Pinky Flexor Tendon Laceration Will I Ever Be Able to Fully Move It Again
Indian J Plast Surg. 2013 Sep-Dec; 46(3): 458–471.
Treatment of unfavourable results of flexor tendon surgery: Ruptured repairs, tethered repairs and pulley incompetence
David Elliot
Department of Hand Surgery, St Andrew'south Centre for Plastic Surgery, Broomfield Infirmary, Chelmsford, Essex
Thomas Giesen
Section of Hand Surgery, St Andrew'due south Centre for Plastic Surgery, Broomfield Hospital, Chelmsford, Essex
Abstract
As main repair of divided flexor tendons becomes more common, secondary tendon surgery becomes largely that of the complications of primary repair, namely ruptured and adherent repairs. These occur with an incidence of each in near reported series earth-broad of around v%, with these problems having changed little in the last two decades, despite strengthening our suture repairs. Where the master referral service is less well-adult, and every bit a more than occasional occurrence where chief treatment is the routine, the surgeon faces different problems. Patients arrive at a hand unit of measurement variable, but longer, times subsequently the principal insult, having had no, or bad, previous treatment. Sometimes the situation is the same, viz. an extended finger with no active flexion, but now no longer acquiescent to primary repair. Often, it is much more complex as a result of injuries to the other tissues of the digit and, also, equally a outcome of the unaided healing process within the digit in the presence of an inactive flexor arrangement. We nowadays our experience in dealing with ruptured repairs, tethered repairs and caster incompetence.
Key WORDS: Flexor tendon injury, flexor tendon reconstruction, flexor tendon caster reconstruction, secondary flexor tendon repair, tenolysis
INTRODUCTION
As chief repair of divided flexor tendons becomes more common, secondary tendon surgery becomes largely that of the complications of principal repair, namely ruptured and adherent repairs. These occur with an incidence of each in most reported series world-broad of effectually 5%, with these problems having changed little in the concluding two decades, despite strengthening our suture repairs (Elliot and Giesen, 2013a).[1]
Failures of master surgery tin can be simply unlucky only they include many who volition do poorly with any surgery. These patients by and large fall into ii groups. The first have had 'bad' injuries, many of which might have led to finger amputation or never been considered for surgery in 1950, so would never have come up to secondary flexor surgery. The 2nd group are 'bad' patients. This is non a moral judgement but an observation of features held in common past many of this group, many of which are outwith the control of the individual patient. Some make more than scar than the 'normal', some have low pain thresholds, some present tardily because they have not realised that their finger is non bending properly, some cannot attend for therapy or cannot cover what is being asked of them. As well, of form, there are those who will not attend for therapy and will non comply with instructions. If they proved poor candidates for primary flexor surgery, they are likely to practice badly again with secondary surgery.
Where the principal referral service is less well-developed, and equally a more than occasional occurrence where primary handling is the routine, the surgeon faces different bug. Patients arrive at a hand unit of measurement variable, simply longer, times after the primary insult, having had no, or bad, previous treatment. Sometimes, the situation is the same, viz. an extended finger with no active flexion, but, now, no longer acquiescent to primary repair. Oft, it is much more complex equally a effect of injuries to the other tissues of the digit and, also, every bit a upshot of the unaided healing process inside the digit in the presence of an inactive flexor system.
EXTENSOR TENDON TETHERING
This problem, due to fibrin in the oedema following injury filling the loose areolar tissue superficial and deep to the extensor tendons and sticking the tendons to the skin and skeleton to forbid passive flexion of the fingers, was discussed in a previous article (Elliot and Giesen, 2013a).[1] As this complication is far the greatest cause of morbidity subsequently all flexor tendon surgery, wherever and however it is done and whoever does the surgery, information technology is reiterated here. This will vary in degree, according to the magnitude of the injury, the individual patient's trend to form oedema, and the rehabilitation efforts of the patient and the medical squad to move the manus quickly and pump the glue out earlier it starts 'setting'. Information technology has always been said that the Caucasian hand is more liable to this problem than those of the Indian sub-continent and this is probably true. However, it does not mean this can exist ignored in India. We accept seen hands with extensor tendon tethering in India and, perhaps, its relative rarity makes the surgeon less probable to recognise that this factor, and not the primary pathology and/or operation, is hampering the recovery of the mitt.
The manus functions mostly past flexion of the digits to allow them to power, compression and bridge grip, with the extensors setting the digits back to zero, ready to flex again for the next gripping activity. Our hands can tolerate quite a restriction from full extension before this becomes a functional problem. There has to be considerable adherence of the extensor tendons before we see any significant loss of extension at all. This is only usually seen in very grossly swollen hands. The functional problem acquired by extensor tethering is largely one of loss of digital flexion considering the adherent extensor tendons cannot glide distally to permit finger flexion. Even the slightest extensor tethering volition restrict flexion significantly. With the more moderate swelling normally seen after flexor tendon injury, this can be a problem requiring considerable therapy endeavour to prevent loss of flexion at some bespeak in the recovery. By 3 to iv months, the problem may have resolved. However, at this time and in cases without obvious swelling in the early postal service-operative menses, extensor tethering will but be recognised if one is looking for information technology, first, in the complaints of the patient, and second, by examining for information technology. These patients will complain that they have pain along the dorsum of the digits and/or hand on tight or prolonged gripping and their grip remains weak. They may accept reasonable, though unremarkably not perfect gratis active flexion, but testing passive flexion of the involved fingers will identify the fine degrees of extensor tendon tethering causing these problems. The two tests we use for this are described in detail in a previous article (Kulkarni et al., 2006).[two] They are adapted to become diagnostic tests from the means whereby therapists treat this problem. Once identified, the tendon tethering should be addressed by further therapy. The problem will rarely go away untreated every bit, with fourth dimension, the 'glue' sets as the fibrin converts to fibrosis. If astringent, in that location is a need for surgical extensor tenolysis. When oedema is not obvious visually, this trouble is oft missed and the patient retains the same complaints and a permanent inability. It goes without proverb that whatsoever secondary surgery to the flexors, whatever the trouble, cannot exist washed if at that place is meaning extensor tethering. The maximum active flexion which will be achieved by secondary flexor tendon surgery volition also be that allowed by the limitation of flexion resulting from the extensor tethering and the tightening of the dorsal capsules of the joints.
