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PartiallyDividedFlexorTendonInjuries:ShouldTheyBeRepairedorNotShkelzenB.
Duci1HasanR.
Ahmeti21ClinicofPlasticSurgery,UniversityClinicalCenterofKosovo,Prishtina,Kosovo2ClinicofPediatricSurgery,UniversityClinicalCenterofKosovo,Prishtina,KosovoSurgJ2016;2:e89–e90.
AddressforcorrespondenceHasanR.
Ahmeti,PhD,AssociateProfessor,ClinicofPediatricSurgery,UniversityClinicalCenterofKosovo,Prishtina10000,Kosovo(e-mail:hasanahmeti@yahoo.
com).
Flexortendoninjuriesarecommonbecausethetendonslieclosetotheskin.
Therefore,theyareexposedtoinjurieslikelacerationsandcrushinjuries,andoccasionallytheycanruptureattheirboneinsertions.
1Tendoninjuriesarethesecondmostcommonhandinjuriesinorthopedicpatients.
2Thecorrectmanagementofpartiallydividedexortendoninjuriesisstillcontroversial.
Opinionsregardingwhetherpartiallydividedexortendoninjuriesshouldberepairedstillvaryacrosstheliterature.
3Controversyalsoexistsintheliteratureregardingthepropertreatmentofpartialexortendonlacerations.
Wrayetalcreatedconsiderablecontroversybyrecommend-ingthatpartialexortendonlacerationsberepaired.
4,5Severalauthorshavereportedanincreasedriskoftriggering,entrap-ment,orruptureassociatedwithlacerationsofthetendonandhaveadvocatedsurgicalrepairofthoseinjuries.
6–10Ontheotherhand,Bishopetalstudiedacaninemodelanddescribedtherelativeeffectsoftenorrhaphy.
Theyalsode-scribedhealingwhentheexortendonwasnotrepaired.
6Parametersevaluatedafter35-dayhealingperiodincludedexcursion,breakingstrength,energyabsorption,andstiff-ness.
Dataanalysisintheirstudyrevealedstatisticallysigni-cantadverseeffectsonbreakingstrength,stiffness,andenergyabsorptionwhenrepairedbymodiedKesslertech-niquecomparedwiththetendonsthatwerenotrepaired,whichresultedintendonmorphologyclosertonormal.
Similarly,McGeorgeandStilwellstudiedpartiallylacerat-edexortendoninjuriesandcomparedtheresultsofrepairwiththoseofnonrepair,showingbetterresultsintendonsthatwerenotrepaired.
10Theauthorsconcludedthatpartiallylaceratedtendonsshouldnotberepaired.
Also,thelevelofexortendoninjurycarriesaprognosticimplicationbecauseofthedifferentanatomicconstraintstotheexortendonsovertheircoursefromthemusclebellyintheforearmtotheirinsertioninthephalanges.
Verdandevelopedauniformnomenclature(zoneItozoneV)thathasnowbeenacceptedbymosthandsurgeons.
11Manyfactorsareuniquetotendoninjuries,especiallyinzoneII,makingitdifculttorepairthetendonsinthisarea.
Mostinjuriesinthiszonethatlaceratethetendonalsodisruptthenutritionalsystemsofthetendonthatsupportrecovery.
Particularly,damageofthedigitalsheathleadstoleakageofthesynovialuidcontainedwithinit.
Thislossofsynovialuidmaystarvethetendonrepairprocess,be-causenutrientsarenormallyprovidedtothetendonpri-marilyviadiffusionthroughthisuid.
Furthermore,evenifthelossofuidisnotgreat,damageinthesheathcanimpairtendonnutrition,becauseitallowsthepressureoftheuidinthesheathtodissipate.
Thislossofpressurecandeprivethetendonofnutrients,becausethedistributionofthesenutrientsisnormallypropelledbyaprocessofimbibition,inwhichsynovialuidisforcedintotheKeywordsexorlaceratedtendonAbstractThecorrectmanagementofpartiallydividedexortendoninjuriesisstillcontroversial.
Opinionsvaryregardingwhetherpartiallydividedexortendoninjuriesshouldberepaired.
Flexortendoninjuriesarecommonbecausethetendonslieclosetotheskin.
Thetendonsarethereforeexposedtoinjurieslikelacerationsandcrushinjuries,andoccasionallytheycanrupturefromwheretheyarejoinedtothebone.
Tendoninjuriesarethesecondmostcommonhandinjuriesinorthopedicpatients.
receivedFebruary20,2016acceptedafterrevisionAugust10,2016DOIhttp://dx.
doi.
org/10.
1055/s-0036-1593356.
