Upper Limb Research
Featuring:
Single-Cross-Grasp Four Strand (Adelaide) Tenorrhaphy
To successfully repair a severed flexor tendon, specific biomechanical factors during the rehabilitation period must be considered, as the flexor tenorrhaphy relies on the suture material and its grasp on the tendon for at least the first three weeks, irrespective of the type of repair (Wagner et al, 1994).
A satisfactory repair technique should be biomechanically sound biologically inert user friendly The repair should have a low Iinherent Gapping Potential (IGP), use available suture material and be relatively simple to understand and reproducible in a variety of clinical situations.
We have reviewed the results of the Savage technique and have modified this concept to a more "user friendly" four strand single cross grasp repair with 4-0 or 3-0 braided polyester suture for most flexor tendon repairs. This has been demonstrated to have sufficient tensile strength (median tensile strength: 4 strand 4-0 Ethibond = 45N, 4 strand 3-0 Ethibond = 80N) to allow safe active mobilisation.
The diagram below is for the left hand. Each bite is inserted using the phrase - "in the end and then out to start the first grasp - then go in the direction of the next strand (go the way you are going)on the outside and come back inside the tendon transversely - and then go across the first outside pass (on the outside) to form the single cross grasp and then out the end (inside the tendon)"
"In the end and out to start the grasp, go the way and come back, then across and out the end".
Then cross the tendon gap ensuring the ends are well opposed, and insert the next bite. The transverse pass of the next grasp must be tensioned as it is generally not possible to take up the slack once a grasp is inserted. Nylon and Prolene will allow tensioning at the end of the repair, but have been shown in our laboratory studies to be inferior to braided polyester in terms of ultimate tensile strength for the same USP rating.
 As it is generally not possible to adjust the tension of each strand at the end of the repair, it is critical that the tendon ends remain accurately approximated throughout the repair. This is typically achieved with the standard technique of transfixing hypodermic needles. However this method of tendon stabilisation does not easily permit adjustment of tendon coaptation during the repair and precludes movement of the tendon within the flexor sheath until the needles are removed. A coaptation device (Pactan, Wright Medical Technology) maintains approximation of the tendon ends and allows adjustment during repair.
Pactan Repair Device (www.kaltec.com.au)
As the needles do not transfix the tendon and sheath, the tendon can be advanced or retracted for better access. For most FDP and FPL repairs 3-0 Ethibond or similar is recommended however for smaller tendons, a 4-0 braided polyester suture is sufficient. A 5-0 nylon epitendinous repair is generally performed, but typically only on the palmar aspect of the tendon. The epitendinous suture is used to prevent catching due to irregularity or retraction of the tendon edge and does not contribute significantly to the overall strength of the repair.
Upper Limb Research at Wakefield Orthopaedic Clinic Animated Carpal Motion at True Life Anatomy -
visit: www.truelifeanatomy.com.
Proximal scaphoid costo-osteochondral replacement arthroplasty.
Sandow MJ J Hand Surg [Br] 1998 Apr 23:2 201-8
Abstract
Deficiency of the proximal pole of the scaphoid due to fracture or necrosis was treated by costo-osteochondral replacement arthroplasty using rib bone/cartilage autografts in 22 patients who were followed prospectively and assessed at a median 24 month follow-up (range, 12-72 months). Improvement of wrist function occurred in all patients with increased motion, improved grip strength and less pain. The average modified Green and O'Brien Wrist Function Score improved from 53 out of 100 preoperatively to 80 at the most recent review.
All patients were graded fair or poor at initial review and all but three improved to good or excellent at the most recent assessment. Despite the absence of the scapholunate ligament, carpal alignment did not deteriorate in any patient and there were no graft non-unions or significant complications. In the short and medium term a costo-osteochondral autograft can satisfactorily restore mechanical integrity of the scaphoid proximal pole and maintain wrist motion while avoiding the potential complications of alternative replacement arthroplasty techniques.
