Flexor Tendon Injuries

Leul MeridOrthopedic surgery resident (R-1)

Outline

• Introduction • Basic Science:• Injury zones• Tendon Repair:• Rehabilitation• Outcomes• Recommendation• Primary repair• Reconstruction• References

Historical background

Flexor Tendon Injuries

• Restoration of satisfactory digital function after flexor tendon lacerations remains one of the most challenging problems in hand surgery

• Prior to the 1960’s tendons lacerated in “no man’s land” were not repaired in favor of delayed grafting

Flexor Tendon Injuries

• Kleinert and Verdan (1960’s) showed superior results with primary repair leading to general acceptance of this approach

• Years of anecdotal experience and surgical dogma followed pertaining to repair techniques and postoperative management

Flexor Tendon Injuries

• In the past 25 years more scientifically sound research has advanced our understanding of flexor tendon structure, nutrition, healing, biomechanics, response to stress, repair techniques

• Many studies have examined passive and active motion protocols

• Greatest limiting factor: absence of a universal system for assessing outcome

Flexor Tendon Injuries

• Questions– Primary repair vs delayed grafting?– Repair of FDS and FDP vs FDP alone?– Flexor sheath excision? repair? neither?– Type of suture material?– Repair technique?– Benefit of postoperative motion? Active or

passive? How much?

Tendon Morphology

• 70% collagen (Type I)• Extracellular components

– Elastin– Mucopolysaccharides (enhance water-binding

capability)• Endotenon – around collagen bundles• Epitenon – covers surface of tendon• Paratenon – visceral/parietal adventitia

surrounding tendons in hand• Synovial like fluid environment

Surgical anatomy The microscopic anatomy of the tendon consists of a A central core (the endotenon) that is composed

primarily of acellular, longitudinal, collagenous fibers that are sparsely interspersed with fibroblasts.

A thin epitenon layer of cells surrounds the central core.

• The epitenon cells are fibroblasts that may have different functional properties and characteristics from the internal fibroblasts of the endotenon.

• The epitenon cells are arranged in a matrix that is presumed to have a proteoglycan composition.

Anatomy

• Extrinsic flexors– Superficial group

• PT, FCR, FCU, PL• Arise from medial

epicondyle, MCL, coronoid process

Anatomy

• Extrinsic Flexors– Intermediate group

• FDS• Arises from medial

epicondyle, UCL, coronoid process

• Usually have independentmusculotendinous originsand act independantly

Anatomy• Extrinsic flexors

– Deep group• FPL – originates from

entire medial third of volar radius

• FDP – originates on proximal two thirds of the ulna, often has common musculotendinous origins

Anatomy

• Carpal tunnel– 9 tendons– Median

nerveFDS runs with 3rd and 4th slips superficial to 2nd and 5th

FDP often indistinct here and proximal

Median nerve is superficial to tendons

Carpal Tunnel

Anatomy• Flexor sheaths

• approx distal palmar crease

– Predictable annular pulley arrangement

• Protective housing• Gliding surface• Biomechanical advantage• Synovial layers

merge at MP level

• Flexor tendons weakly attached to sheath by vinculae

Anatomy

• Camper’s Chiasma

Camper’s Chiasma

Tendon relationships

Vincula• Long and Short to each tendon in fingers

– Long variable– Short

• VBP inserts at head of middle phalanx• VBS at head of proximal phalanx

• Provide some vascular supply• Can confuse exam• Thumb

– Vinculum brevis to FPL in 90%– Inserts on IP volar plate and distal part of proximal

phalanx

Vincula

Tendon Nutrition

• Vascular– Longitudinal vessels

• Enter in palm• Enter at proximal synovial fold

– Segmental branches from digital arteries• Long and short vinculae

– Vessels at osseous insertions• Synovial fluid diffusion

– Imbibition (pumping mechanism)

Tendon Nutrition

• Dorsal vascularity• Avascular zones

– FDS (over proximal phalanx– FDP (over middle phalanx)

• Nutrition vital for rapid healing, minimization of adhesion and restoration of gliding