FLEXOR TENDON RUPTURE AFTER PRIMARY REPAIR
Although concern about tendon rupture has been one of the major determinants in the evolution of the various techniques of tendon suture and early postoperative mobilization throughout the last 10 years of the 20th century, there was almost no information in the literature early in this century as to whether immediate re-repair of ruptures is successful. In 1982, Leddy stated that 'the preferred treatment (of ruptures) is prompt re-exploration and repair' (Leddy, 1982)[3] without proof that this was correct, although a number of earlier studies had suggested that immediate re-repair of a ruptured flexor tendon and a further full period of mobilisation is likely to accomplish results virtually as adept as the original repair, whatever the flexor tendon injury and whatever the technique of mobilisation, when a patient presents inside 72 h of rupture within the commencement five weeks following primary surgery. In 2006, we reviewed 44 rupture re-repairs of zone 1 and 2 master flexor tendon repairs in our unit of measurement betwixt 1989 and 2003, with the re-repairs done with the same two strand repair as we used for the main repair, to assess the result of firsthand re-repair, with a view to identifying whether this should exist an changeless policy (Dowd et al., 2006).[4] This written report found this general dominion to be broadly truthful, although these cases only achieved good or excellent results in 51% of cases overall, with a re-rupture charge per unit of 12.5%. In other words, the results of re-repair were not as skilful as main repair but immediate re-repair was still worth consideration. With about l% of patients rupturing the main repair as a result of an act of stupidity and an action contrary to therapy communication (Harris et al., 1999),[5] peradventure this effect is all one could expect. Nevertheless, closer analysis of this information showed that re-repair in the index, centre and ring fingers achieved 66% expert or first-class results and few re-ruptures. Re-repair in the pinkie was the problem: In this finger, re-repair achieved only 31% good or excellent results, with four of the five ruptures after all of the re-repairs occurring in the pinkie.
Certain pre-operative factors require consideration before undertaking immediate re-repair and may preclude this, viz. the general medical condition of the patient, advanced or very young age, an noncompliant patient, other mitt pathologies such as gross multi-joint osteoarthritis, infection, wound dehiscence, a finger which is as well swollen and stiff, a delay between rupture and presentation of more than than 72 h to presentation, and rarely, rupture occurring five or more weeks after principal surgery when the finger is in the 'wooden' phase of intense healing. Patient reluctance is nigh likely where a profundus tendon ruptures and PIP flexion by an intact FDS tendon is acceptable for his/her function. In excluding diverse patients pre-operatively from firsthand re-repair, one is mostly moving them toward a flexor tendon graft. In these situations, i is usually in the aforementioned position as with a 'stuck' tendon of having to wait for the finger to recover and soften before undertaking surgery. The finger, which is oft bloated and moving poorly, is mobilised by passive therapy for as long as necessary to regain its maximum mobility, unremarkably three or more months. The patient buddy straps the finger to an next finger during active use of the mitt, which can be started immediately, to keep the finger from remaining extended and catching during mitt activity. When the finger has recovered its mobility and pliability and the scars are soft, secondary flexor tendon reconstruction tin can be considered.
If 1 does re-operate after rupture, the patient needs to realise pre-operatively that it may evidence impossible to conduct out a re-repair for reasons which just become apparent during surgery and alternative options of treatment must be discussed pre-operatively. Under these circumstances, tendon grafting is likely to give the best result. However, the patient may not want this, or be unable to spare further time, so the alternatives of doing nothing farther, except to shut the finger, or carrying out a procedure — either distal tendon tenodesis or distal interphalangeal joint fusion — to forestall distal articulation hyperextension should be discussed.
Re-repair is not e'er piece of cake and it is best performed by an experienced surgeon. At surgery, the tendons may be too swollen or friable to hold sutures, or too adherent to their surrounds, or the proximal tendon end may have retracted too far. This list is more theoretical than a result of our ain experience, as most of the ruptures we explore are re-repaired. The problem of swollen tendons which are unlikely to glide postoperatively inside the confines of the tendon sheath if re-repaired conventionally can usually be overcome by excising the proximal function of the FDS tendon to make more room within the sheath for the repaired profundus tendon. The distal part of the FDS tendon is sutured to the sheath at the level of the proximal phalanx to avert late swan-necking of the PIP joint. In Caucasian fingers with previous injury to this side of the digit, this is an unlikely complication, but this precaution should generally exist taken in the Indian finger. Retraction of the proximal tendon end, most ordinarily a problem of the FPL tendon, can often be overcome by lengthening the proximal tendon.
We customarily tendon graft in ii stages. It is ofttimes an appropriate saving of time to perform the first stage, inserting a rod, when information technology is realised at surgery that re-repair volition not exist possible. If one-stage tendon grafting is favoured or necessary, this is sometimes possible under these circumstances but more than likely to achieve a good consequence in the fully healed and supple finger and nix is lost by inserting a rod at this operation to make the after grafting procedure simpler.
We have previously discussed technical difficulties repairing the small tendons in the little finger (Elliot, 2002).[half-dozen] The pocket-sized size of the digit also makes rehabilitation after primary repair more difficult and this experience was repeated in re-repairing ruptures of the master repairs (Dowd et al., 2006).[4] In this study, the percentage of ruptures of primary repairs was very much greater in the little finger (46%) than in the other fingers. Re-repair had a 35% chance of creating a little finger which is a hindrance because of loss of sufficient extension and hooking and/or insufficient flexion power to provide adept grip function and prevent objects dropping out of the ulnar side of the manus. Re-repair besides had a twenty% chance of a second rupture. Unfortunately, four and 6 strand repairs are less piece of cake to accommodate in the flexor tendons of this finger, especially nether the circumstances of a re-repair. We would non re-repair a rupture of the profundus tendon with a stiff intact FDS tendon. Even so, fifty-fifty when simply the FDP tendon of the little finger has ruptured, doing nothing may not be an option as the FDS tendon may be absent, or too weak to provide sufficient PIP joint flexion for useful function. Regrettably, secondary surgery to the flexor tendons of this finger is no less difficult.
