S C Winters

St. Luke's Hospital (MO, USA), Saint Louis, Michigan, United States

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Publications (8)10.95 Total impact

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    ABSTRACT: Elongation (gap formation) at the repair site has been associated with the formation of adhesions and a poor functional outcome after repair of flexor tendons. Our objectives were to evaluate the prevalence of gap formation in a clinically relevant canine model and to assess the effect of gap size on the range of motion of the digits and the mechanical properties of the tendons. We performed operative repairs after sharp transection of sixty-four flexor tendons in thirty-two adult dogs. Rehabilitation with passive motion was performed daily until the dogs were killed at ten, twenty-one, or forty-two days postoperatively. Eight tendons ruptured in vivo. In the fifty-six intact specimens, the change in the angles of the proximal and distal interphalangeal joints and the linear excursion of the flexor tendon were measured as a 1.5-newton force was applied to the tendon. The gap at the repair site was then measured, and the isolated tendons were tested to failure in tension. Twenty-nine tendons had a gap of less than one millimeter, twelve had a gap of one to three millimeters, and fifteen had a gap of more than three millimeters. Neither the time after the repair nor the size of the gap was found to have a significant effect on motion parameters (p > 0.05); however, the ultimate force, repair-site rigidity, and repair-site strain at twenty newtons were significantly affected by these parameters (p < 0.05). Testing of the tendons with a gap of three millimeters or less revealed that, compared with the ten-day specimens, the forty-two-day specimens failed at a significantly (90 percent) higher force (p < 0.01) and had a significantly (320 percent) increased rigidity (p < 0.01) and a significantly (60 percent) decreased strain at twenty newtons (p < 0.05). In contrast, the tensile properties of the tendons that had a gap of more than three millimeters did not change significantly with time. Our data indicate that, in a dog model involving sharp transection followed by repair, a gap at the repair site of more than three millimeters does not increase the prevalence of adhesions or impair the range of motion but does prevent the accrual of strength and stiffness that normally occurs with time.
    The Journal of Bone and Joint Surgery 08/1999; 81(7):975-82. · 3.23 Impact Factor
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    ABSTRACT: To determine the relationship between the intrinsic properties of tendon and tendon excursion in 2 types of autogenous tendon grafts, hindpaw intrasynovial and extrasynovial tendons were transferred to the lateral and medial forepaws of adult mongrel dogs (16 experimental and 16 control tendons). After each digit was marked with radiopaque markers, it was placed in a specialized jig, and weights of 25 g, 100 g, or 200 g were applied to the flexor tendons. Specialized radiographs were obtained with the digit in flexion and extension. Tendon excursion and joint rotation were calculated. There were no statistically significant differences between experimental groups for tendon excursion or for joint angular rotation (p>.05). For intrasynovial tendon grafts, the angular rotation per millimeter tendon excursion was 10.9°± 2.4°/mm, 9.4°±1.2°/mm, and 9.0°±1.4°/mm with 25-g, 100-g, and 200-g loads, respectively. Comparisons between experimental groups revealed that a statistically significant difference could not be determined (p>.05). With varying proximal loads, both intrasynovial and extrasynovial grafts showed similar amounts of tendon excursion. Variations in proximal load did not significantly influence the amount of excursion within the range of loads tested. Based on these data, it appears that the difference in repair potential for these 2 types of tendon grafts is not related to a differential in the amount of tendon graft excursion following transfer to the synovial space.
    The Journal Of Hand Surgery 04/1998; · 1.57 Impact Factor
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    ABSTRACT: To explore crucial early molecular events involved in contact healing of the intrasynovial flexor tendon, integrin expression was evaluated at the transcriptional and post-transcriptional levels during the first two weeks following injury, repair and controlled passive motion in a canine model. Specifically, immunohistochemical and reverse transcription polymerase chain reaction (RT-PCR) techniques were employed to evaluate expression of the fibronectin, vitronectin and endothelial cell binding integrin receptor subunits alpha5, alphav and alpha6, along with the common beta1 subunit. The two techniques revealed increasing expression of the four subunits over the two week post-repair period. Immunohistochemistry revealed that beta1 and alpha5 expression was concentrated in the epitenon layer near the repair site and interiorly within the wound area, while alpha6 was associated with capillary-forming endothelial cells near the wound. RT-PCR and quantitation by NIH image analysis demonstrated peak messenger RNA expression of beta1 and alpha5 at ten days post-repair and peak expression of alpha6 and alphav at 15 days. The results in this study correlate well with previous results demonstrating increased fibronectin deposition and angiogenesis during the same time period in a similar injury/repair model.