Biomechanics

• Effeciency of flexor system = the degree to which tendon excursion and muscle contraction translates into joint motion

• Governed by integrity of the pulley system and resistance to glide– A2 and A4 most significant

• Pulleys decrease the moment arm length at each joint leading to increased joint motion

Biomechanics

Tendon Healing

• Inflammatory phase (0-5 d)– Strength of the repair is reliant on the strength of

the suture itself

• Fibroblastic phase (5d – 6 wks)– collagen-producing phase

• Remodelling (6 wks-9 mos)

Tendon Healing

Two forms– Intrinsic healing

• occur through the activity of the fibroblasts derived from the tendon.

– Extrinsic healing• occurs by proliferation of fibroblasts from the peripheral epitendon• adhesions occur because of extrinsic healing of the tendon and limit

tendon gliding within fibrous synovial sheaths

Balance between the two determines amount of extrinsic adhesion vs intrinsic tendon healing

Tendon Healing

• Factors affecting tendon healing, and adhesion formation– Surgical technique

• decreased vascularity• Gapping• Meticulous technique

– Postoperative motion (passive, active)

Tendon Adhesion

• Increased adhesion formation with:– Traumatic/surgical injury

• Crush injuries

– Ischemia• Disruption of vinculae

– Immobilization– Gapping at repair site– Excision/injury to flexor sheath components

• Debate over benefit of sheath repair

Tendon Adhesion

• Experimental attempts to minimize adhesion formation– Oral: steroids, antihistamines, NSAIDS– Topical: beta-aminoproprionitrile, hydrocyprolins,

hyaluronic acid, collagen solutions, fibrin– Physical: silicone/cellophane wrapping,

polyethylene tubes, interposed sheath flaps• Varying lab success but none proven

definitively or adopted into clinical practice

Tendon Healing

• “It now seems irrefutable that the most effective method of returning strength and excursion to repaired tendons involves the use of strong, gap resistant suture techniques followed by the frquent application of controlled motion stress”

-Strickland

Diagnosis

hx

o Age, occupation, dominant hand

o Causes Sharp object RTA Sport inj Rupture Machine inj bite

p/e

o Volar and dorsal skin integrity

o Angular deformities Met, phal #/dsl

o Distal NV Capillary refill, 2 pt discr

o Continuity of the tendonDiscuss nature of injury and postoperative course with patient

How to recognize flexor tendon injury

1.Natural position of fingers , cascade2.Passive extension wrist not produce flexion3.Wrist flexion even greater extension of finger4.Loss of normal tension of affected finger5.Loss of active flexion(difficult elicit in acute-pain)

6.FDP unable to flex DIP wiz PIP stabilized• FDP flexes distal phalanx

– Usually tethered except for index7.FDS unable to flex PIP , when adj 2 fingers kept fully extended• FDS flexes middle phalanx

– Independent slips– Hold adjacent digits in full extension– For index use paper grip test

8.Both tendons neither PIP nor DIP flex, wiz MCP immobilized9.FPL IP not flexed , MCP stabilized10.Weakness of hand with inability to hold objects11.Incomplete closure of fingers wiz wide digit to palmar distance

Zones

Flexor Tendon Repair

• Timing• Incisions• Tendon Retrieval• Repair Techniques• Relationship of suture design to

biomechanical strength

Timing1.Primary repair

– Golden period– With in 24hrs in a clean wound– Best results

2.Delayed primary repair– 24-10 days– Done: suspicion of infection , viability questionable or came late

3.Secondary repair --b/n 10-14days up to 4wks 4.Late secondary

– After 4 wks

• Delayed equal or better than emergent repair– Acute or subacute acceptable– Tendon deterioration/shortening after several wks– Delay several days if wound infected

Incisions

• Factors– Avoid crossing joints

at 90 deg.– Preference– Existing lacerations– Need to expose other

structures

A, Incision outlined on digit and palm. B, Exposure of flexor tendon sheath after flap

elevation. C, Closed incision

Tendon Retrieval• Avoid trauma to synovial sheath lining• Forcep/hemostat/skin hook if proximal stump

visible• Proximal to distal milking, reverse esmarch• Suction catheter• Suture catheter to proximal tendons in palm

and deliver distally

Tendon Retrieval

- Retraction often limited to A1/A2 pulley region by vinculae

- If lacerated proximal to vinculae or if vinculae disrupted, tendon ends may retract into plam

