| BackgroundTendon injuries account for a large proportion in hand injuries,especially in cases of simple tendon injuries or combined tendon injuries,which account for about 30%of cases of hand injuries.Healing after tendon injury and the quality of repair directly affects the appearance and functional recovery after hand injury.The tendon repair has been in the stage of exploration,try and innovation.Sterling Bunncll,one of the founders of hand tendon injury and repair,holds that" one of the most difficult problem in hand surgery is to restore the finger tendon unction",which emphasizes the difficulty and importance of tendon repair.Numerous scholars over the years has made unremitting efforts in the aspects of microsurgical anatomy,tendon healing and repair,tendon nutrition,suture material,preventing adhesion improvement,operation,postoperative rehabilitation function exercise.Although the level of repair of tendon injury has been continuously improved,tendon repair effect has been poor.That is produced in the main reason that postoperative tendon adjoins with the surrounding tissue,which causes tendon sliding is limited,and another broken after poor tendon repair,which seriously affect the functional recovery of hand injury after operation.That causes the appearance of the affected hand and different degrees of disability,bringing many adverse effects to the patient's work and life,especially for those playing piano,guzheng and other musical instruments,players,calligraphy,painting and other opponents,those who have higher need for functional recovery Tendon injury repair is a long way to go.The diversity of the mechanism of tendon injury leads to a variety of forms of tendon injury.The diagnosis of tendon injury sometimes is difficult,especially the closed incomplete tendon injury.,children and infants with tendon injury cannot cooperate with the inspection,the old tendon injury or tendon injury adhesive with surrounding tissue.The dysfunction of the tendon injury that is associated with nerve injury such as radial nerve or peroneal nerve injury,easily overlooked or cover which leads to delayed diagnosis and treatment even missed,adversely affect patients exist at the same time a certain degree of misdiagnosis and missed diagnosis of medical disputes.Some patients who suffered from poor condition of tendon after trauma or could not directly repair the tendon defect after defect or debridement sometimes need the second operation,such as delayed repair,even tendon transplantation or extension,which was difficult in healing and ineffective after operation.The effect of extensor tendon injury with phalangeal fractures especially with proximal phalanx fractures is poor.After the repair of the tendon,due to the influence of the brake after the fracture,the repaired tendon cannot be timely regular rehabilitation training.Tendon adhesions lead to varying degrees of limited finger flexion and joint stiffness,especially more callus formation in the process of fracture healing between tendon and bone,further increasing the tendon adhesion postoperative dysfunction.In this case,it often exerts the help of secondary tendon release to further improve the appearance and function of the affected hand in that the limited flexion caused by adhesions by is difficult to obtain good postoperative functional recovery.Extensor tendon is wide,flat and thin,with poor nutrition and elasticity.Once the fracture damage,its lacerate stump was not whole or from the extensor tendon insertion avulsion amputation and combined tendon avulsion fracture.Extensor tendon in the middle phalanx to stop in the middle at the distal part of the base of the distal phalanx from both sides of tendon converging end tendon,named the extensor tendon I area.The extensor tendon rupture in phalangette presents cannot unbend,flexion deformity,called mallet finger.According to the anatomical and mechanical characteristics of mallet fingers,mallet fingers were divided into bony mallet fingers(combined with extensor tendon insertion avulsion fracture)and tendinous mallet fingers(extensor digitorum tendon and tendon rupture).So far,there are many methods for the treatment of mallet finger malformation,and the treatment effect is different.Before treatment and treatment in abroad for mallet fingers tend to conservative treatment,after long-term clinical data analysis and clinical evaluation.surgical treatment compared with conservative treatment is easier to achieve the objectives and requirements of treatment,surgical repair of mallet finger deformity by more and more people accept and as a preferred treatment of mallet finger.Malocclusion is caused by avulsion or avulsion fracture of extensor tendon.Traditional pull-through wire method is used to reconstruct the insertion point of extensor tendon while the healing time is long and unstable,and the malformation cannot be completely corrected or when external force is easy to fracture again,which leads to deformity recurrence.Two surgical removal of internal fixation steel wire may cause a broken tendon in the broken end of the steel wire to cause the tendon to be repaired again after the tendon repair.In addition,after clinical observation,the operation often combined with