The pinkie remains unsolved. We continue to re-repair in this finger in some cases, every bit the direction, when successful, is simpler for the patient than the culling of grafting. However, we are more inclined to move to tendon grafting than in the other fingers for indications already discussed, with insertion of a rod just at the outset operation. Nosotros as well admit the bug of this finger from the outset and increment therapy time for these patients after principal repair. If patient compliance, or other problems, has become apparent during primary rehabilitation, nosotros feel that rupture of the little finger should be treated past two-stage secondary reconstruction, a rod existence inserted into the finger as an culling to re-repair. When show that stronger re-repairs give better results in the little finger is available, this policy may crave modification.
THE 'STUCK' OR ADHERENT Principal TENDON REPAIR
The other failure of main flexor tendon surgery is tendon adherence with loss of full active finger flexion, extension or both. As sticking nearly always occurs during the beginning eight weeks after main repair, the therapists cannot be more ambitious for fear of rupture. They tin, however, increment the frequency of therapy, which can be useful. The patient has to be told that it is not advisable to re-open up the finger until information technology has lost its redness and swelling and is soft over again, which tin have 3, 6 or more months. If functioning is too early, it tin be hard to place and separate the structures, or to suture them, and the hand often responds with a worse healing reaction and more tendon adherence. The skin scars, the swelling of the finger and its pliability are adept indicators of the stage of healing inside. The extra fourth dimension in therapy is useful. The losses of flexion and extension are rarely complete and sometimes improve with further time and therapy. Plenty may be restored to be adequate for the patient's needs. Even if not, some patients will determine to practice nothing further as they discover they can manage, or are non prepared to lose more than piece of work fourth dimension on the problem.
There are actually ii possible problems in these digits: Which is present only becomes obvious at surgery. The tendon may merely be stuck to the surrounding sheath and require freeing, or the repair may have gapped causing the tendon to move less and become secondarily adherent. The latter is a hidden rupture and has to be treated equally a late presenting rupture. The latter possibility should be discussed with the patient pre-operatively, so that the possible need for procedures other than simply tenolysis is clearly understood. On discovering a gapped tendon at tenolysis, we would continue to gratuitous all of the scarred contracted tissues, equally described immediately below, then either proceed to single stage tendon grafting or insert a tendon rod every bit the beginning phase of a two-stage grafting procedure, which is our usual preference.
Earlier contemplating exploration of stuck repairs, it is important to realise, and the patient should also know, that all of the tissues on the front of the finger can be scarred to a variable degree and each layer may require handling. And then the terms 'tenolysis' and 'tendon grafting', which announced routinely on operating schedules, are often a gross simplification for the surgery needed and the fourth dimension and surgical skill involved. The degree of this scarring is frequently surprising in a hand or finger which appears to have achieved resolution of the initial thickening and stiffness from the injury and/or primary surgery. The peel itself is occasionally of poor quality and requires replacement simply information technology is much more common to notice a loss of skin pliability with longitudinal pare shortage equally a result of scarring of the subcutaneous tissues. Our preference for opening these fingers using a mid-lateral incision which comes onto the palm as a 'V' (Moiemen and Elliot, 1994)[seven] allows the skin and subcutaneous tissues to be moved distally equally necessary, leaving a gap in the suture line which lies on the fatty of the palm, well away from the tendon surgery, is discussed in a previous commodity (Elliot and Giesen, 2013b).[viii]
The sheath anterior to the tendons is also ofttimes thickened past scar tissue, contributing to the loss of extension of the digit. Nosotros usually excise all of the thickened sheath except the A2 and A4 pulleys to expose the tendons, thereby resolving this cause of shortening [Figure 1]. It is generally recognised that the A2 and A4 pulleys, or at least a good part of them, by which is probably meant over fifty%, must exist retained to let the flexor system to function in bending the finger. For reasons discussed subsequently, nosotros also endeavour to retain the A3 caster during this sheath resection.
A finger undergoing 'tenolysis' subsequently sheath excision with preservation of the A2, A3 and A4 pulleys (the latter is not shown). The thickness of the scarred sheath is illustrated
Well-nigh, just non all, will take adherent tendons, in which instance freeing of the adhesions, or 'tenolysis', volition be necessary. This curt judgement belies the difficulty which tin can be encountered in trying to achieve a free running tendon. Some surgeons prefer Beaver blades for this procedure. The authors routinely utilize a standard xv guage bract and Stilley scissors. Probably the most important asset to carrying out a tenolysis is sufficient time and patience. Information technology is particularly difficult to complimentary the tendons on their dorsal surfaces under the pulleys and even the slightest small strand of fibrous tissue linking the tendons to one of the pulleys will finish movement. Although rarely admitted, division of a pulley - usually the A4 - at this stage is probably the commonest cause of pulley loss. When the tendons are very bloated and tight under the A2 pulley and seem likely to stick again, we remove the FDS tendon.
The deepest problem and the nigh likely to give rise to a recurrence of loss of extension are the ligaments of the underlying joints which can be scarred to a thickness of several millimetres. The PIP joint may only require proximal release of the palmar plate but, more frequently, the accessory collateral ligaments too have to be released. If the scarring is more astringent, releasing the truthful lateral ligaments may be necessary. Sometimes, we carry out complete excision of a very thick and scarred PIP palmar plate, using distal tenodesis of the FDS to replace the palmar plate if the excision makes the articulation dorsally unstable. I have establish anything brusk of complete excision of a contracted DIP palmar plate does non straighten the DIP or go on it straight in the long-term. This procedure is not done by the states sufficiently ofttimes to recommend it over DIP joint fusion in the very difficult cases with flexion contracture of both interphalangeal joints and a truthful 'hook' finger.
