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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.

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).

The current clinical methods of flexor tendon repair are remarkably different from those used 20 years ago. This article starts with a review of the current methods, followed by presentation of past experience and current status of six eminent hand surgery units from four continents/regions. Many units are using, or are moving toward using, the recent strong (multi-strand) core suture method together with a simpler peripheral suture. Venting of the critical pulleys over less than 2 cm length is safe and favours functional recovery. These repair and recent motion protocols lead to remarkably more reliable repairs, with over 80% good or excellent outcomes achieved rather consistently after Zone 2 repair along with infrequent need of tenolysis. Despite slight variations in repair methods, they all consider general principles and should be followed. Outcomes of Zone 2 repairs are not dissimilar to those in other zones with very low to zero incidence of rupture.

In this review I detail the protocol that I use after flexor tendon repair and outline my experience regarding how its framework might be used for other disorders. The early passive–active flexion protocol has a sufficient number of cycles of active flexion in each exercise session, which is at least 40, and ideally 60 to 80. The frequency of exercise sessions may range from 4 to 6 a day, distributed in the morning, afternoon and evening. Increasing the number of daily sessions without a sufficient number of runs in each session is ineffective. In the first 2–3 weeks after surgery, active digital flexion should go through only a partial range. In weeks 4–6, the patient gradually moves through the full range. With modifications, I suggest generalization of the partial-range finger motion to therapy after treating other hand injuries. I consider partial-range active flexion a generalizable working principle for different hand disorders.

We investigated the effects of the transverse components of a tendon core suture on tensile resistance and strength of 4-strand repairs. Forty-four pig flexor tendons were repaired with one of the following four methods: double Tsuge, U-shaped, 4-strand cross and 4-strand rectangular repairs. We recorded the number of the repaired tendons that formed a 2 mm gap between the tendon ends during cyclic loading for 20 cycles, stiffness of the tendon at the 1st and 20th cycle, gap distance at the repair site and ultimate strength of the repair at the 20th cycle. When transverse components were added to the core suture, a greater number of tendons formed a 2 mm gap during cyclic loading. The stiffness gradually decreased, and the repair site's gap distance after cyclic loading increased with the presence of transverse components of the sutures. We conclude that the core suture's transverse components negatively impact the tensile resistance of 4-strand tendon repairs.

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.

We investigated the influence of cyclooxygenase (COX)-1 and COX-2 siRNAs delivered through a nanoparticle-gel system on the strength of flexor tendon repairs. Sixteen flexor digitorum profundus (FDP) tendons of chicken toes were transected, repaired and wrapped with gels to evaluate gel adherence. We found that the gel adhered to the tendon surface firmly. Next, 56 tendons were used in a first set of in vivo experiments to compare the therapeutic effects of different doses of COX siRNAs. Another 15 tendons were added in a second set to further assess the effects of a dosage of 12 μg. After 4 weeks, the mean strength of the repaired tendons increased most notably in the toes treated with 12 μg COX siRNAs, and the number of samples with low strength (

Tendon stem/progenitor cells (TSPCs) are considered promising seed cells for tendon regeneration. Previous studies reported that a low seeding density favors TSPC growth, whereas a high seeding density favors tenocyte growth. We aimed to distinguish TSPCs from tenocytes by seeding tendon-derived cells at a density gradient. In this study, tendon-derived cells were isolated from flexor digitorum profundus tendons of mice and seeded at the initial densities of 50, 500, 5,000, and 50,000/cm

In this article, I review how my team and I addressed clinical concerns in Zone 2 flexor tendon repair, and how major findings in each step of our research were translated into clinical practice. The focus of the article is on the thought processes behind each new investigation, the interpretation of research findings and conclusions drawn from the basic and clinical studies.

This article summarizes the current views and proposed approaches to treating soft tissue defects of the hand. The article also outlines some key considerations of digital reconstruction. There are many options in treating soft tissue defects. For defects of the hand, local flaps are primarily considered if the defects are small or moderate in size. A vascularized free flap is only considered for a defect of large size (3 cm long or larger). Thumb reconstruction is of primary importance, while reconstruction of two fingers is necessary when all fingers are lost. Reconstructions of a missing distal part of a finger or reconstruction of an entire finger if only one finger is lost are cosmetic restorations; functionally these defects do not need reconstruction. Sensation is of great importance in repair or reconstruction of the tip of the thumb or finger. Therefore, sensory evaluation is a key factor in assessing and selecting the best options of surgery.