    Connective Tissue Research 02/1998; 39(4):309-16. · 1.79 Impact Factor
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    ABSTRACT: This study was designed to determine the effects of in vivo multistrand, multigrasp suture techniques on the strength and gliding of repaired intrasynovial tendons when controlled passive motion rehabilitation was used. Twenty-four adult mongrel dogs were divided into 4 groups and their medial and lateral forepaw flexor tendons were transsected and sutured by either the Savage, the Tajima, the Kessler, or the recently developed 8-strand suture method. The tendon excursion, joint rotation, and tensile properties of the repaired tendons were evaluated biomechanically at 3 and 6 weeks after surgery. It was found that neither time nor suture method significantly effected proximal and distal interphalangeal joint rotation or tendon excursion when the 4 techniques were compared to each other. Normalized load value (experimental/control) was significantly affected by both the suture method and the amount of time after surgery, however. The Savage and 8-strand repair methods had significantly greater strength than did the Tajima method at each time interval (p < .05 for each comparison). In addition, the 8-strand method had significantly greater normalized load values than did the Savage method at each time interval (p < .05 for each comparison). Normalized stiffness (experimental/control) for the 8-strand repair method was significantly greater than that for the Tajima and Savage methods at 3 and 6 weeks after surgery (p < .05). In addition, the normalized stiffness values for the 6-week groups was significantly greater than those for the 3-week groups (p < .05). It was concluded that the method of tendon suture was a significant variable insofar as the regaining of tendon strength was concerned and that the newer low-profile 8-strand repair method significantly expands the safety zone for the application of increased in vivo load during the early stages of rehabilitation.
    The Journal Of Hand Surgery 01/1998; 23(1):97-104. · 1.57 Impact Factor
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    ABSTRACT: This review describes the evolution of recently developed multi-strand, multi-grasp flexor tendon suture techniques. Analyses of digital angular joint rotation, tendon excursion, and ultimate tensile load at the time of repair and at three and six weeks following repair allowed comparison of a variety of innovative grasping and non-grasping multi-strand techniques. The first series of experiments describes an analysis of the Tajima, Tsuge, Savage, Kessler, double loop locking suture, and recently developed eight-strand suture techniques at the time of repair. The Tajima, Savage, and eight-strand repair methods were found to have statistically significant improved gliding function compared to those methods that featured external knots (Kessler and Tsuge) and methods that tended to bunch at the repair site (double loop locking suture). With regard to ultimate tensile load, the eight-strand repair was found to have the greatest strength (69N) of all tested methods (p < 0.05). The second series of experiments examined the Tajima, Kessler, Savage, and eight-strand suture methods at three and six weeks following tendon repair. A high percentage of failure within the Kessler repairs precluded their inclusion for final comparative analysis. The results for the remaining three techniques were normalized (experimental/control) to allow inter-group comparison. For intrasynovial tendon repair gliding function, all prepared specimens were found to have significantly less tendon excursion, proximal interphalangeal joint rotation, and distal interphalangeal joint rotation than their respective controls. However, no statistical differences were noted in gliding function between the Tajima, Savage, and eight-strand repair at three and six weeks (p < 0.05). Ultimate tensile testing ascertained that the eight strand method demonstrated significantly greater strength at three (52.6N) and six (70.9N) weeks than both the Tajima and Savage techniques (p < 0.05), while the Savage repair had significantly greater strength than the Tajima repair (p < 0.05). On the basis of these findings, we suggest that early controlled active motion protocols be devised using the multi-strand multi-grasp techniques, as exemplified by the eight strand tendon repair method, in an effort to achieve consistently improved results for intrasynovial flexor tendon repairs.
