Zon iki fleksör tendon yaralanmalarında A2 pulley plastiği ile diğer cerrahi yöntemlerin karşılaştırılması: Deneysel ve biyomekanik kadavra çalışması
Küçük Resim Yok
Tarih
2021
Yazarlar
Dergi Başlığı
Dergi ISSN
Cilt Başlığı
Yayıncı
Ege Üniversitesi, Tıp Fakültesi
Erişim Hakkı
info:eu-repo/semantics/openAccess
Özet
Amaç: Zon iki fleksör tendon yaralanmaları günümüzde hala el cerrahisinin, zorlayıcı uğraşlarından biri olmaya devam etmektedir. Yaralanma sonrası el fonksiyonlarında mükemmel sonuçlara ulaşmak, her zaman mümkün olmamaktadır. Literatürde zon 2 fleksör tendon yaralanmalarının tedavisinde, tendon onarımı ve A2 pulleye yapılacak cerrahi teknik konusunda bir uzlaşma yoktur. Zon 2 bölgesindeki dar fibro-osseöz kanal yapısı, yapılan cerrahi onarıma bağlı hacim artışı nedeniyle, adezyonların oluşmasına ve parmakta hareket kaybına neden olabilmektedir. Bu durumun önüne geçebilmek için farklı cerrahi teknikler tanımlanmıştır. Çalışmamızda zon 2 fleksör tendon yaralanmaları tedavisinde; FDP tendonu onarımına ek olarak yapılacak cerrahi teknikler arasında; FDS tek slip onarımı, A2 pulley gevşetmesi ve iki farklı pulley plasti yönteminin (Kapandji ve V-Y pulley plasti) biyomekanik sonuçlarının karşılaştırılması amaçlanmıştır.
Gereç ve Yöntem: Çalışmamızda 12 adet modifiye Larssen solüsyonu (MLS) ile korunmuş, kol orta ½ seviyesinden ampute edilmiş, insan üst ekstremite kadavrası kullanıldı. Toplamda 36 parmak (Her kadavra için iki, üç ve dördüncü parmak kullanıldı) dört gruba ayrıldı ve her grup için 9 adet parmak kullanıldı. Parmak tam fleksiyondayken FDS ve FDP tendonları A2 pulleyin tam ortasından kesildi ve dörtlü çapraz merkezi dikiş (cruciate four-strand) ile onarıldı. Gruplara yukarıda tarif edilen cerrahi teknikler uygulandı. Uygulama öncesi ve sonrası farklı yüklerde (50- 700 gr) parmakların fotoğrafları çekildi. Dijital ortamda fotoğraflar üzerinde proksimal interfalangeal (PİP) eklem açısı, PİP eklem maksimum fleksiyon açısı ve bowstring mesafesi ölçüldü. PİP eklem açısı, , tek aşamalı eksponansiyel denkleme uygulanarak kayma katsayısı hesaplandı. Pulley yetmezlik testinde, dört farklı cerrahi teknik giderek artan kuvvete karşı test edildi. Her parmak için yetmezliğin geliştiği kuvvet kaydedildi.
Bulgular: Kayma katsayısı cerrahi sonrası tüm gruplarda anlamlı şekilde arttı. Bu nedenle PİP eklem maksimum fleksiyon açısı ise tüm gruplarda cerrahi sonrası anlamlı şekilde azaldı. Ancak cerrahi teknikler arasında istatistiksel olarak anlamlı bir fark saptanamadı. Gruplar arası Bowstring mesafesi karşılaştırıldığında kapandji pulley plasti, V-Y pulley plasti ve FDS tek slip onarımı gruplarında yakın sonuçlar elde edilirken, A2 pulley gevşetme grubunda diğer üç gruba göre bowstring mesafesinin anlamlı derecede arttığı saptandı. A2 pulley yetmezlik testinde gruplar arasında anlamlı fark saptandı. Grupların sırasıyla yetmezlik kuvveti değerleri; FDS tek slip onarımı 449,33 ∓ 82,29 N, A2 pulley gevşetmesi 252,28 ∓ 73,39 N, V-Y pulley plasti 156,11 ∓ 40,25 N ve Kapandji plasti 107,67 ∓ 32,74 N olarak saptandı.
Sonuç: Fleksör tendon onarımı sonrası parmak hareketi olumsuz biçimde etkilenir. Farklı cerrahi yöntemler arasında kayma direnci ve fleksiyon açısı açısından benzer sonuçlar bulunmuştur. Bu durumda FDS tek slip onarım yöntemi ile A2 pulleyin anatomisini koruduğu için ön plana çıkmaktadır.