How to accelerate tendon healing remains a clinical challenge. In this study, a suture carrying nanoparticle/pEGFP-basic fibroblast growth factor (bFGF) and pEGFP-vascular endothelial growth factor A (VEGFA) complexes was developed to transfer the growth factor genes into injured tendon tissues to promote healing. Polydopamine-modified sutures can uniformly and tightly absorb nanoparticle/plasmid complexes. After tendon tissues were sutured, the nanoparticle/plasmid complexes still existed on the suture surface. Further, we found that the nanoparticle/plasmid complexes delivered into tendon tissues could diffuse from sutures to tendon tissues and effectively transfect genes into tendon cells, significantly increasing the expression of growth factors in tendon tissues. Finally, biomechanical tests showed that nanoparticle/pEGFP-bFGF and pEGFP-VEGFA complex-coated sutures could significantly increase the ultimate strengths of repaired tendons, especially at 4 weeks after operation. Two kinds of nanoparticle/plasmid complex-coated sutures significantly increased flexor tendon healing strength by 3.7 times for Ethilon and 5.8 times for PDS II, respectively, compared with the corresponding unmodified sutures. In the flexor tendon injury model, at 6 weeks after surgery, compared with the control suture, the nanoparticle/plasmid complex-coated sutures can significantly increase the gliding excursions of the tendon and inhibit the formation of adhesion. These results indicate that this nanoparticle/plasmid complex-coated suture is a promising tool for the treatment of injured tendons.

We assessed the effects of tendon core sutures' transverse components on the tensile resistance of two commonly used 6-strand tendon repairs. Tang and Yoshizu #1 repairs (6-strand) were tested and compared with 4-strand rectangular and double Kessler sutures (4-strand). A total of 40 pig flexor tendons were tested under cyclic loading. We recorded the number of tendons that formed a 2-mm gap between two tendon ends during 20 cycles of cyclic loading test, stiffness at the 1st and 20th loading cycle, and gap distance at the repair site and the ultimate repair strength at the 20th cycles. We found that the Yoshizu #1 repairs were more prone to form gaps and their ultimate strength was significantly lower than that of the Tang repair. The transverse components in a 6-strand repair affect gap formation and failure strength.

Tendon rupture after distal radius fractures were found with or without surgical treatment. The timing of the tendon rupture varies from days or months after fracture or many years after surgical treatment. The most common incidence is associated with open reduction and internal fixation when the plate is not placed in a correct position and most commonly involved tendons are extensor tendons. The clinical presentation of tendon rupture is the same with that seen after traumatic tendon disruption. Treatment include tendon transfer or grafting to reconstruct tendon function with generally good functional outcomes.

The tendon-to-bone healing after trauma is usually slow and weak, and the repair site is easily disrupted during early mobilization exercise. bFGF and VEGFA gene therapy may hold promise in augmenting the tendon-to-bone healing process through enhancing cell proliferation and angiogenesis. This study is conducted to determine the effects of nanoparticle-mediated co-delivery of bFGF and VEGFA genes to the tendon-to-bone repair interface on the healing strength and biological responses in a chicken model. The PLGA nanoparticle/pEGFP-bFGF + pEGFP-VEGFA plasmid complexes were prepared and were characterized in vitro and in vivo. The nanoparticle/plasmid complexes can effectively transfer bFGF and VEGFA genes to the tendon-to-bone interface. Nanoparticle-mediated co-delivery of bFGF and VEGFA genes significantly improved the tendon-to-bone healing in terms of healing strengths and histology in a chicken flexor tendon repair model. Our results suggest a new biological approach to accelerate the tendon-to-bone healing.