In a small number of cases, the digit will still not extend, even after such extensive releases because of musculo-tendinous shortening. As the secondary tendon surgeon was often not the main surgeon, or has no precise memory of the event, it is impossible to say whether this is due to true muscle shortening as a result of the digit having been in a flexed position for a long period of time before primary repair or is a consequence of tendon trimming at principal surgery. It is the writer's impression, from cases treated entirely in our ain unit that musculus shortening does occur, although it is non clear why this should occur in some patients and not others. This is a particular, and well recognised, problem for the long flexor of the thumb. When this does occur, it is often but by a small degree, which is amenable to lengthening of the tendon within the muscle, as described by Le Viet, in 1986 [Effigy 2].[9] The intramuscular part of the tendon is cutting across and the tenotomy gapes to dissever the tendon ends by approximately one centimetre, with continuity being maintained by the muscle fibres alone. Should two to iii such tendon divisions within the muscle give insufficient increment of tendon length, conventional step lengthening of the tendon is then carried out. We do this at the musculo-tendinous junction, instead of just proximal to the distal wrist crease in the free tendons, in order to allow the stride procedures to exist wrapped in the muscle to speed healing and improve gliding.
Le Viet's intramuscular tendon lengthening procedure
All of these cases are treated with antibiotics for v days post-operatively as infection will create and so much more fibrin-oedema mucilage that the tendons are likely to adhere again. There is no repair to protect and much more ambitious active and passive rehabilitation tin be started immediately. This is started the day after performance under a continuous local anaesthetic infusion through a percutaneous cannula onto the median or ulnar fretfulness, or their branches in the palm, proximal to the site of surgery, as an in-patient to achieve as much motion as possible as early every bit possible (Kulkarni and Elliot, 2003).[10] The economic science of such a policy may be questioned. Notwithstanding, much hangs on this secondary performance. If information technology fails, the patient's coin, or that of the Country, has been dissipated and a considerable amount of surgical and therapy time entirely wasted. Nigh important of all, the patient is unlikely to be offered a repeat operation and is left with his/her original, occasionally a worse, arrears of hand part. This is ordinarily the 'last' functioning for this paw!
The 'frayed tendon programme' of rehabilitation was advocated by Strickland and his co-workers (Cannon and Strickland, 1985)[11] in cases with frayed, or sparse, tendons and/or poor soft tissue cover of the palmar aspect of the digit. This involves passive full flexion of the digit, and then active maintenance of the flexed position by the patient instead of active flexion through the total range of motion. While, theoretically, this may be safer in such cases, it places an onus on the therapists to carry out a regimen of handling which is not their norm without rupturing poor tendons. Consequently, nosotros prefer to supersede such tendons past rods and bear out secondary grafting with routine therapy direction later in the more severely damaged cases, then placing the onus of judgement every bit to whether these tendons will survive the mail-operative period back in the operating theatre.
It is sometimes the instance that tendons with astringent scarring, or which are desperately frayed, cannot exist freed without irrevocable damage to the tendons or the vital pulleys. In these cases, tendon grafting and/or caster reconstructions will be necessary later freeing the palmar side of the finger from the scarring in the other tissues and excising the tendons. Necessity, or preference, may make up one's mind that this may be done at the same performance. We believe that most such cases lend themselves to two-stage tendon reconstruction, firstly because the degree of scarring is severe and, ofttimes, as well because a caster reconstruction over a rod, which does not have to cope with the forces of tendon activity immediately, is much simpler to manage, as will be explained afterward.
THE OPTIONS OF Handling IF Master REPAIR IS IMPOSSIBLE OR FAILS
Outwith the short menstruum when the appropriate patient and appropriate conditions allow master flexor tendon repair and with failures of relieve of rupture or tendon tethering afterward main repairs, the options of handling of the divided flexor tendon include doing no flexor tendon repair, delayed primary repair, and flexor tendon grafting in one or two stages. It is plain of import that there be full give-and-take with the patient of all of the handling options where any secondary flexor tendon procedure is contemplated, as the length of time involved may take significant life and piece of work implications. In particular, it should exist understood that tendon grafting is a complicated treatment option with imperfect results which involves lengthy periods off work.
DOING NO FLEXOR TENDON REPAIR
Under near circumstances, when this decision is made at any time, the patient buddy straps the flail finger to the side by side finger to stop it catching during activeness, or, in the case of a pollex with no flexor office of the distal joint, allows the thumb to flex at the metacarpophalangeal joint only. The option of doing nothing is mostly used temporarily while waiting for digits to soften and become amenable to further surgery. It is used occasionally as a long-term solution, usually in the elderly. In others, delayed re-repair or grafting is likely to give the all-time issue but, occasionally, the patient may not want, or be unable, to spare further time for further surgery. A decision to do nothing tin can exist reversed after any length of delay until quondam age intervenes.
When but an FDS tendon has been divided, it is not normally necessary to repair the tendon, as the FDP tendon will fully flex the finger. Nevertheless, some loss of power and dexterity is likely and consideration of these facts may necessitate repair for particular manus uses. Where but the FDP has been divided, the FDS may provide adequate finger flexion for some individuals, although only flexing the MP and PIP joints, but not for others. In a proportion of these patients, the DIP articulation will hyperextend in fingers working without a FDP tendon, when pressure level is applied to the fingertip. Tenodesis of the distal office of the FDP tendon by suture to the sheath at the level of the middle phalanx or actual fusion of the DIP joint, although providing no DIP joint flexion, will prevent this and is a uncomplicated culling to tendon grafting in those patients content with MCP/PIP flexion merely. Distal tenodesis of the FPL may also achieve the stability required for pinching in a thumb with a divided FPL flexing the pollex adequately by CMC and MCP flexion only. If the distal stump of the FDP or FPL is found to be inadequate for this purpose at the time of surgery, information technology can exist reinforced by a length of palmaris tendon to permit this procedure. The alternative is a distal joint fusion.