ISSN2378-5128.
Copyright2016byThiemeMedicalPublishers,Inc.
,333SeventhAvenue,NewYork,NY10001,USA.
Tel:+1(212)584-4662.
THIEMEReviewArticlee89intersticesbetweentendonfasciclesduringexionandextensionofthedigit.
12,13Althoughthereweremorecontroversiesamongdifferentauthorsregardingrepairofexortendondigito-rumsupercialisandtheexortendondigitorumprofun-dusinzoneIIinjuryduetothecreationofadhesions,mostauthorsrecommendthatbothtendonsshouldberepaired,withtheexordigitorumsupercialistendonrepairedrst.
14Inbrief,multipleinvestigatorshaveconcludedthatpartiallacerationsinvolving60%ofthetendon'scross-sectionalareashouldnotberepaired.
Thatrecommendationissup-portedbybothinvivoandexvivobiomechanicalstudiesthathavedemonstratedthatnonrepairedpartiallacerationsbearsignicantlygreaterultimateloadsandexhibitgreaterstiff-nessthanrepairedtendons.
6,10,15Therecommendationofthemajorityofauthorsforinju-riesinvolving60%ofthetendoncross-sectionalareaisdebridementofthetendon.
Injuriesinvolving>60%ofthetendonshouldberepairedwithtraditionalcore-suturemeth-odssupplementedwitharunningepitendinoussuture.
14Futureresearchonthetreatmentofthepartiallylacer-atedexortendonsshouldfocusondevelopmentsandunderstandingofsofttissuehealingatthecellular,molec-ular,andgeneticlevelstoenablesurgeonstomodulatethehealingprocesstoimprovethestrengthoftherepairsitewhileatthesametimereducingadhesionafterinjuryandsurgicalrepair.
References1GrifnM,HindochaS,JordanD,SalehM,KhanW.
Anoverviewofthemanagementofexortendoninjuries.
OpenOrthopJ2012;6:28–352DuciSB.
Justicationofthetopicaluseofpharmacologicalagentsonreduceoftendonadhesionaftersurgicalrepair.
SMJOrthop2015;1(2):10063DuciSB,AriHM,AhmetiHR,etal.
Biomechanicalandmacro-scopicevaluationsoftheeffectsof5-uorouracilonpartiallydividedexortendoninjuriesinrabbits.
ChinMedJ(Engl)2015;128(12):1655–16614WrayRCJr,HoltmanB,WeeksPM.
Clinicaltreatmentofpartialtendonlacerationswithoutsuturingandwithearlymotion.
PlastReconstrSurg1977;59(2):231–2345WrayRCJr,WeeksPM.
Treatmentofpartialtendonlacerations.
Hand1980;12(2):163–1666BishopAT,CooneyWPIII,WoodMB.
Treatmentofpartialexortendonlacerations:theeffectoftenorrhaphyandearlyprotectedmobilization.
JTrauma1986;26(4):301–3127McCarthyDM,BoardmanNDIII,TramagliniDM,SotereanosDG,HerndonJH.
Clinicalmanagementofpartiallylacerateddigitalexortendons:asurvey[corrected]ofhandsurgeons.
JHandSurgAm1995;20(2):273–2758BilosZJ,HuiPW,StamelosS.
Triggerngerfollowingpartialexortendonlaceration.
Hand1977;9(3):232–2339LehfeldtM,RayE,ShermanR.
MOC-PS(SM)CMEarticle:treatmentofexortendonlaceration.
PlastReconstrSurg2008;121(4,Suppl):1–1210McGeorgeDD,StilwellJH.
Partialexortendoninjuries:torepairornot.
JHandSurg[Br]1992;17(2):176–17711AgarwalP.
Closedruptureoftheexordigitorumprofundustendonoflittlenger:acasereport.
IndianJPlasticSurg2004;37(1):71–7312HannanJA,ArnoczkySP.
Effectofcyclicandstatictensileloadingonwatercontentandsolutediffusionincanineexortendons:aninvitrostudy.
JOrthopRes1994;12(3):350–35613ManskePR,LeskerPA.
Flexortendonnutrition.
HandClin1985;1(1):13–2414BoyerMI,StricklandJW,EnglesD,SacharK,LeversedgeFJ.
Flexortendonrepairandrehabilitation:stateoftheartin2002.
InstrCourseLect2003;52:137–16115ChowSP,YuOD.
Anexperimentalstudyonincompletelycutchickentendons—acomparisonoftwomethodsofmanagement.
JHandSurg[Br]1984;9(2):121–125TheSurgeryJournalVol.
2No.
