COMPLEX SURGICAL TREATMENT OF TROPHIC AND FUNCTIONAL DISORDERS IN ASSOCIATED INJURIES TO FLEXOR TENDONS OF FINGERS
Novosibirsk State Medical University,
Novosibirsk State Regional Clinical Hospital,
Institute of Computational Technologies,
Novosibirsk, Russia
Regional Clinical Center of Miners’ Health Protection,
Leninsk-Kuznetsky, Russia
Treatment of patients with associated injuries to the hand has the great social significance, because an injury to the upper extremity and the hand constitutes up to 41.6 % of all locomotor injuries [4]. Disability after injuries to the upper extremity is about 32 % from the whole number of non-working days [1]. Up to 73 % of patients are at the age from 18 to 60. Treatment of such pathology is time and labor consuming, as well as unsatisfactory for patients and their attending doctors in high number of cases [2, 5, 9].
Because of the anatomical features of the hand, many structures are involved in the pathologic process of the injury: tendons, nerves, arteries and surrounding soft tissues. Multiple studies with review of treatment of such injuries give significant attention to restoration of anatomical congruity of the above-mentioned structures. However in absence of blood flow decompensation, correction of trophic disorders relating to an injury is not made. Currently the great importance is associated with the angiosomal theory of construction of the segments of the extremities. Blood flow restores significantly, especially with consideration of the theory. Absence of adequate perfusion in the injury region results in tissue fibrosis and development of tendogenous and arthrogenic contractures and delay in union of fractures.
More important and contradictive topic is postsurgical management of patients. The opinions by the authors are extremely diverse: from use of complete immobilization [8] to early active development of motions. Active-passive tactics of early training of motions is dominating currently. Most surgeons prefer such tactics [7].
The data about usage of botulinum toxin immediately for treatment of orthopedic patients are extremely rare. With consideration of indirect solution of the orthopedic problems, botulinum toxin is widely used for correction of spastic states after stroke or for inborn pathologies [6, 10]. However the range of usage of this agent is underestimated in traumatology and orthopedics.
All abovementioned facts present the cause of initiation of the study. The objective of the study was to substantiate the surgical tactics for treating patients with associated injuries to the hand on the basis of complex correction of trophic and functional disorders.
MATERIALS AND METHODS
The main group included 30 patients who received restoration of the injured tendons with improvement in local and peripheral perfusion in the injury site. Considering the angiosomal structure of the injury, we used botulinum toxin for prevention of uncontrolled motions, as well as pulls of monofilament fibers for early development of motions.
The comparison group included 30 patients who received tendon restoration by means of the common techniques (suturing, plastics). Improvement of local perfusion in the injury site was not used during realization of the interventions.
The main proportion of the patients consisted of the individual of working age. The patients at the age of 20-60 were 74.2 % in the comparison group and 77.5 % in the main group. There were no non-adults (the age < 20) in the main group. The remaining patients were older than 60. The persons of young and middle age were the main category of the injured. The mean age was 29.07 ± 1.52 (M ± m) in the control group and 31.36 ± 1.52 in the main group. The groups were similar in terms of the age and were within the working age.
Table
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Àge distribution of patients |
| Note: No significant differences between groups were found (p > 0.05). |
According to their gender the patients were distributed in the following way: the main proportion – men: 25 (83.3 %) in the comparison group and 23 (76.67 %) in the main group.
The patients of the main group received treatment with orientation to complex correction of functional and trophic disorders with consideration of angiosomal structure of the segments. It included the following components:
– suturing of all arteries including recessive ones;
– obligatory restoration of the veins in the positions of 2 and 10 hours of the finger segment;
– improvement in perfusion of the injured region with usage of flaps and consideration of individual vascular architectonics and results of topographic and anatomical examination [3], angiosomal structure of the injured region, the data of mathematical modelling of biomechanics of motions of tendons;
– realization of decompression at the level of palmar aponeurosis and the carpal canal.
The patients of the main group received botulinum toxin for decreasing muscular tone of the injured tendons for reducing time of immobilization, prevention of spastic rupture of tendons and improvement in muscular trophism. The site of introduction was determined before surgery as the points of maximal strain of the muscles of the finger flexors (Fig. 1). 40-60 units were introduced into the flexor muscles during surgery and after completion of surgery under ultrasonic control (Fig. 2). The effect appeared on the days 3-5. The duration of the effect was 2-3 weeks. It allowed non-usage of plaster immobilization in two weeks after surgery.
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Figure 1 The points of administration of botulinum toxin A |
Figure 2 Ultrasound controlled administration of botulinum toxin A |
This group of the patients received early training of motions with use of external pulls of tendons which were installed during surgery. Prolene 4.0-5.0 was conducted through the tendon within the sheath. The suture was derived from the wound in proximal direction (Fig. 3). Next day passive training of motions was initiated by means of moving the pulls proximally (Fig. 4). Concurrently, adhesions extend, and the risk of formation of a dense adhesion of a tendon to surrounding tissues decreases significantly. After removal of the pulls the training of motions was continued at the outpatient stage.
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Figure 3 Placement of pull lines of monofilament fibers |
Figure 4 Early development of motions with use of pull lines |
The clinical case. The patient, age of 26. An old injury to the tendons of the flexors of the second finger of the left hand, to the general finger artery and to the nerve of the fingers 2-3. An injury as result of stabbing (Fig. 5).
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Figure 5 Appearance of the patient’s hand before surgery |
Figure 6 The surgical stage |
The sutures were made for the tendons of the flexors of the second finger of the left hand, the common digital artery and the nerve, vascularization of the region of the suture of the tendons with use of the flap from musculi lumbricales (Fig. 6). The pulls of monofilament fibers were placed. After completion of surgery botulinum toxin A was introduced in fan-shape manner to the previously marked points (Fig. 7). The results were estimated in 1 year and 5 months. DASH was 31, left hand strength – 35 kg, right hand strength – 38 kg (Fig. 8).
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Figure 7 Introduction of botulinum toxin A |
Figure 8 The long term putcome |
The patients of the comparison group were operated with the common techniques for restoration of injured structures. The long term examinations were conducted with the standard techniques for estimation of results for microsurgical techniques within the terms from 6 months till 5 years. The volume of active motions in degrees, restoration of sensitivity and percentage of lost labor ability were estimated. Cold testing, thermometry, duplex scanning of the vessels of the extremity in comparison with the healthy limb and time characteristics of EMG were estimated.
The measurement of the volume of motions showed 92 % restoration in comparison with the healthy extremity in the main group, and 87.5 % restoration in the comparison group. The results of the cold test: the main group – 20.5 ± 1.5 min, the comparison group – 21.5 ± 1.8 min. Duplex scanning of the vessels of the extremities: the main group – 2.7 ± 1.2 ml/min, the comparison group – 2.51 ± 1.2 min. The results of intramuscular electromyography showed almost full restoration of the extremity to the presurgical level in 6 weeks.
The complex estimation of the long term results of the treatment showed the good outcomes in 87.5 % of the patients in the main group. The comparison group showed the good outcomes in 56 %.
CONCLUSION
1. Use of type A botulinum toxin decreases muscular activity, prevents uncontrolled muscular contractions that excludes the risk of a ruptured tendon.
2. Angiosomal reconstruction of perfusion in a region of an injury to a tendon reduces the risk of development of excessive scar changes, preserves the sliding properties of the flexors of the fingers.
3. Use of external pulls allows controlled realization of early development of motions at the background of postsurgical pain syndrome. It significantly reduces time intervals of rehabilitation.