The determination to tendon graft in cases with an intact and operation FDS and divided FDP tendon has been greatly debated in the past and many surgeons will non contemplate it for fear of compromising FDS office. The author'due south experience has been that grafts running through an intact FDS tendon rarely adhere following two-phase tendon grafting followed by early mobilisation by proficient therapists in a well-motivated patient. Our therapists determine the motivation of the patients from previous encounters if the case is a failure of primary surgery and by arranging a catamenia of pre-operative mobilisation of the digit passively if it is non.
DELAYED PRIMARY REPAIR
Where a patient presents for the first fourth dimension subsequently a considerable delay with a divided flexor tendon, information technology is sometimes possible to behave out a delayed primary repair. This has been discussed recently by us in detail in this journal (Elliot and Giesen, 2013a).[one] If the routine of the surgeon is to acquit out one-stage tendon grafting, re-repair without tension would appear to take advantage over bridging the gap with a graft when possible.
TENDON GRAFTING
When both flexor tendons remain divided, there is ordinarily no dilemma for discussion if reconstitution of a fully flexing finger is desired. On most occasions where no chief surgery has been carried out to the divided flexor tendon, the situation is like to that of the ruptured main tendon repair or the adherent tendon with gapping of the tendon after chief repair, with or without a need to bargain with extensor tendon tethering and/or scar contracture of the other tissues of the palmar surface of the finger.
Tendon grafting may exist done in a single stage or in two stages, with definite preferences past different surgeons for 1 or other technique. Which is preferable is a philosophical question to which we believe we do not take an answer. The results of secondary flexor tendon surgery are very much dependent on the starting land of scarring of the finger, the patient's intrinsic scarring trend after further surgery, his/her psychological make-upwards and his/her ability to interact with the surgeons and/or therapists for a multitude of reasons mail-operatively. While unmarried stage tendon grafting has advantages for the patient in terms of a single catamenia off work, it carries a chance of graft adherence, requiring farther surgery and further time off work, as the new tendon is being placed in a bed of healing tissue from which the sometime tendon system has only just been removed. Although it seems to be 'overkill' when the sheath is non badly scarred, those who favour two-stage grafting would debate that information technology is impossible to tell either how much scarring there will exist after the grafting surgery, or what upshot fifty-fifty very small degrees of scarring will have on the ability of any particular patient to maintain movement of the digit post-operatively. No one has established how to identify the patient who volition either scar desperately or exercise no therapy!
Perchance it is worth remembering that the ii-phase graft was introduced because of dissatisfaction with the results of the ane stage procedure. It is based on the premise of improving the bed into which the tendon graft is placed by the cosmos of a pseudo-sheath by inserting a flexible silicone rod into the hand at a first operation and delaying the actual grafting procedure for several months. Ii stage grafting was pioneered in the 50s by Bassett and Carroll[12] (1963) and the nowadays technique of two-phase tendon grafting was perfected by Hunter and his co-workers (Hunter, 1965).[xiii] The perceived advantage over single stage grafting is that mobilisation postal service-operatively is started with the graft moving in a smooth-walled pseudo-sheath and in a less traumatised, less painful and more than supple hand. Despite a very minor incidence of reaction to silicone rods and a small incidence of infection and/or extrusion of the rods, the two-stage procedure appears at least to reduce the influence on results of the 'scarring' factors, if not the other considerations beyond the surgery which bear on outcome of tendon grafting.
Our own preference for two-stage surgery is partly based on these arguments and partly on surgical upbringing at a fourth dimension and in a place where it was believed to give the best results, although published prove for this is scarce. Information technology may too be influenced past the fact that nigh cases of tendon grafting in our unit of measurement follow failure of main surgery and these patients have already demonstrated 1 failure to maintain adequate mobilisation of a tendon repair, for any reasons. Even so, mayhap we should exist considering a move back again to a unmarried stage graft in more cases at present our sutures are stronger and our rehabilitation more robust.
Under particularly agin circumstances, those inclined to single-stage grafting might consider the 2-phase procedure as more likely to provide near-normal finger function than one-stage grafting, and then secondary tenolysis of the adherent graft. The total period off work is arguably less with 2-stage grafting. Whenever inserted, the period of protecting the tendon graft is the same. Insertion of a rod requires 2 weeks, or less, off work of a sedentary kind and a little more for the transmission labourer. Return to work in this time is unlikely after tenolysis.