Several methods can be used for identifying tissues for transfer in donor-site-depleted patients. A fillet flap can be temporarily stored in other parts of the body and transferred back to the site of tissue defect, including covering the amputated stump of the lower extremity. Human arm transplant is rare and has some unique concerns for the surgery and postsurgical treatment. Cosmetics of the narrow neck of transferred second toes can be improved with insertion of a flap. Lymphedema of the breast after cancer treatment can be diagnosed with several currently available imaging techniques and treated surgically with lymphaticovenous anastomosis.

Vascularized small-bone grafting is an efficient and often necessary surgical approach for nonunion or necrosis of several bones in particular sites of the body, including scaphoid, lunate, distal ulna, and clavicle. The medial femoral condyle is an excellent graft source that can be used in treating scaphoid, ulna, clavicle, or lower-extremity bone defects, including nonunion. Vascularized bone grafting to the small bones, particularly involving reconstruction of damaged cartilage surfaces, should enhance subchondral vascular supply and help prevent cartilage regeneration. Vascularized osteoperiosteal and corticoperiosteal flaps are useful for treating nonunion of long bones.

This article summarizes the major changes seen in lymphatic microsurgery and microvascular surgery in first 20 years of the 21st century. Lymphatic microsurgery is discussed first, as more advances have been seen in imaging of the lymphatic system, lymphatico-venous anastomosis, and vascularized lymph node transfers. During the past 2 decades, there have been more patient population changes than major technical evolutions in microvascular surgery, although new techniques and modifications emerged and became clinical routines, with the landscape of microvascular surgery evolving in this time period.

Survival rates of digital replantation vary in different regions and countries, and Asian surgeons see more challenging cases and have developed some unique methods. Replantation of multiple digits in one or both hands can follow a structure-by-structure method or a digit-by-digit method. For replanting all 10 digits, 3 or 4 teams should be organized. Flow-through flaps, often venous flaps, can be taken from the distal forearm or lower extremity to repair defects of soft tissues and arteries. A pedicled digital artery flap from the adjacent digit can also repair tissue defects and supply blood to the replanted digit.

Tendon injuries are common diseases. The healing capacity of tendon is limited due to its special composition of extra-cellular matrix and hypocellularity and hypovascularity. The purpose of this study was to evaluate the effectiveness of nanoparticle-coated sutures carrying growth factors for accelerating tendon repair. A variety of experimental methods had been used to investigate the characteristics and therapeutic effects of the modified sutures. Nanoparticles could adhere uniformly to the surface of the suture through polydopamine. Even sutured in the tendon, most of nanoparticles were still remained on the surface of suture, and the loaded proteins could spread into the tendon tissues. In vivo study, the ultimate strength of repaired tendons treated with bFGF and VEGFA-releasing sutures was significantly greater than the tendons repaired with control sutures at multiple time-points, whether in the chicken model of flexor tendon injury or the rat model of Achilles tendon injury. At week 6, the adhesion score in the bFGF and VEGFA-releasing suture group was significantly lower than those of the control suture group. Tendon gliding excursion was significantly longer in the bFGF and VEGFA-releasing suture group than that in the control bare sutures. Work of digital flexion was significantly decreased in the bFGF and VEGFA-releasing suture group. In a word, we developed a platform for local and continuous delivery of growth factors based on the nanoparticle-coated sutures, which could effectively deliver growth factors to tissues and control the release of growth factors. This growth factors delivery system is an attractive therapeutic tool to repair injured tendons. STATEMENT OF SIGNIFICANCE: Tendon rupture is a common clinical injury, due to the special character of the tendon with mainly extra cellular matrix and hypocellularity and hypovascularity, the healing capacity of the injured tendon is limited. In this study, nanoparticle-coated surgical sutures carrying growth factors were prepared to accelerate tendon repair. After treatment, bFGF and VEGFA loaded nanoparticle-coated sutures can significantly enhance tendon healing, and significantly improve tendon gliding function and effectively inhibit the formation of adhesion. Moreover, these nanoparticle-coated sutures have good biocompatibility and no obvious tissue reaction, which provides more guarantee for further clinical application. This is an attractive and promising approach that uses surgical suture as a growth factor delivery tool to repair tendon injury, which can simplify the treatment. And this kind of bioactive sutures may be applied to other tissue repair, such as muscle, nerve, intestinal canal, blood vessel, skin, and so on.