complications such as nerve and blood vessel injury,finger scarring,infection,finger pressure ulcers and finger tip ischemia necrosis.Then someone tried to study treatment of mallet finger with Kirschner wire combined with extensor tendon repair application in the premise that the tendon ends up to the distal end of the extensor tendon with at least two millimeters of fine residual tendons that can be stitched together.Since the tendon avulsion or distal tendon insertion site distance of less than 2 mm cannot be directly repaired,it needs reconstruction.With the development of clinical materials,Mitek Mini bone anchor was applied in the treatment of mallet finger,further expansion of the treatment of mallet finger repair effect of surgical indications and postoperative.Some scholars believe that the bone anchor is relatively large and heavy foreign body reaction causes inflammation or extrusion.Besides,operation cost is more expensive and it should be careful to use for the patients who severe osteoporoses is prone to be loose.In recent years,our country has reported that the finger deformity has achieved good results by the treatment of the palmaris longus tendon graft,including double ring suture through the tunnel cross pressure treatment with avulsion fracture of mallet finger extensor tendon reconstruction,improvement of the treatment of mallet finger,and palmaris longus tendon graft for the treatment of mallet finger deformity.Further improvement based on the above mentioned operative methods has made and designed treatment of mallet finger deformity with a modified palmaris longus tendon graft through a bone tunnel.Treatment of mallet finger deformity with a modified palmaris longus tendon graft through a bone tunnel will be restored to the original state as much as possible from the aspects of anatomy and biomechanics of the distal interphalangeal joints,which overcomes the similar operation in the triangular piece of tendon suture and suture caused by Ru in the triangle between the two longitudinal forces dispersed.analysis of modified operations close to the extensor tendon insertion anatomic reconstruction from a biomechanical perspective.The tendon donor is a piece of palmaris longus tendon,which is not completely cut off the palmaris longus tendon and further reduces the damage and the effect on the function of the tendon donor area.The effect of modified surgical is exact while tendon healing time is short.Since it does not consider the healing of tendon and tendon stop point,so we can achieve the premise of reconstruction in the early functional exercise under the guarantee check point of failure,early functional exercise reduced the risk refers to the probability of interphalangeal joint stiffness and tendon adhesion,finger distal interphalangeal joint(DIP)function significant improvement.The modified operation is simple,no special tools,low cost,small damage,and small recurrence probability of the mallet finger.It is especially suitable for the popularization and application of the basic hospital.This paper objectively,accurately and truly confirms the feasibility of operation from the angle of biomechanics.Through comparative biomechanical and traditional surgical,it proves the superiority of the improved operation method.And through the experimental study,it also found that the operation need to pay attention to the details and adverse factors that may affect the effect of the operation which at the same time provides the theoretical basis for further improvement and has important significance in a new treatment idea for treatment of mallet finger deformity.Purpose(1)By making biomechanical model of extensor digitorum tendon in fresh frozen human finger specimens,it can be knew anatomy structure of extensor apparatus and terminal tendon,master the technique of making a mallet finger biomechanical model(2)Through biomechanical experiments,it has mastered that the operation skills of CSS-44020 type biomechanical testing machine(Changchun test machine Institute),tendon specimen fixture,calculation control software TestExpert Version3.6,and the interpretation of experimental results.(3)Through the measurement of random grouping of different age and different forearm and different fingers maximum biomechanical force and tensile strength measurement,random grouping of different age and different forearm different fingers mallet finger model of pull-through wire method after surgical repair of biomechanical maximum force and tensile strength of the original data and the maximum force and tensile strength of the biomechanical repair of modified palmaris longus tendon graft through a bone tunnel,based on the original data were statistically analyzed the feasibility and superiority of the modified surgical treatment of mallet finger.Through the analysis of biomechanical experiment results,the advantages and disadvantages of the modified operation can be objectively summarized,and the factors that affected the experimental results provides guidance and objective indicators for improving the effect of operation(4)The paper summarizes clinical data of modified and traditional pull-through wire and compares the effect evaluation system made by Patel Besides,compared the wound