- If proximal stumps have retracted into the palm the correct orientation of FDS and FDP must be re-established (such that FDP lies volar to Camper’s Chiasm)

Tendon Advancement

– Previously advocated for zone 1 repairs, as moving the repair site out of the sheath was felt to decrease adhesion formation

– Disadvantages• Shortening of flexor system• Contracture• Quadregia effect• Little excursion distally, therefore adhesions near

insertion less of an issue

Repair Techniques

• Ideal– Gap resistant– Strong enough to tolerate forces generated by

early controlled active motion protocols• 10-50% decrease in repair strength from day 5-21 post

repair in immobilized tendons• This is effect is minimized (possibly eliminated) through

application of early motion stress– Minimal bulk– Uncomplicated– Minimal interference with tendon vascularity

The R/ship suture design to biomechanical strength of repair

To provide tendon repairs of sufficient strength to permit passive

and active motion rehabilitationRepair Techniques – Concepts• Suture material , caliber• Placement dorsal Vs volar• Pass Locking Vs “grasping”• 2 Vs 4 strands• ? knot placement In Vs out• Core , Epitendinous • configuration• Cutting vs tapered needle• Avoid accordion , gapping

• Although there is general consensus regarding the timing of flexor tendon repair, there continues to be controversy regarding the ideal flexor tendon repair technique.

• Strickland outlined six characteristics that a flexor tendon repair should satisfy prior to clinical application —

1. easy placement of sutures in the tendon, 2. Secure suture knots, 3. smooth junction of tendon ends, 4. minimal gap formation at the repair site, 5. minimal interference with tendon vascularity, and 6. sufficient strength throughout healing to permit the application of

early motion stress to the tendon.• Although many repair techniques have been proposed, few satisfy all six criteria.

Suture Material/Size• Historically stainless steel (strongest and least reactive) but

difficult to work with• Braided polyester Synthetics sutures (Ethibond, Ticron;

Mersilene) -most commonly used• Caprolactam family (Supramid) • Nylon• Polypropylene (Prolene)• Polydiaxanone (PDS)

• Increased caliber felt to increase tensile strength• 2-0 or 3-0 recommended with early active motion protocols as many

4-0 suture strength are less than the fatigue strength of many 2 and 4 strand repairs

Ultimate Strength and Repair Technique

• Proportional to number of strands– Number of strands

• Two strand- 2-3 kgf• Four nearly doubles• Six – 6.8 kgf

– 6 and 8 strand repairs strongest• Steep learning curve• Increased bulk and resistance to glide• Increased tendon handling and adhesion formation • May not be necessary for forces of early active motion

– Several four strand repairs appear to have adequate strength without complexity of 6 and 8 strand repairs

Lee (4 strand) and Savage (6 strand)

Dorsal vs Volar

– Historically dorsal placement avoided due to tendon vascular anatomy

– Diffusion now felt to be primary source of nutrition during healing

– Biomechanical advantage and increased tensile strength found during finger flexion with dorsal sutures (Komanduri, Soejima, Stein)

– Increase work of flexion with volar sutures (Aoki)• Dorsal stronger• Less vascular disruption on volar side

Length of suture purchase

Strongest @1cm no greater strength after 1cm. Weaker under 1cm

Locking vs Grasping Loops

– Locking stronger, and greater gap resistance in two stranded repairs (Manske et al.)