When carried out as a single procedure, one, or both, tendons are removed from the digit through incisions in the tendon sheath intended to minimise the damage to the sheath and, at the very least, preserve the A2 and A4 pulleys. The FDS tendon is only removed if non intact or grossly bloated, and the distal office of this tendon must be retained or replaced to prevent time to come swan-necking of the PIP articulation if this joint tin can be hyperextended at the fourth dimension of surgery. Distal attachment of the FDP tendon and tensioning of the graft are done in a variety of ways (Wilson and Sammut, 2003).[14] We go out 0.5 cm of the FDP tendon attached to the distal phalanx after excising the balance of the tendon. A tunnel is prepared backside this tendon remnant into which the distal end of the tendon graft will be 'snugged'. A graft of the palmaris longus tendon from the same upper limb is harvested where possible for convenience and to minimise morbidity. If this is not present, the other palmaris tendon, one or other plantaris tendon, or other tendons (a long extensor of a 2d, third or fourth toe, the ipselateral extensor indicis or extensor digiti minimi) are recommended for utilize, with the donor sites usually being examined in the order given above until a suitable donor tendon is found. Our preference, where neither palmaris is present, is to use the extensor indicis tendon, equally it is almost always present and rarely missed functionally. The discarded proximal FDS tendon of the injured finger can also be used as a gratis graft but may be swollen, causing problems when passed through the pulleys in the finger. The tendon graft is passed from the palm through the tendon sheath. Conventionally, it is sutured to the distal phalanx with a suture passed through the phalanx, through the nail and tied over a button on the blast. More commonly, we pass the sutures along the sides of the phalanx and through a hole in the tuft of the distal phalanx, to avoid the push button (Sood and Elliot, 1996).[fifteen] The tendon can be attached more proximally to the distal phalanx in a like manner, or using a bone tag. The graft is sutured to the proximal role of either the FDP, or FDS, tendon (each has its advocates) with a Pulvertaft weave, either in the palm or at the wrist. The former is easier when using the palmaris longus tendon every bit it is not long plenty to reach the wrist unless harvested more than proximally in the forearm, then the proximal finish 'cleaned' of attached musculus fibres. If the FDP tendon is used proximally equally the motor of the graft, tendon junction at the wrist automatically avoids the possibility of the motor pulling through the lumbrical and extending the finger at the interphalangeal joints during activity, the so-called 'intrinsic-plus miracle'. Some authors who utilize palmar proximal tendon junction detach the lumbrical from the FDP in the palm to avoid this trouble, seemingly without functional disadvantage. We generally use palmar tendon junction without lumbrical disengagement, except when the lumbrical is badly scarred, and have but rarely seen the intrinsic plus phenomenon. When the lumbrical is desperately scarred, we remove the muscular office in toto, again without causing functional problems. When performing the Pulvertaft weave, the graft is woven through the tendon of the proximal motor three or more times. Initially, it is set under tension with 1 or two horizontal mattress sutures of 3/0 or 4/0 forcefulness, such that the finger-tip lies in the appropriate position in the cascade from little finger nearly flexed to index finger least flexed when the anaesthetised hand lies on the table with the wrist in the neutral position. This can exist more difficult later severe finger injuries, or when the other fingers are but partially present, or do not lie in this cascade for other reasons. While preparing this first stage of the tendon weave, it is important to adjust for the fact that the tendon weave is inevitably lifted slightly out of the palm while suturing, so the tendon length is always slightly greater when the weave is returned to the palm. Except when the wrist is fused, correct tendon length is confirmed by lifting the manus off the table and moving the wrist passively to movement the fingers, by the wrist tenodesis effect, while watching to determine that the involved finger remains in the correct position in the cascade. If necessary, the sutures are removed to permit change of length at the weave. Achieving total extension and full flexion of a finger after tendon grafting is very difficult and information technology is common to lose 1 extreme or the other, indicating that the graft was slightly too tight, or slightly too slack. Many surgeons, accepting this, make the grafts slightly tighter in the ulnar two fingers and slightly less tight in the radial 2 fingers than will agree the finger-tip position in the cascade. After ensuring the correct tension of the proximal weave, it is completed, conventionally, by addition of a horizontal mattress suture for each tendon weave. The senior author prefers to use a continuous Prolene suture passed back and forth through the weaves from 1 finish to the other then back to the starting cease, to reduce the number of external suture knots to a single knot. Other surgeons find it more convenient to tension the tendon by performing the proximal weave first and tensioning the tendon distally, using 1 of the modifications of the distal zipper technique originally described by Pulvertaft (Pulvertaft, 1965;[16] Wilson and Sammut, 2003).[14] The above replacement of the whole of the tendons within the sheath is generally preferred to simply replacing any missing segment of tendon with a shorter graft, leaving one, or 2, tendon repairs within the sheath, although at that place are those who use this approach.
After completion of the tendon graft suturing, the peel is airtight and the repair protected in a dorsal plaster slab. Mail-operative management is controversial, with grafts being treated conventionally for 3 to 4 weeks without move. However, better results following mobilisation in Kleinert traction and by early on active mobilisation, with or without condom bands, accept been reported (Tonkin et al., 1988;[17] Khan et al.,[eighteen] 1997) and our experience of mobilisation by active extension — active flexion (controlled active motion) is like. Mobilisation exactly equally for primary repairs is a convenient unit policy.
When two-stage grafting is used, the old tendons are removed at the start operation. The proximal FDS or FDP motor tendon is held to physiological length by suturing it, with a non-absorbable ii/0 or three/0 suture, to either the deep transverse ligament in the palm or the ligamentous structures of the flexor aspect of the wrist. Our ain preference is for a proximal profundus-graft junction in the palm every bit this requires a shorter graft and we have but rarely seen the intrinsic plus miracle. Nosotros have only express experience of the Paneva-Holevich technique of suturing the distal end of the proximal FDS to the distal stop of the profundus tendon in the palm at the beginning performance and meet no particular advantage to this technique. The proximal FDS is not our start choice as a graft as it tin can be slightly thickened and a petty tight within the flexor sheath and almost of the few cases in which the senior author has used this procedure accept healed this tendon connectedness with considerable inflammatory swelling which required tenolysis (just where all of the flexor tendons enter the narrow carpal tunnel) with paring downwardly of the bulk of the junction. A silicone rod of approximately the bore of one of the patient'south flexor tendons is placed betwixt the proximal motor and the distal phalanx. These rods are manufactured in round and oval shape: Either works equally well. We use sizes 3 or 4 most commonly. The distal stop of the rod is cut obliquely and passed behind the FDP stump distally, to maintain a pocket, then sutured to the FDP stump. It is passed proximally through the tendon sheath to the palm or the wrist. The costless proximal terminate of the rod is not sutured and should attain slightly proximal to the sutured terminate of the motor tendon in the palm or wrist. The hand is closed and mobilised fully until completely supple, then the tendon grafting process is carried out. Usually between iii and five months is an adequate delay. Impatience to consummate the second stage in the surgeon or the patient is counterproductive every bit the final result is generally much amend if the healing process of the beginning, and larger, operation is completely over. At the second functioning, it is but necessary to expose the rod at its two ends to allow zipper of the graft distally and proximally as described above for one-stage grafting. The showtime stage of a staged tendon graft procedure requires no protection postal service-operatively and the patient usually returns to work inside two to 3 weeks. Subsequently the 2nd stage, the graft must be protected every bit for a primary repair or single-stage grafting. Equally the 2d stage can be carried out at whatsoever time later the hand has go supple, the patient has a wide selection of the timing of the second functioning. This, and the fact that the second stage is inevitably being planned with a minimum of 3 to 4 months notice, is frequently convenient to the work state of affairs. Nonetheless, two-stage surgery can be unrealistic to the economic needs of many patients in many parts of the globe and pragmatism in this respect is probably the major determinant of the preferences of different surgeons for single or 2-stage grafting!