    Annales de Chirurgie de la Main et du Membre Supérieur 01/1997; 16(3):229-34.
  • Annales de Chirurgie de la Main et du Membre Supérieur 01/1997; 16(3):229-234.
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    ABSTRACT: Fifty patients (54 hands) who underwent carpal tunnel release for carpal tunnel syndrome were evaluated to determine the relationship between the prominence of specific clinical symptoms and the early results of carpal tunnel release. Patients were evaluated preoperatively, 3 weeks after surgery, and 3 months after surgery by questionnaire, physical examination, and Semmes-Weinstein monofilament pressure testing. The symptoms evaluated included hand/wrist/forearm pain, night pain/paresthesias, intermittent paresthesias, hand clumsiness, hand weakness, constant numbness, and difficulty with work related tasks. All symptoms showed significant improvements at 3 months after surgery. Overall symptom reduction at 3 months after surgery was 49% +/- 73%. Overall satisfaction at 3 months after surgery was 7.8 +/- 2.8 (0 to 10 scale). the severity of preoperative subjective hand weakness was significantly associated with surgery and with less improvement of function at 3 months after surgery and with less satisfaction with overall symptom relief at 3 months after surgery. Although subjective outcomes in this study were markedly improved after carpal tunnel release regardless of preoperative symptomatology, patients with more preoperative night symptoms and intermittent paresthesias and less preoperative hand/wrist pain, numbness, weakness, clumsiness, and difficulty with work related tasks were the most satisfied with their surgery.
    Clinical Orthopaedics and Related Research 06/1996; · 2.79 Impact Factor
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    ABSTRACT: This review describes the evolution of recently developed multistrand, multi-grasp flexor tendon suture techniques. Analyses of digital angular joint rotation, tendon excursion, and ultimate tensile load at the time of repair and at three and six weeks following repair allowed comparison of a variety of innovative grasping and non-grasping multi-strand techniques. The first series of experiments descrbes an analysis of the Tajima, Tsuge, Savage, Kessler, double loop locking suture, and recently developed eight-strand suture techniques at the time of repair. The Tajima, Savage, and eight-strand repair methods were found to have statistically significant improved gliding function compared to those methods that featured external knots (Kessler and Tsuge) and methods that tended to bunch at the repair site (double loop locking suture). With regard to ultimate tensile load, the eight-strand repair was found to have the greatest strength (69N) of all tested methods (p<0.05). The second series of experiments examined the Tajima, Kessler, Savage, and eight-strand suture methods at three and six weeks following tendon repair. A high percentage of failures within the Kessler repairs precluded their inclusion for final comparative analysis. The results for the remaining three techniques were normalized (experimental/control) to allow inter-group comparison. For intrasynovial tendon repair gliding function, all prepared specimens were found to have significantly less tendon excursion, proximal interphalangeal joint rotation, and distal interphalangeal joint rotation than their respective controls. However, no statistical differences were noted in gliding function between the Tajima, Savage, and eight-strand repair at three and six weeks (p<0.05). Ultimate tensile testing ascertained that the eight strand method demonstrated significantly greater strength at three (52.6N) and six (70.9N) weeks than both the Tajima and Savage techniques (p<0.05), while the Savage repair had significantly greater strength than the Tajima repair (p<0.05). On the basis of these findings, we suggest that early controlled active motion protocols be devised using the multi-strand multi-grasp techniques, as exemplified by the eight strand tendon repair method, in an effort to achieve consistently improved results for intrasynovial flexor tendon repairs.RésuméLes différentes techniques nouvelles de réparation des tendons fléchisseurs, utilisant plusieurs fils, sont revues à point. Les auteurs ont analysé la rotation articulaire digitale, l'excursion tendineuse et la résistance à la rupture, le jour de la réparation, à 3 et 6 semaines, en comparant les différentes