Intrasynovial flexor tendon injuries and repair

Edsfeldt, S. 2017. Intrasynovial flexor tendon injuries and repair. Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine 1307. 67 pp. Uppsala: Acta Universitatis Upsaliensis. ISBN 978-91-554-9838-2. Complications after surgical repair of intrasynovial flexor tendon injuries in the hand occur despite advanced suture techniques and structured postoperative rehabilitation regimens. Early controlled tendon mobilization prevents adhesion formations and improves tendon healing as well as digit range of motion. To allow early postoperative rehabilitation, the strength of the repair must withstand forces created during the rehabilitation maneuvers. Improvements in suture biomechanics have increased repair strength, but up to 18 percent of repaired tendons still rupture. The overarching aim of this thesis was to investigate how to best treat intrasynovial flexor tendon injuries with limited risk of repair rupture, decreased adhesion formations, and to estimate the effect of individual patient and injury characteristics on functional outcome. In two observational studies, we identified risk factors for rupture of repaired intrasynovial flexor digitorum profundus (FDP) tendons, and studied effects of these risk factors on the long-term outcome. Age was associated with increased risk of repair rupture and impaired digital mobility the first year after surgical repair. Concomitant flexor digitorum superficialis (FDS) transection was associated with increased risk of repair rupture without affecting digital mobility. Concomitant nerve transection lowered the rupture risk without affecting digital mobility. To better understand forces generated in the flexor tendons during rehabilitation maneuvers, we measured in vivo forces in the index finger FDP and FDS tendons during rehabilitation exercises. Highest forces were measured during isolated FDP and FDS flexion for the FDP and FDS respectively. For the FDS tendon, higher forces were observed with the wrist at 30° flexion compared to neutral position, and for the FDP tendon, forces were higher during active finger flexion compared to place and hold. PXL01 is a lactoferrin peptide with anti-adhesive effects previously demonstrated in animal studies and a clinical trial to improve digital mobility when administrated around repaired tendons. We studied the mechanism of action of its corresponding rabbit peptide, rabPXL01 in sodium hyaluronate (HA) in a rabbit model of flexor tendon transection and repair and used RTqPCR to assess mRNA levels for different genes. Increased levels of PRG4 (encoding lubricin) were observed in rabPXL01 in HA treated tendons. The expression of Interleukin 1β, 6, and 8 was repressed in tendon sheaths. RabPXL01 in HA might stimulate the release of lubricin and diminish inflammation, which correspondingly reduces tendon-gliding resistance and adhesion formations during postoperative rehabilitation exercises. The results of this thesis suggest individually adapted treatment plans, depending on repair strength, patient and injury characteristics, as a possible way to improve outcome after flexor tendon repair. Sara Edsfeldt, Department of Surgical Sciences, Hand Surgery, Akademiska sjukhuset, Uppsala University, SE-75185 Uppsala, Sweden. © Sara Edsfeldt 2017 ISSN 1651-6206 ISBN 978-91-554-9838-2 urn:nbn:se:uu:diva-316559 (http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-316559) To Martin, Lea and Ellen