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Flexor tendon adhesions in the hand

I am looking for any ideas how to "break" or loosen heavy flexor tendon adhesions particulary in zone 2 of the hand. From what I have ret in the literature this could be the ultrasound, but I don't have good results, maybe due to wrong choise of parameters. Some people say lasers, but I never have meet them in the "serious" literature on the topic. And what about ionophoresis with iodine? Anybody tried that? Please people, share your knowledge and experience. Thank you!

Georgi Petrov

4 months ago

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gvpetrov223
gvpetrov223

A little update - I tried the Iontophoresis technique described by prof. Bellew and it really softens the scar very nicely. Even with one procedure. Just be careful to not make a burn as it happened with one of the patients that I tried with (now I think that 4mA is too much for 20 min.) And I am not sure that it does something deeper than the dermis layer. So any recomendations hot to treat this small burn? Thanks to all.

gvpetrov223
gvpetrov223

First of all thanks for the answers! So, Cliff, I have never been using Shockwave, but I have seen this machine.. isn't it too big and strong for such a small and delicate structure as the proximal phalanx of the small finger? Is it appropriate in the acute postoperative phase. Can you link some of the studies you mentioned? Here is a link on early US on flexor tendon repairs in zone 2 - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4075224/
For me what these people did is quite brave, but I tried it (with written consent) on a complicated case of second reconstruction of a flexor tendon in zone 3. Today was the end of the fourth postoperative week for this patient and it looks promising, but I'll be quiet about that until the rehab is over. Anyway, Alison, I am aware of the basics and I agree with you about the small bits, this is the usual practice, but this doesn't work for some patients - those who don't have "the nerves" to be so strict with the rehab regimen (this is why the Indian therapists from the link above tried the early US - their patients simply couldnt understand and follow the complex early mobilization protocols). Parrafin wax is good idea.. I am using hot packs for the fingers since they are the easiest thing to do, but the wax could be more efficient. The other problem in this particular patient that I am talking about is that his tendon doesnt have sinovial sheath (very damaged from the first operation and has to be removed and the canal to be reconstructed with tendon graft) and this leads to excessive adhesions. About the US parameters - I basicly try to increase the temperature of the tissue to a degree that I can clearly feel. It takes 10 minutes. Since my transducer is 5cm2 ( I am waiting for the 1,5 cm2 one) I use water bath for application technique for the fingers. For most of the patients this is sufficient to achieve immediate increase of the ROM - the younger the scar, the bigger the increase. And with this patient was the same but it looks like the scar became too strong very quickly (2 days) after his last visit. So I am looking for some "special" technique to influence the adhesions .That's it. I hope this long post makes the picture clear. Thanks one more time for your thoughts and ideas on that. Now I am going to check the WALT recommendations about LLLT.

alison.hoens229
alison.hoens229

Thank you for this additional information. It is a 'relief' that the most recent adhesions (post tenolysis) have been in process only since March. This is within the 3-6 month window of opportunity for 'malleability' of collagen. Given the propensity for the bonds between the collagen molecules to reform as the tissue cools post heating, it makes good sense to do "little bits often" ie. heating and stretching for short periods (e.g. 10 minutes) frequently (every 1-2 hrs) while awake. Thus, in addition to what you provide in the clinic for the patient, consider asking the patient to add use of paraffin wax at home throughout the day. With respect to use of another EPA in the clinic, what duration did you use for the Ultrasound? recall that the duration should be increased to account for the size of the area being insonated and the size of the transducer head. Check out the guidance on Electrotherapy.org for dosing of ultrasound. LLLT is also a possibility and guidance on dose is available from the WALT guidelines (World Association of Laser Therapy). Finally, check out the EPA contraindications/precautions special issue from Physiotherapy Canada (Nov 2010) to see if there are any concerns re selection of an EPA for this specific patient. Hope this helps ... Please keep us posted on your selection, parameters and results :)

Cliff Eaton
Cliff Eaton

Georgi Some experimental studies have shown that Shockwaves may induce fibrotic tissue to be reduced during initial repair and remodelled in scar tissue. Cliff

gvpetrov223
gvpetrov223

Prof Bellew, thank you for that. It sounds easy and can do no harm, so I can try it and if I do I'll post the result. Alison, about the patient - this is male patient in his mid twenties. In the summer of 2016 (forgo the exact date) he cut his right fifth finger at the base (both tendons) and got tendon repair followed by immobilization protocol (3 weeks immobilization and then therapy). Due to the unsatisfactory results he came to our clinic and in 8th of March this year underwent tenolysis and A1 pulley repair with palmaris longus graft. He started therapy immediately but is not very good at following the instructions and doing the exercises (this is not an excuse). Therapy includes nighttime extension static splint , daytime MCP blocking splint so he can do his blocking exercises many times. Now he have full MCP range of motion, 20-30 degrees fllexion in the PIP and 10 degrees in DIP. He says after the night with the splint the finger is straight , but I see it in a slight flexion contracture of both DIP and PIP. We tried ultrasound (continious both 3 and 1 mhz, in the range of 1-2 W/cm2) with the idea to warm up the adhesions but it didn't do much. I feel that US even somehow accelerated the adhesions (or this guy is just geneticaly predisposed to adhesion formation). So I will be gratefull to any idea that could help. Cheers, Georgi Petrov

alison.hoens229
alison.hoens229

Hello - in order to guide my reply I would be grateful to learn further details such as the duration that the adhesions have been present, the mechanism(s) [ie. were they secondary to a specific surgical intervention?] that precipitated the adhesions and any specific characteristics of the patient (contraindications/precautions) that influence or preclude the application of any type of energy form (e.g. light, sound or electrical). Kind regards, Alison Hoens

Prof James Bellew
Prof James Bellew

Georgi, Thank you for your question. As you asked for, I will take this opportunity to contribute my knowledge and experience, and I will add my current opinion hoping to hear from others. Because of the relative superficial location of these adhesions, iontophoresis presents as a possible option. You mention iodine which has commonly been proposed for an "anti-scar" effect. Commonly administered as a 5-10% solution from the cathode as potassium-iodine, there is limited evidence that the iodine itself specifically contributes to the anti-scarring effect. For years, we have experimented on superficial scars using iontophoresis but without iodine (or potassium iodine). We have simply administered cathodal stimulation over the scar using tap water (not distilled). The cathodal stimulation attracts Na+ ions which attracts water and decreases the protein density in the local area thus providing a sclerolytic response of tissue softening. We observed this local tissue softening many years ago under the cathode when delivering dexamethasone and began to experiment with local scars. To date we have not published any data but have recommended this technique to local clinicians with very favorable responses. We have typically administered 4mA of DC for 20-30min 2-3x per week. If you have a device that can deliver DC then you may have all you need to try this.

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