3/2016PartiallyDividedFlexorTendonInjuriesDuci,Ahmetie90
Duci1HasanR.
Ahmeti21ClinicofPlasticSurgery,UniversityClinicalCenterofKosovo,Prishtina,Kosovo2ClinicofPediatricSurgery,UniversityClinicalCenterofKosovo,Prishtina,KosovoSurgJ2016;2:e89–e90.
AddressforcorrespondenceHasanR.
Ahmeti,PhD,AssociateProfessor,ClinicofPediatricSurgery,UniversityClinicalCenterofKosovo,Prishtina10000,Kosovo(e-mail:hasanahmeti@yahoo.
com).
Flexortendoninjuriesarecommonbecausethetendonslieclosetotheskin.
Therefore,theyareexposedtoinjurieslikelacerationsandcrushinjuries,andoccasionallytheycanruptureattheirboneinsertions.
1Tendoninjuriesarethesecondmostcommonhandinjuriesinorthopedicpatients.
2Thecorrectmanagementofpartiallydividedexortendoninjuriesisstillcontroversial.
Opinionsregardingwhetherpartiallydividedexortendoninjuriesshouldberepairedstillvaryacrosstheliterature.
3Controversyalsoexistsintheliteratureregardingthepropertreatmentofpartialexortendonlacerations.
Wrayetalcreatedconsiderablecontroversybyrecommend-ingthatpartialexortendonlacerationsberepaired.
4,5Severalauthorshavereportedanincreasedriskoftriggering,entrap-ment,orruptureassociatedwithlacerationsofthetendonandhaveadvocatedsurgicalrepairofthoseinjuries.
6–10Ontheotherhand,Bishopetalstudiedacaninemodelanddescribedtherelativeeffectsoftenorrhaphy.
Theyalsode-scribedhealingwhentheexortendonwasnotrepaired.
6Parametersevaluatedafter35-dayhealingperiodincludedexcursion,breakingstrength,energyabsorption,andstiff-ness.
Dataanalysisintheirstudyrevealedstatisticallysigni-cantadverseeffectsonbreakingstrength,stiffness,andenergyabsorptionwhenrepairedbymodiedKesslertech-niquecomparedwiththetendonsthatwerenotrepaired,whichresultedintendonmorphologyclosertonormal.
Similarly,McGeorgeandStilwellstudiedpartiallylacerat-edexortendoninjuriesandcomparedtheresultsofrepairwiththoseofnonrepair,showingbetterresultsintendonsthatwerenotrepaired.
10Theauthorsconcludedthatpartiallylaceratedtendonsshouldnotberepaired.
Also,thelevelofexortendoninjurycarriesaprognosticimplicationbecauseofthedifferentanatomicconstraintstotheexortendonsovertheircoursefromthemusclebellyintheforearmtotheirinsertioninthephalanges.
Verdandevelopedauniformnomenclature(zoneItozoneV)thathasnowbeenacceptedbymosthandsurgeons.
11Manyfactorsareuniquetotendoninjuries,especiallyinzoneII,makingitdifculttorepairthetendonsinthisarea.
Mostinjuriesinthiszonethatlaceratethetendonalsodisruptthenutritionalsystemsofthetendonthatsupportrecovery.
Particularly,damageofthedigitalsheathleadstoleakageofthesynovialuidcontainedwithinit.
Thislossofsynovialuidmaystarvethetendonrepairprocess,be-causenutrientsarenormallyprovidedtothetendonpri-marilyviadiffusionthroughthisuid.
Furthermore,evenifthelossofuidisnotgreat,damageinthesheathcanimpairtendonnutrition,becauseitallowsthepressureoftheuidinthesheathtodissipate.
Thislossofpressurecandeprivethetendonofnutrients,becausethedistributionofthesenutrientsisnormallypropelledbyaprocessofimbibition,inwhichsynovialuidisforcedintotheKeywordsexorlaceratedtendonAbstractThecorrectmanagementofpartiallydividedexortendoninjuriesisstillcontroversial.
Opinionsvaryregardingwhetherpartiallydividedexortendoninjuriesshouldberepaired.
Flexortendoninjuriesarecommonbecausethetendonslieclosetotheskin.
Thetendonsarethereforeexposedtoinjurieslikelacerationsandcrushinjuries,andoccasionallytheycanrupturefromwheretheyarejoinedtothebone.
Tendoninjuriesarethesecondmostcommonhandinjuriesinorthopedicpatients.
receivedFebruary20,2016acceptedafterrevisionAugust10,2016DOIhttp://dx.
doi.
org/10.
1055/s-0036-1593356.
ISSN2378-5128.