– Dorsal vs volar placement did not affect strength with locking repairs, but did affect strength of grasping repairs (Stein)

• Single locking loop best

Locking v. Grasping

Direction of locking circles

horizontal weaker than perpendicular/oblique

Cross-Sectional Area

– Increasing the cross-sectional area of the locking loop from 10 to 50% proportionately increased the ultimate tensile strength of the repair (Hatanaka, Manske)

• Has been demonstrated with core and circumferential suture tecniques

Size of locking loop

Found 25% tendon width locking loops did best

Suture Knot Location

• In – interference with healing at repair site• Out – interference with tendon gliding• Knots outside superior in one in vitro study

(Aoki)• Statistically significant increase in tensile

strength at 6 wks with knots-inside technique in canine model (Pruitt)

• Few studies,No consensus• Weak point• Location inside 60-80% the strength of outside

Gap Formation

• Gapping at tendon repair site associated with increased adhesion formation in laboratory/histological analysis (Lindsay)

• Gapping > 3mm correlated with decreased tensile strength in canine model (Gelberman)

• Gapping > 2mm correlated with poorer clinical results (Seradge)

Suture Configurations• Group 1= Simple

– Simple sutures; the suture pull is parallel to the tendon collagen bundles

– Shearing parallel to bundles– Weak

• Group 2=End-to-end locking– Bunnell suture; stress is transmitted directly across the juncture by

the suture material– Pull converted to compressive force around bundles– Strength near that of suture

• Group 3=Interweave– Pulvertaft technique (fishmouth weave); sutures are placed

perpendicular to the tendon collagen bundles and the applied stress– Strongest– Bulky

End-to-end suture of tendon using Bunnell crisscross stitch

Bunnell

Bunnell

Kessler

The Kessler grasping suture is a modification of the Mason-Allen

suture.

Modified Kessler(1 suture)

Kessler-Tajima(2 sutures)

Tajima tendon repair. Double-armed needles on suture are helpful for this

method

Kleinert modification of Bunnell crisscross suture technique.

Cruciate 4 Strand Repair

- McLarney

The ideal repair? - Strickland

Strickland modification of flexor tendon repair techniques described

by Kessler and Tajima

Double right-angle suture with single monofilament or multifilament wire suture threaded on curved needle.

Core Suture TechniquesCommon End-to-end types

Crisscross stitch

More techniques

Mason-Allen stitch

Core Sutures

• Current literature supports several conclusions regarding core sutures– Strength proportional to number of strands– Locking loops increase strength but may collapse and lead

to gapping– Knots should be outside repair site– Increased suture callibre = increases strength– Braided 3-0 or 4-0 probably best suture material– Dorsally placed suture stronger and biomechanically

advantageous– Equal tension across all strands

Circumferential Sutures– Initially were designed to improve tendon glide– Have been shown to add tensile strength (by 10–50%)

and gap resistance to repairs (Diao, Pruitt, (Diao, Pruitt, Silverskiold, Wade)Silverskiold, Wade)

• Also confirmed in cyclic loading studiesAlso confirmed in cyclic loading studies– Running locked, horizontal mattress,

epitenon/intrafibre, and cross-stitch have been shown to be the strongest

• Significant strength improvement• Simple 1 kgf• Mattress 2 kgf• Locking mattress 3 kgf

Type of epi repair

Type of epi repair

Interlocking horizontal mattress suture

Two basic versions of cross-stitch.

Epitenon-first technique

Strength vs Force(Core suture with running epitendinous suture)

• Some 2-strand repairs vulnerable during 1-3 wks post repair with light active motion

Repair Augmentation

– Augmenting repairs with tendon splints or mesh has been associated with concerns related to decreased tendon glide and increased adhesion formation due to foreign body reaction

– Has not been accepted in clinical practice

Sheath Repair

• Advantages– Barrier to extrinsic adhesion formation– More rapid return of synovial nutrition

• Disadvantages– Technically difficult– Increased foreign material at repair site– May narrow sheathand restrict glide

• Presently, no clear cut advantage to sheath repair has been established

AUTHOR'S PERSPECTIVE• preferred technique for flexor tendon repair within the

digital sheath follows the previously noted principles,• but it also takes into consideration the ease or difficulty of

suture placement.• The core consists of two two-strand locking sutures (3-0

braided polyester) as described by the Pennington modification of the Kessler technique , resulting in four strands across the repair site. (If surgical exposure allows, a third locking suture can be placed, resulting in six strands.)

