100md.com