Copyright2016byThiemeMedicalPublishers,Inc.
,333SeventhAvenue,NewYork,NY10001,USA.
Tel:+1(212)584-4662.
THIEMEReviewArticlee89intersticesbetweentendonfasciclesduringexionandextensionofthedigit.
12,13Althoughthereweremorecontroversiesamongdifferentauthorsregardingrepairofexortendondigito-rumsupercialisandtheexortendondigitorumprofun-dusinzoneIIinjuryduetothecreationofadhesions,mostauthorsrecommendthatbothtendonsshouldberepaired,withtheexordigitorumsupercialistendonrepairedrst.
14Inbrief,multipleinvestigatorshaveconcludedthatpartiallacerationsinvolving60%ofthetendon'scross-sectionalareashouldnotberepaired.
Thatrecommendationissup-portedbybothinvivoandexvivobiomechanicalstudiesthathavedemonstratedthatnonrepairedpartiallacerationsbearsignicantlygreaterultimateloadsandexhibitgreaterstiff-nessthanrepairedtendons.
6,10,15Therecommendationofthemajorityofauthorsforinju-riesinvolving60%ofthetendoncross-sectionalareaisdebridementofthetendon.
Injuriesinvolving>60%ofthetendonshouldberepairedwithtraditionalcore-suturemeth-odssupplementedwitharunningepitendinoussuture.
14Futureresearchonthetreatmentofthepartiallylacer-atedexortendonsshouldfocusondevelopmentsandunderstandingofsofttissuehealingatthecellular,molec-ular,andgeneticlevelstoenablesurgeonstomodulatethehealingprocesstoimprovethestrengthoftherepairsitewhileatthesametimereducingadhesionafterinjuryandsurgicalrepair.
References1GrifnM,HindochaS,JordanD,SalehM,KhanW.
Anoverviewofthemanagementofexortendoninjuries.
OpenOrthopJ2012;6:28–352DuciSB.
Justicationofthetopicaluseofpharmacologicalagentsonreduceoftendonadhesionaftersurgicalrepair.
SMJOrthop2015;1(2):10063DuciSB,AriHM,AhmetiHR,etal.
Biomechanicalandmacro-scopicevaluationsoftheeffectsof5-uorouracilonpartiallydividedexortendoninjuriesinrabbits.
ChinMedJ(Engl)2015;128(12):1655–16614WrayRCJr,HoltmanB,WeeksPM.
Clinicaltreatmentofpartialtendonlacerationswithoutsuturingandwithearlymotion.
PlastReconstrSurg1977;59(2):231–2345WrayRCJr,WeeksPM.
Treatmentofpartialtendonlacerations.
Hand1980;12(2):163–1666BishopAT,CooneyWPIII,WoodMB.
Treatmentofpartialexortendonlacerations:theeffectoftenorrhaphyandearlyprotectedmobilization.
JTrauma1986;26(4):301–3127McCarthyDM,BoardmanNDIII,TramagliniDM,SotereanosDG,HerndonJH.
Clinicalmanagementofpartiallylacerateddigitalexortendons:asurvey[corrected]ofhandsurgeons.
JHandSurgAm1995;20(2):273–2758BilosZJ,HuiPW,StamelosS.
Triggerngerfollowingpartialexortendonlaceration.
Hand1977;9(3):232–2339LehfeldtM,RayE,ShermanR.
MOC-PS(SM)CMEarticle:treatmentofexortendonlaceration.
PlastReconstrSurg2008;121(4,Suppl):1–1210McGeorgeDD,StilwellJH.
Partialexortendoninjuries:torepairornot.
JHandSurg[Br]1992;17(2):176–17711AgarwalP.
Closedruptureoftheexordigitorumprofundustendonoflittlenger:acasereport.
IndianJPlasticSurg2004;37(1):71–7312HannanJA,ArnoczkySP.
Effectofcyclicandstatictensileloadingonwatercontentandsolutediffusionincanineexortendons:aninvitrostudy.
JOrthopRes1994;12(3):350–35613ManskePR,LeskerPA.
Flexortendonnutrition.
HandClin1985;1(1):13–2414BoyerMI,StricklandJW,EnglesD,SacharK,LeversedgeFJ.
Flexortendonrepairandrehabilitation:stateoftheartin2002.
InstrCourseLect2003;52:137–16115ChowSP,YuOD.
Anexperimentalstudyonincompletelycutchickentendons—acomparisonoftwomethodsofmanagement.
JHandSurg[Br]1984;9(2):121–125TheSurgeryJournalVol.
2No.
3/2016PartiallyDividedFlexorTendonInjuriesDuci,Ahmetie90
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