• The knots for each of the two sutures are tied within the repair site.

• The circumferential suture is a criss-cross suture using 6-0 Prolene.

Fish-Mouth End-to-End Suture (Pulvertaft)

End-to-Side Repair

Tendon-to-Bone Attachment

Tendon attachment through finger flap.

One method of attaching tendon to bone

Zone I injury. Profundus tendon is advanced and reinserted into distal phalanx using pull-out wire suture and tie-over

button.

RehabilitationGoal promote intrinsic tendon healing & minimize

extrinsic scarring to optimize tendon gliding & functional range of motion

Early post-repair motion stress _ biologically alter the process of scar formation and

maturation at the repair site such that collagen is laid down parallel to the axial forces (increase strength), and decrease adhesions :tendon adhesions are stretched (increased tendon glide)

– Load at failure for mobilized tendons twice that for immobilized tendons at 3 wks (Gelberman)

Rehabilitation

• Bunnel (1918)– Postoperative immobilization– Active motion beginning at 3 wks postop.– Suboptimal results by today’s standards

• Improved suture material/technique as well as postoperative rehabilitation protocols

Immobilization programme

Indicated1.Children and adults who r unable to

comprehend and follow thru with a cpx mobilization protocol

2.Associated injury to the adjacent structure sa fracture

3.d/ors and health conditions that affect tissue healing sa RA

Kleinert splint with palmar pulley Kleinert (1950s)

Posterior splint, wrist in flexionRubber bands from fingernails to volar wrist area hold fingers in flexionPatient able to actively extend against rubber bands (within confines of splint)Fingers pulled passively back into flexionUsed widely since with some modificationsShowed superior results with primary repair vs delayed grafting

Duran programme

Designed premise that 3-5mm of tendon glide would Px restriction adhesion

• Passive DIP ext wiz PIP,MP in flex=glide FDP away from FDS suture site

• Passive PIP ext wiz DIP,MP in flex=glide both tendons away from injury site

Duran and Houser

Strickland’s active motion prog.• Depend on strong repair technique• Force applied during rehab. <TS of repair to Px

gapping/rupture

• Combined MP flex+WRIST ext=least tension on repair site to allow most d/tial excursion b/n FDP and FDS=tenodesis motion with hinged splint

Req’t :• Good pt cooperation and comprehension• Controlled edema• Minimal wound complication

tenodesis splint with a wrist hinge is fabricated to allow for full wrist flexion. wrist extension of 30 degrees. and maintenance of MCP Ilexion of at least 60 degrees.

After composite passive digitaillexion. the wrist is extended and passive flexion is maintained.

The patient actively maintains digital flexion and holdsthat position for about 5 seconds. Patients are instructed to use the lightest muscle power necessary to maintain digital flexion.

There are protocols that incorporate EAM while using a kleinert:

• EVANS• SLFVERSKIOLD and MAYBased on force application and individual tissue

response=GROTH proposes a methodic rehab model

.can be used with any existing protocol,not limited to zone,type of repair, or time of sequence

.Flexion lag , resolution lag

Groth’s pyramid of progressive force application

1. Resistive isolated joint motion2. Resistive hook and straight fist 3. Resistive composite fist4. Isolated joint motion5. Hook and straight fist6. Active composite fist7. Place and hold finger flexion8. Passive protected digital extension

Differential gliding exercises

FDP and FDS blocking exercises

Grading outcome • A no of systems suggested to report function of finger(digital

performance)• Most used calculating or estimating ROM Boyes • FOF estimated by msr distance b/n pulp and distal palmar crease• Distance relates to amt of composite flexion & gives est finger

function• Quick & easy Strickland• Dev’d formula for reporting results• Most stringent system currently available for measuring results• Accurately reflects differential functions of tendon repair• Most accurate for cross comparing studies

To calculate digital performanance • % of Nl PIP&DIP motion= (PIP+DIP flexion)-(extension lag) x100 175

Recently standardize outcomes as ass’t tools in repair result:

1.SF 362.Disability of arm,shoulder and hand

questionair(DASH)3.Hand jebson-tayler test4.Purdue pegboard test

Partial Flexor Tendon Lacerations If a tendon is lacerated 60% or more,• treated the same as a complete transection. • A core suture is placed in the tendon, and the surface of the tendon is

sutured with a continuous 6-0 nylon suture. • The flexor sheath is repaired when possible. • Postoperative management same as for a complete transection, with

immobilization, early controlled passive motion, and restoration of forceful activities at 10 to 12 weeks.