Objective: Zone 2 flexor tendon injuries are still one of the challengs for hand surgeons. It is not always possible to achieve perfect results in hand functions after these injuries. There is no consensus in the literature regarding the treatment of zone 2 flexor tendon injuries, tendon repair and surgical technique to be applied to A2 pulley. The narrow fibro-osseous canal structure in zone 2 can cause adhesions and loss of motion due to the increase in tendon volume due to surgical repair. Different surgical techniques have been defined to prevent this situation. In our study, in the treatment of zone 2 flexor tendon injuries; Among the surgical techniques to be performed in addition to FDP tendon repair; We aimed to compare the biomechanical results of single FDS slip repair, A2 pulley release and two different pulley plasty methods (Kapandji and V-Y pulley plasty). Materials and Methods: In our study, 12 human upper extremity cadavers preserved with modified Larssen solution (MLS) and amputated at the mid ½ level of the arm were used. A total of 36 fingers (second, third and the fourth fingers were used for each cadaver) were divided into four groups and 9 fingers were used for each group. With the finger fully flexed, the FDS and FDP tendons were cut right in the middle of the A2 pulley and repaired with cruciate four-strand technique. The surgical techniques described above were applied to the groups. Photographs of fingers with different loads (50- 700 gr) were taken before and after the application. Proximal interphalangeal (PIP) joint angle, PIP joint maximum flexion angle and bowstring distance were measured. Gliding coefficient was calculated by applying the PIP joint angle to the the single-phase exponential association equation. In the pulley failure test, four different surgical techniques were tested against progressive force. The force with which the insufficiency developed was recorded for each finger. Results: Gliding coefficient increased significantly in all groups after surgical applications. Therefore, the PIP joint maximum flexion angle decreased significantly after surgery in all groups. However, there was no statistically significant difference between surgical techniques. Bowstring distance between single FDS slip repair, kapandji pulley plasty and V-Y pulley plasti showed no significant difference in most loads. Bowstring distance was significantly increased in the A2 pulley release group compared to the other three groups. There was a significant difference between all groups in the A2 pulley failure test. The pulley failure strength were 449.33 ∓ 82.29 N, 252.28 ∓ 73.39 N, 156.11 ∓ 40.25 N and 107.67 ∓ 32.74 N for single FDS slip repair, A2 pulley release, V-Y pulley plasty and Kapandji plasty respectively. Conclusion: digital motion was negatively affected after flexor tendon repair. Similar results were found in terms of gliding coefficient and maksimum flexion angle among different surgical methods. As single FDS slipe repair preserves the anatomical structure of the A2 pulley therfore we prefer it as ideal method for zon 2 flexor tendon repair.
Objective: Zone 2 flexor tendon injuries are still one of the challengs for hand surgeons. It is not always possible to achieve perfect results in hand functions after these injuries. There is no consensus in the literature regarding the treatment of zone 2 flexor tendon injuries, tendon repair and surgical technique to be applied to A2 pulley. The narrow fibro-osseous canal structure in zone 2 can cause adhesions and loss of motion due to the increase in tendon volume due to surgical repair. Different surgical techniques have been defined to prevent this situation. In our study, in the treatment of zone 2 flexor tendon injuries; Among the surgical techniques to be performed in addition to FDP tendon repair; We aimed to compare the biomechanical results of single FDS slip repair, A2 pulley release and two different pulley plasty methods (Kapandji and V-Y pulley plasty). Materials and Methods: In our study, 12 human upper extremity cadavers preserved with modified Larssen solution (MLS) and amputated at the mid ½ level of the arm were used. A total of 36 fingers (second, third and the fourth fingers were used for each cadaver) were divided into four groups and 9 fingers were used for each group. With the finger fully flexed, the FDS and FDP tendons were cut right in the middle of the A2 pulley and repaired with cruciate four-strand technique. The surgical techniques described above were applied to the groups. Photographs of fingers with different loads (50- 700 gr) were taken before and after the application. Proximal interphalangeal (PIP) joint angle, PIP joint maximum flexion angle and bowstring distance were measured. Gliding coefficient was calculated by applying the PIP joint angle to the the single-phase exponential association equation. In the pulley failure test, four different surgical techniques were tested against progressive force. The force with which the insufficiency developed was recorded for each finger. Results: Gliding coefficient increased significantly in all groups after surgical applications. Therefore, the PIP joint maximum flexion angle decreased significantly after surgery in all groups. However, there was no statistically significant difference between surgical techniques. Bowstring distance between single FDS slip repair, kapandji pulley plasty and V-Y pulley plasti showed no significant difference in most loads. Bowstring distance was significantly increased in the A2 pulley release group compared to the other three groups. There was a significant difference between all groups in the A2 pulley failure test. The pulley failure strength were 449.33 ∓ 82.29 N, 252.28 ∓ 73.39 N, 156.11 ∓ 40.25 N and 107.67 ∓ 32.74 N for single FDS slip repair, A2 pulley release, V-Y pulley plasty and Kapandji plasty respectively. Conclusion: digital motion was negatively affected after flexor tendon repair. Similar results were found in terms of gliding coefficient and maksimum flexion angle among different surgical methods. As single FDS slipe repair preserves the anatomical structure of the A2 pulley therfore we prefer it as ideal method for zon 2 flexor tendon repair.
Açıklama
Anahtar Kelimeler
Fleksör Tendon, Yaralanma, A2 Pulley, Kadavra, Flexor Tendon, Injury, A2 Pulley, Cadaver