A major advantage of the 2-stage management of the tendon is that all reconstitution of the skin and/or the pulleys tin can exist carried out at the first stage when these will not be compromised by post-operative management considerations intended to protect a repaired flexor tendon system (see subsequently).
BOW-STRINGING AND PULLEY RECONSTRUCTION
Except after surgical intervention, clinically obvious bow-stringing virtually only occurs in the proximal finger and thumb [Figure 3] and requires that the finger A2 pulley or the thumb A1 and oblique pulleys are not functional only at least i flexor tendon is intact. This is an unusual problem, probably because a lacerating injury which is longitudinal, or oblique enough, to cut these pulleys while leaving at to the lowest degree one flexor tendon intact is unusual. Occasionally, a severe crush injury of the finger with bursting lacerations of the pare, and usually a badly comminuted proximal phalanx, will include rupture of the A2 pulley. Occasionally, A2 partition is a consequence of bad previous surgery [Figure iv]. Sometimes, the destruction of the A2 pulley in the initial injury may merely go obvious during the procedure of freeing badly scarred flexor tendons at tenolysis. Sometimes, this procedure can issue in inadvertent devastation of the pulley.
Clinical bow-stringing of the pollex as a result of the primary injury in a patient presenting for the start time for surgery
Absence of the A2 pulley in a patient referred with bow-stringing three years later on principal flexor tendon surgery to this finger
Occasionally, when a patient has clinically obvious bow-stringing, he, or she, may not request reconstruction as objects being gripped in the manus will flatten the tendons back against the digit. The treatment of proximal bow-stringing in the presence of ane, or two, intact flexors demands a pulley reconstruction which is strong, so that mobilisation tin beginning immediately. Probably the commonest reconstruction used currently is that in which a strong tissue such as the extensor retinaculum (Lister, 1979),[xix] or the palmaris tendon, is passed circular the os and sutured to itself [Figure 5]. Bearing in listen the problem of extensor tethering mentioned earlier, there must exist some reservations on theoretical grounds about this technique. It may exist preferable in this respect to suture the new pulley to the sides of the phalanx and avoid invading the extensor infinite. However, conventional suturing is not strong enough to take immediate loading by early mobilisation. Perhaps, mini bone tags may achieve this force in such a pulley reconstruction, but we accept not nevertheless tried this.
Replacement of the A1 and oblique pulleys of the thumb of the patient illustrated in Fig iii with a palmaris longus tendon wrapped effectually the skeleton of the thumb and passing under the extensor tendon
We, much more than normally, accept a need for pulley reconstruction when we explore a flexor secondarily and come beyond severe scarring [Figure 6]. The A2 caster may have been destroyed in the original injury, or is nonexistent by the end of the tenolysis, equally freeing the tendon(due south) under the intact pulleys is the most difficult part of this hard procedure. Where the potential for bow-stringing arises later on flexor tenolysis surgery, pulley reconstruction should be carried out. This has to be strong immediately, as for clinical bowstringing, if the tendons remain intact, or a policy decision is made to graft in a single stage. Information technology is more simple to reconstruct a new pulley at the first phase of a 2-stage tendon graft when the missing A2 caster can be replaced without having to take the strain of the functioning tendons immediately. Fortunately, it is normally the case that A2 pulley reconstruction is being carried out in combination with tendon reconstruction, so it is possible to cull to reconstruct the tendon in two stages. A length of the tendons beingness removed from the finger, or, if these are too poor, the more than proximal part of the ane which will not exist used later as the motor for the graft, tin can exist used every bit textile to reconstruct the pulleys at the first phase [Figure 7]. The tendon, split up longitudinally and turned through ninety degrees, will provide enough cloth to make as many pulleys every bit required [Effigy 8]. Because there will be no strength on the reconstructed pulleys, they can simply be sutured to the remnant edges of the sheath, over a silicone rod. They will be strongly bound past the time they have to withstand a mobilising tendon in 3 to 6 months. It is possible to reconstruct a considerable length of the tendon sheath by this technique and we routinely supercede equally much of the A2, C1, A3, C2 and A4 pulleys as are desperately scarred, flimsy or absent-minded. This technique too avoids the employ of extensor retinaculum to make pulleys, as harvesting this tissue leaves an obvious scar on the very visible dorsum of the wrist.
Severely scarred flexor tendons and sheath with considerable likelihood of tenolysis ending without an intact A2 pulley and with the tendons severely frayed or divided
Afterward tenolysis, the flexor tendons have been replaced by a silicone rod. The redundant superficialis tendon proximal to the finger may be excised, split longitudinally and used for reconstruction of pulleys over the rod (see also Fig 8)
Reconstruction of multiple pulleys over a rod with material harvested from discarded flexor tendon as in the previous figure
Where isolated loss of the A4 pulley has occurred, for whatever reason, and well-nigh of the residuum of the sheath remains intact, function is unlikely to be afflicted. Bow-stringing at the distal joint in isolation is a clinical situation which the authors have never seen and the potential for this to occur on flexion of the joint, even when non gripping an object and forcing the tendon back confronting the skeleton, is minor every bit the distal articulation flexes likewise niggling and the length of gratuitous tendon is besides curt. For distal bowstringing to occur requires that the whole length of the sheath distal to the A2 pulley exist missing [Effigy ix], which happens nearly usually because nosotros starting time all secondary flexor surgery in the finger by opening the sheath through the A3 and C pulleys and commonly destroying them in the process. So, either an already disrupted A4 caster is revealed or this caster is disrupted during the dissection to gratuitous the tendon under information technology. The problem of distal bowstringing can largely exist avoided by also preserving part of the A3 pulley [Figure 1] whenever possible at the start of dissection and, secondly, by replacing the A4 caster when necessary. Where all of the sheath has been removed distal to the distal edge of the A2 pulley and distal bow-stringing is anticipated. Information technology can often be replaced with local tissue from discarded tendon as described above. Nosotros would question the wisdom of the suggested technique of A4 pulley reconstruction by passing a segment of palmaris or plantar is tendon around the middle phalanx and so superficial to the extensor tendon. The space around the extensor tendon over the heart phalanx is so small-scale every bit to make extensor tethering with loss of DIP flexion almost inevitable. Over and above the space occupation by such a caster reconstruction and the scarring, if it were sufficiently tight to part as a pulley information technology would be unlikely to allow movement of the extensor tendon. A tenodesis of this tendon, with loss of distal joint flexion, would seem inevitable. Fortunately, the need to carry out this reconstruction in isolation is more hypothetical than real.