If the laceration is less than 60%, . evaluated for the risk of triggering. .If triggering is seen, the flap of tendon is smoothly débrided, and the

flexor sheath is repaired to help avoid entrapment or triggering of the flap in the defect in the flexor sheath.

.Postoperatively, the part is protected with dorsal block splinting for 6 to 8 weeks, and more forceful activities are resumed gradually after approximately 8 weeks

Children

• Usually not able to reliably participate in rehabilitation programs

• No benefit to early mobilization in patients under 16 years

• Immobilization > 4 wks may lead to poorer outcomes

FDP Avulsions

• Commonly male athletes• Forced extension at DIP during maximal

flexion (jersey finger)• Often missed due to normal xray and intact

flexion at MP and PIP– Opportunity for FDP reinsertion lost if treatment

delayed

FDP Avulsions

Leddy and Packer

FDP Avulsions- Type 1: zig-zag exposure

- Tendon delivered through pulley system with catheter passed retrograde

- Fixed to base of phalanx with monofilament suture through distal phalanx and nail plate and tied over button

- Fix within 7-10 days before tendon degeneration and myostatic shortening occurs

FDP Avulsions- Type 2: small bony

fragment retracts to A3 level- Can fix up to 6 wks post

injury (less shortening)- May convert to type 1 if

tendon slips through A3 pulley and into palm

- Use same technique as for type 1

FDP Avulsions

- Type 3: large bony fragment retracts to A4 level- Bony reduction and

fixation of fragment

Reconstruction

Single Stage Tendon GraftingZone 2

• Indications– Delayed treatment making end to end repair

impossible• Patient factors prevent repair• Late referral, missed tendon laceration or avulsion

– Supple joints with adequate passive ROM

Single Stage Tendon Grafting Zone 2

• Technique– 1 cm distal FDP stump left intact– 1 cm of FDS insertion left intact (decreased

adhesion formation vs granulating insertion site)– Tenodesis of FDS tail to flexor sheath (10-20 deg

of flexion) optional• Hyperextension at PIP in absence of FDS tendon occurs

occasionally

Single Stage Tendon Grafting Zone 2

• Technique– Graft donors

• Palmaris longus• Plantaris• Long toe extensors• (FDS)• (EIP)• (EDM)

Single Stage Tendon Grafting Zone 2

• Technique– Graft passed through pulley system

• Atraumatic technique

– Distal fixation with tension set proximally or proximal fixation first

– Multiple methods for fixation of graft ends

Single Stage Tendon Grafting Zone 2

• Technique– Distal

juncture

Single Stage Tendon Grafting Zone 2

• Technique– proximal

juncture

Pulvertaft weave creates a stronger repair vs end to endtechniques, and allows for greater ease when setting tension

Single Stage Tendon Grafting Zone 2

• Setting tension– GA

• With wrist neutral• Fingers fall into semi flexed position (slightly less than

ulnar neighbour), allowing estimation of tension– Local anesthesia, active flexion– Electrical stimulation

• Bunnel – “tendons shrink”• Pulvertaft – “tendons stretch”

Secondary Reconstruction Zone 1

• Zone 1 (functioning FDS)– Eg. Late presentation of FDP avulsion– DIP fusion– Tendon graft

• Risks damaging FDS function through injury/adhesions in a very functional finger

• ? Young patients, supple joints, need for active DIP flexion

Secondary Reconstruction Zones 3, 4 and 5

• Usually associated with 3 – 5 cm gap– Interposition graft– FDS to FDP transfer– End to side profundus juncture