healing,pain,appearance,joint activity,deformity recurrence,complications and so on,it proves the feasibility and advantages of the improved operation from the clinical level.Method(1)The selection and grouping of experiment samples:choosing 9 fresh adult hands without appearance deformation,damage,and destruction of bone confirmed by X-ray examination and no fracture,deformity and tumor of bone as the experimental specimens.Each finger needs to be the dislocation frommetacarpophalangeal joint,sealed in a 20 0C below zero freezing for the spare specimens with double plastic bags.The 45 fingers were randomly divided into 3 groups(A\B\C).Group A was a normal group;group B and group C cut the end of the extensor tendon from the stop point with a scalpel to make a model of the mallet finger.Group B was the control group.The mallet finger model was repaired by pull-through wire.C group was the experimental group,and the mallet finger model was repaired by a modified palmaris longus tendon graft through a bone tunnel.(2)Anatomy of finger extensor apparatus and construction of mallet finger deformity model:specimens will be took at 2h before test to avoid repeated freezing effects on the biomechanical properties of tendon.After the natural thawing at room temperature,the nail deck is removed.Surgical incision along the Side Central Line of both sides of the fingers is used to remove the dorsal skin of the finger completely,and the extensor tendon and perilineal membranes are protected,and the integrity is ensured.The shape and structure of each part of the finger extensor apparatus are observed.The extensor tendon and the free end device with the phalanx base of dorsal extensor tendon is connected,in order to facilitate model and biomechanical testing machine clamp connection and prevent tendon specimen clamping position tendon avulsion fracture Influence experiment implementation,designing the model will stop the central tendon carefully cut,keep the extensor apparatus complete the thick and dense,the keycap part and fixture for tendon cohesion,and extensor tendon strength against tension,with a diameter of 1 mm Kirschner wire through the middle and distal phalanx bent in a U shape is fixed on the bottom of the tendon specimen fixture.The construction of the mallet finger model:dissecting the free complete extensor tendon at the end of the extensor tendon with a scalpel.Keep the integrity and wetness of the extensor tendon in order to avoid the effect of the biomechanical experiment.Construction of the mallet finger model of pull-through wire:Distal interphalangeal joint(DIP)with a diameter of 1 mm Kirschner wire was fixed in extension.A hand surgical steel wire with a diameter of 0.5 millimeters is used to stitch the broken end of the tendon through the needle of the 5ml syringe for Bunnell.20ml syringe needle stick phalanx base on both sides inclined at an angle of 45 degrees from the dorsal oblique to wear finger volar,wire piercing finger through the basin shaped black plastic button,tighten wire and screw.Modified palmaris longus tendon graft through a bone tunnel method mallet finger model:At the end of the dorsal part of the phalangeal basement,the diameter of 2.0mm kirschner wire was used to transverse run through the borehole.,Drill perpendicular to the transverse bone tunnel with the diameter of 2.5mm kirschner wire or drill in the median dorsal phalanx base,and transverse bone tunnel communicates with longitudinal bone tunnel(not drill through volar half bone).Exposed and cut about 7cm long shallow semitendinosus tendon palmaris longus tendon,the end part of the tendon sagittal incision into two parts which are in a Y shape,two parts of tendon graft respectively through the longitudinal bone tunnel and out of both sides of transverse bone hole.symmetrical back turning to the proximal side of the tendon,into the dorsal bone hole slightly proximal and main tendon suture.(3)A comprehensive analysis on the biomechanical properties of 3 kinds of models:The model is fixed on the biomechanical test machine for biomechanical experiments,biomechanical testing machine of finger extensor tendon was pulled to record mallet finger repair failed when the maximum tensile strength of extensor tendon and the maximum stress.The experimental data were statistically analyzed using SPSS 13.0.The difference between different groups was analyzed by variance analysis.The two groups were compared by double tail t test.The significant level was set to 0.05.When the P value was less than 0.05,the difference was statistically significant(4)Clinical efficacy analysis:The patients were followed up for the surgical treatment of mallet finger in hand surgery in our hospital from September 2015 September 2011.A total of 85 cases were followed up,27 cases were pull-through wire,28 cases were Mini bone anchor,and 30 cases were improved by the treatment of mallet finger deformity with a modified palmaris longus tendon graft through a bone tunnel.Patients were followed up from wound healing,pain,appearance,joint mobility,deformity recurrence and complications.According to the evaluation system of mallet fingers established by Patel.Consequence1.Biomechanical experiment:The maximum tensile strength and the maximum