Distal bow-stringing beyond the distal border of the A2 pulley in the absence of the C1, A3, C2 and A4 pulleys
Avoiding SECONDARY SURGERY
Although nosotros can achieve flexor function by secondary surgical techniques, it is important to realise that, whatever problems we have after master surgery and skilful therapy, the results are much better overall than those of secondary surgery. Secondary surgery of the flexor tendons remains difficult, with, often, poor results.
Although we have to do secondary procedures, sometimes we tin can avoid them. Probably the major determinant of whether more, or less, divided flexor tendons are repaired primarily in any location is the local doctor-political situation. It is appreciative on senior paw surgeons to involve themselves in the battle for more manus surgical availability — more than surgeons, therapists and facilities — and for arrangement and education of the emergency services to permit these injuries to be relocated to appropriately trained surgeons and hand therapists. Extending delayed chief repair and re-repair of ruptured principal repairs, both discussed earlier, may avert secondary surgery. Considering the patient is a major risk factor in this process, he cannot exist a rider. He must empathize the difficulties: A movement from the top of the fence on which he is walking is a disaster waiting to happen. Also much movement and the repair snaps, besides piffling and it sticks. If either happens, save surgery — which is what secondary flexor tendon surgery is in these circumstances — will mostly end upward with a worse consequence.
Knowledge of technical tricks may also allow us to avoid secondary surgery. Le Viet intramuscular lengthening of the proximal tendon has been discussed and may avoid grafting a divided long flexor tendon of the pollex specially. This technique can occasionally exist useful to overcome the same problem of musculus retraction later on late presentation of divisions or pull-off of the finger flexors. Secondary surgery can too, sometimes, be avoided using this technique in cases presenting with small segments of tendon missing. The advantage of repairing only the FDP tendon in certain severe injuries in Zone 2C and Zone iv in lodge to avoid secondary surgery has also been discussed. Secondary surgery can be avoided in cases in which an FDP pull-off presents belatedly with the FDP too swollen to pass under the A4 pulley, by halving the distal part of the FDP tendon and passing one-half of the tendon through the pulley to reattach it (Elliot et al, 2001).[twenty] The double-barrelled nature of the distal office of the FDP lends itself to this manoeuvre. Equally the palmaris tendon is routinely less than half the diameter of the FDP, half of the FDP should be stronger than a palmaris graft. It is too much easier to insert a Kessler suture into the half FDP than into the palmaris, or plantaris, tendon.
There are several situations when we should not carry out secondary surgery. One tin categorise these cases broadly into unsuitable patients and unsuitable hands. Where cases presenting for secondary surgery are failures of chief surgery, our therapists know these patients and can tell us if the patient is unlikely to achieve anything from further surgery. Thus, unsuitable patients can exist weeded out before embarking on something which is across their capabilities of co-operation. Occasionally, patients present with specific clinical situations which are unsuitable for secondary flexor tendon grafting. An instance of this is the long-standing injury of the index finger which is being bypassed. Pollex pinching to the eye finger has been established at a cerebral level and there is little possibility of a secondary flexor tendon reconstruction achieving a pinching index finger, although the finger may contribute to ability gripping after restoration of flexion activity.
SIMPLIFYING SECONDARY SURGERY
Where secondary surgery is necessary, many techniques which simplify the surgery have already been discussed, e.g. distal FDP tenodesis when the FDS is intact instead of trying to re-establish FDP function, attachment of the detached FDP and tendon grafts to the distal phalanx without a button, pulley reconstruction over a tendon rod at the first stage of a two-phase procedure and standardising rehabilitation when mobilising primary flexor repairs, flexor tendon grafts, tenolyses, flexor tendon transfers and replantations/revascularisations.
CONCLUSION
Primary flexor tendon surgery has advanced a long way in the last 50 years. By dissimilarity, secondary surgery has inverse piffling in this time and remains hard technical surgery, after which it is difficult to achieve good results. As the number of patients having secondary surgery gets less, our expertise may also be diminishing. Mayhap, also, the fact that nosotros are notwithstanding using many of the same surgical techniques used in the 1950s to deal with these bad injuries and bad patients may exist contributing to our results getting no better.
We would like to cease with a caveat. In this era, at that place can exist few cases in which amputation, either within the finger or equally a ray amputation, is justified for flexor tendon dysfunction. Autonomously from the cosmetic implication and the grip loss of even a single finger amputation, formation of a single end-neuroma of ane of the divided digital fretfulness can render a hand which was a nuisance completely functionless and, sometimes, destroy the patient's life. This affiliate has been a resumé of conventional secondary flexor tendon surgery. Over and in a higher place the considerable possibilities of such surgery, we should exist looking for such new alternatives as the vascularised transfer of the flexor tendon with its gliding bed from the distal forearm to the digits which has been so beautifully demonstrated and performed clinically in many severely scarred cases by Jean-Claude Guimberteau of France to avert amputation (Guimberteau, 2001).[21]
Footnotes
Source of Support: Nil,
Disharmonize of Involvement: None declared.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3897088/
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