Two Stage Reconstruction

• Primary grafting likely to give poor result, but salvage of functioning finger still desirable

• Sub-optimal conditions– Extensive soft tissue scarring

• Crush injuries• Associated fractures, nerve injuries

– Loss of significant portion of pulley system

Two Stage Reconstruction

• Patient selection– Motivated– Absence of neurovascular injury– Good passive joint motion

• Balance benefits of two additional procedures in an already traumatized digit with amputation/arthrodesis

Two Stage Reconstruction

• Stage 1– Excision of tendon remnants

• Distal 1 cm of FDP left intact, remainder excised to lumbrical level

• FDS tail preserved for potential pulley reconstruction

– Incision proximal to wrist• FDS removed/excised• Hunter rod then placed through pulley system and

fixed distally (suture or plate and screw – depending on implant)

Two Stage Reconstruction

• Stage 1– Rod extends proximally to distal forearm in plane

between FDS and FDP– Test glide– Reconstruct pulleys as needed if implant

bowstrings

Two Stage Reconstruction

• Stage 1– Postop

• Start passive motion at 7 days• Continue x 3mos to allow pseodosheath to form

around implant• Before stage 2 joints should be supple, and wounds soft

Two Stage Reconstruction

• Stage 2 – implant removal and tendon graft insertion– Distal and proximal incisions opened– Implant located proximally and motor selected

(FDP middle/ring/small, FDP index)– Graft harvested, sutured to proximal implant and

delivered distally• Fixed to distal phalanx with pull out wire over button

Two Stage Reconstruction

• Stage 2 – implant removal and tendon graft insertion– Proximally sutured to motor with pulvertaft

weave

• FDS transfer from adjacent digit described• Obviates need for graft• Difficulty with length/tension

• Postop• Early controlled motion x 3 wks, then slow progression

to active motion

Pulley Reconstruction

• Pulley loss– Bowstringing = tendon taking shortest distance

between remaining pulleys– Biomechanical disadvantage

• Excursion translates into less joint motion– Adhesions/rupture at remaining pulleys due to

increased stress– A2 and A4 needed (minimum)

• Most biomechanically important• Some authors advocate reconstructing a 3 or 4 pulley

system for optimal results

Pulley Reconstruction

• Most done in conjunction with a two stage tendon reconstruction

• Can be done with single stage tendon graft• generally if extensive pulley reconstruction is

required it is better to do a two stage procedure

Pulley Reconstruction

• Methods– Superficialis tendon

• Insertion left intact• Remnant sutured to original pulley rim, to periosteum,

or to bone through drill holes

– Tendon graft• Sutured as above• Passed through hole drilled in phalanx (risk of fracture)• Wrapped around phalanx (requires 6-8 cm of graft)

Pulley Reconstruction

Pulley Reconstruction

• Methods– Extensor retinaculum

• Excellent gliding surface• Difficult to harvest the 8-6 cm required for fixation

around phalanx

– Artificial materials• Dacron, PTFE, nylon silicone• Due to abundant atogenous material and

disadvantages of artificial materials, this has not become common clinical practice

• May be stronger in long term vs autogenous

Tenolysis

– Release of nongliding adhesions for salvage in poorly functioning digits with previous tendon injury

– Avoid in marginal digits• May not tolerate additional vascular/neurologic injury

– May need concomitant collateral ligament release, capsulotomy

– Prepare patient for possible staged reconstruction

Tenolysis

• Timing– 3-6 mos. Post repair (minimum)– Plateau with physiotherapy

• Anesthesia– Local with sedation

• Allows patient participation• Tests adequacy of release• Motivates patient

Tenolysis

• Technique– Zig zag incisions– Adhesions divided maintaining non-limiting

adhesions– Pulleys reconstructed as needed

• If extensive or not possible convert to staged reconstruction

– Immediate motion postop.

References

Flexor Tendon Injuries - Hand - Orthobullets.com

the American Society for Surgery of the Hand

Hand Surgery, Vol. 6, No. 1

Hand Clin 21 (2005) 257–265

WJO|www.wjgnet.com

Indian J Orthop