force of extensor tendon when mallet finger repair failed:normal group:86.12±57.14N;control group.pull-through wire 18.59±5.73N;experimental group,modified bone tunnel palmaris longus tendon graft method 47.66±17.87N.The reason of reconstruction of the extensor tendon stop point failure:The control group,the failure of the method is the cause of wire binding part of the tendon loose or tear under tension;The experimental group,the reason of modified palmaris longus tendon graft through a bone tunne failure is that bone tunne was destroyed under the action of the tension so that transplantation self organization tendon graft bone tunnel fail.The results of variance analysis F=13.74,P<0.05.The difference between the experimental group and the control group was statistically significant.The method of modified palmaris longus tendon graft through a bone tunnel is a better way to repair the mallet finger than the pull-through wire method.Owing to the selection of experimental specimens,the making methods of biomechanical models,and the accuracy and sensitivity of biomechanical instruments,There may be some deviation in the biomechanical experimental results and the actual results.2.Results of clinical efficacy analysis:In the group of pull-through wire.16 cases were excellent,5 cases were good,3 cases were available,and 3 cases were poor;In the group of mini bone anchor,17 cases were excellent,7 cases were good,4 cases were available;In the group of modified palmaris longus tendon graft through a bone tunnel 22 cases were excellent,7 cases were good,and 1 case was available.The curative effect of three groups was compared with SPSS 13.0 rank sum test by P<0.05.It is considered that there is difference between mini bone anchor and modified palmaris longus tendon graft through a bone tunnel methods.The effect of modified group is better than that of traditional pull-through wire.The type of complications in clinical cases was not consistent.Complication in pull-through wire method was finger pulp pressure sore and some fingertip feel numb,even deformity recurrence caused by tendon injury in the process of taking the wire.The complications of modified palmaris longus tendon graft through a bone tunnel were nodal reaction and suture rejection.The factors influencing the operative effect of pull-through wire are difficult to control.The tightness of steel wire,the texture and injury of extensor tendon,and the incomplete tear of extensor tendon cause the ineffectiveness.Factors that influence the operation effect of the improved operation method for phalangette osteoporosis bone tunnel quality is poor,poor tensile strength and tendon suture,film quality.Results1.The main purpose of the mallet finger treatment is to restore and continuity tendons I area,there is a need for reconstructive surgery for the end-point avulsion.The traditional pull-through wire method and modified by bone tunnel palmaris longus tendon graft reconstruction method insertion strength can meet the treatment of mallet fingers,using modified palmaris longus tendon graft through a bone tunne method not only can achieve the biomechanical stability of the more stable,compared with the traditional operation effect is accurate with small damage,low cost.Recovery time is short,deformity,low recurrence rate,fewer complications,surgical advantages in wide.It can be recommended as a new method to treat mallet finger deformity.2.The traditional pull-through wire method in the operation will be easy to hurt neurovascular bundle in the process that wire runs through abdominal soft tissue,leading to the disability of sensory and blood circulation.Besides,it is difficult to grasp the tightness of the steel wire and steel wire fixation loose is difficult to achieve firmly fixed,even can not realize the tendon healing.Healing can cause a long time and is not strong in case of external fault easily again,the deformity recurrence,which can not achieve the purpose of operation.If wire fixation of distal finger belly button was tight,compression parts will be prone to soft tissue scar,even infection,finger pulp pressure sore,and the serious complications of ischemic necrosis of the end.After the operation,the distal interphalangeal joint has a longer fixed time,which can lead to the stiffness of the joint.The patient has a longer recovery time and greater pain after the operation,but the effect is not good.When the internal fixation steel wire was taken out of the two operations,even deformity recurrence caused by tendon injury in the process of taking the wire.3.The operation effect of the improved operation method depends on the distal phalanx bone quality,the quality of the bone tunnel,and tendon suture quality tablets.Those who have severe osteoporosis or combined phalangette extensor tendon insertion avulsion fracture of the surgical removal of bone tunnel should caution to this method.In addition,the fabrication of bone tunnel is precise and prevents repeated operation,resulting in too much bone damage affecting operation effect.And,the number of sutures should be minimized without affecting the strength of tendon suture,so as to prevent nodal reaction and tendon adhesion. |
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