ATOK (Arthroscopic Trans-Osseous Knotless) Rotator Cuff Repair
Dr. Michael Sandow
Wakefield Orthopaedic Clinic
Adelaide, Australia
The gold standard for repair of disrupted rotator cuff has been the trans-osseous repair. This has stood the test of time and whle arthroscopic repairs have attempted to improve on the execution and means of repair, the open trans-osseous repair has remained the benchmark.
The holy grail of rotator cuff repair however is the ability to perform the trans-osseous repair with its attendant mechanical advantages but by an arthroscopic technique – and without the need to tie knots.
There is a plethora of techniques described as “trans-osseous equivalent” which aim to use anchors either in a double or single row approach and then add a further over the top type repair to provide a downward pressure on the cuff itself to hold the lateral margin down.
While the elegance of inserting anchors into the humeral head and then tying the tendon down onto them has been promoted heavily, and there are multiple studies looking at pull out strengths in cadaver bones and similar, there are a number of mechanical compromises which are required. The art of tying knots is somewhat of a challenge and consequently there are now techniques which avoid insertion of knots to achieve the repair to the great tuberosity. While previously the tendon was pulled into a cancellous bed, the tendon is now laid onto a bare area of bone and the area of bone is now no longer even scarified as various studies have shown that this is sufficient for poorly vascular tendon to heal onto sclerotic great tuberosity bone.
The insertion of a tendon into a cancellous bed trench such as used in the standard trans-osseous repair may have some advantage but these have not been proven. The rotator cuff that is tied down onto the greater tuberosity surface with anchors and knots has a number of possible compromises. Any give of the knot or the anchor will allow for gapping of apposition of the greater tuberosity to the tendon. This in itself may interfere with healing and various reports have suggested an incomplete healing rate with arthroscopic repairs.
  At Wakefield Orthopaedic Clinic we have been using a trans-osseous open repair technique but have now developed a means of achieving the trans-osseous repair but through an arthroscopic technique and without the requirement to tie knots. This involves inserting the sutures into the torn end of the rotator cuff and then preparing a trench and then trans-osseously passing the sutures using a specially designed jig. An anchor is inserted in retrograde fashion to lock the sutures onto the lateral cortex.
At this stage we are using the Smith & Nephew Footprint anchor in an off licence technique and initial series show good cuff apposition with follow up MRI scans showing the durable position of the anchor and correct positioning of the tendon.
We also have an improved and patented anchor which is still under development. The ATOK technique we believe will prove to be the holy grail of rotator cuff repairs. It has the advantages of trans-osseous repair, it avoids knots in the subacromial space and knot tying generally and is adjustable with a low mechanical failure rate - and all this with the reduced morbidity of the arthroscopic approach. Further studies are now underway to validate the apparent satisfactory initial outcome. Preliminary results have been very encouraging.
For more details, contact:
Business Manager, Wakefield Orthopaedic Clinic
woc@woc.com.au
Document created: 26 August 2010
Suprascapular Nerve Rotator Cuff Compression Syndrom in Volleyball Players
Sandow MJ, Ilic J J Shoulder Elbow Surg 1998 Sep-Oct 7:5 516-21
Abstract:
Selective denervation of the infraspinatus muscle producing weakness and wasting has been reported in certain sports (eg, volleyball and baseball). Nerve kinking or friction caused by excessive infraspinatus motion and compression by superior or inferior transverse scapular ligament or ganglions have been proposed as possible causes. However, in extreme abduction with full external rotation of the shoulder, the medial tendinous margin between the infraspinatus and supraspinatus muscles impinges strongly against the lateral edge of scapular spine, compressing the intervening infraspinatus branch of the suprascapular nerve.
Spinaglenoid notchplasty has been performed in 5 elite volleyball players with infraspinatus neuropathy, allowing recovery of shoulder function in all patients and correction of infraspinatus muscle wasting. All returned to the same or higher level of volleyball by 8 months after surgery. An alternative cause of infraspinatus compromise in volleyball players is proposed and has been treated surgically with satisfactory outcome.
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