nouvelles méthodes de suture. La première série étudie les sutures de Tagima, Tsuge, Savege, Kessler ainsi que la nouvelle méthode à 8 fils. Les sutures selon Tagima, Savege, et la suture à 8 fils améliorent de façon significative le glissement, par rapport aux méthodes faisant appel à des nœuds externes (Kessler et Tsuge), et par rapport aux méthodes produisant un bon godronnage au niveau du site de suture (suture en double boucle). Concernant la résistance à la rupture, la suture à 8 fils était la plus solide (69 Newton). La seconde série concernait les sutures selon Tagima, Kessler, Savege et la suture à 8 fils à 3 semaines post-opératoires. Un haut pourcentage d'échecs avec la méthode de Kessler pourrait empêcher leur inclusion dans l'analyse comparative finale. Les résultats des trois techniques restantes ont été comparés concernant le glissement entre un synovial, tous les spécimens avaient une excursion tendineuse significativement plus courte, ainsi que les rotations inter-phalangienne proximale et inter-phalangienne distale, par rapport à chaque groupe contrôle. Toutefois, aucune différence significative n'a été trouvée au niveau du glissement entre les méthodes de Tagima, Savege et la méthode à 8 fils à 3 et 6 semaines. La force tensile à la rupture était significativement plus élévée pour la méthode à 8 fils à 3 semaines (52,6 Newton) et à 6 semaines (70,9 Newton). La méthode de Savege s'est par ailleurs montrée significativement plus solide que la méthode de Tagima. Sur la base de nos résultats, nous suggérons une mobilisation active précoce contrôlée après suture tendineuse selon la méthode à 8 fils.ResumenEsta revisión describe la evolución de las técnicas recientemente desarrolladas de sutura del tendón flexor mediante puntos múltiples y agarre múltiple. El análisis de la rotación angular articular digital, el desplazamiento tendinoso y fuerza de tensión máxima al momento de la reparación, a las tres y a las seis semanas después de la reparación permitieron la comparación de una variedad de innovaciones técnicas de sutura de puntos múltiples con prensión y sin prensión. La primera serie de experimentos describe el análisis de la sutura de Tajima, Tsuge, Savege, Kessler, en doble lazo y la técnica recientemente desarrollada de sutura a 8 puntos en el momento de la reparación. Los métodos de Tajima, Savege y de ocho puntos se hallaron estadisticamente significativos con referencia a la mejoría del deslizamiento comparados a las técnicas en las cuales el punto de sutura es externo (Kessler y Tsuge) y a los métodos que tienden a apelotonarse en el sitio de reparación (sutura en doble lazo). Con referencia a la fuerza de tensión final, la reparación de 8 puntos se halló como el de mayor resistencia (69N) de todos los métodos examinados (p < 0,05). La segunda serie de experimentos examinó los métodos de sutura de Tajima, Kessler, Savege y de 8 puntos a las tres y a las seis semanas después de la reparación tendinosa. Un alto porcentaje de fallos con el método de Kessler lo excluye del análisis comparativo final. Los resultados de las tres técnicas restantes se normalizaron (experimental/control) par permitir una comparación intergrupos. Para la función de deslizamiento intrasinovial del tendón reparado, en todos los espécimenes preparados se halló una excursión tendinosa significativamente inferior así como una rotación articular de la interfalángica proximal y una rotación articular interfalángica distal con referencia a su respectivo control. Sin embargo, no se hallaron diferencias estadisticamente significativas en la función de deslizamiento con la reparación según Tajima, Savege y a 8 puntos a las tres y a las seis semanas (p < 0,05). El test de tensión final constata que el método de 8 puntos presenta una resistencia a la tensión signicativamente mayor a las tres (52,6N) y a las seis (70,9N) semanas que con las técnicas de Tajima y Savege (p < 0,05), mientras que la técnica de reparación de Savege presenta una resistencia moyor estadisticamente significativa con referencia a la técnica de Tajima (p < 0,05). Con base en estos tres hallazgos, sugerimos que los protocolos de movilización activa precoz controlada sean imaginados usando técnicas de varios puntos y varios agarres, como se muestra con la técnica de reparación a 8 puntos, con el fin de lograr regularmente una mejoría de los resultados de la reparación intrasinovial de los tendones flexores.
    Annales de Chirurgie de la Main et du Membre Supérieur.