Delayed Treatment of Flexor Tendons Staged Tendon Reconstruction

Lawrence H. Schneider History and Clinical Presentation

An 18-year-old student lacerated both flexor tendons in zone 2 of his right dominant index finger on broken glass. His primary treatment was by direct repair of both flexor tendons 3 days postinjury, and he was started on a mobilization program in a hand therapy unit. Unfortunately, this did not result in functional pull-through of his flexor tendons. He then underwent flexor tenolysis in an attempt to salvage function, a procedure that was also not successful. He was first seen on my hand surgery service at 4 months postoperative complaining of restricted motion in the operated finger.

Physical Examination

The right hand showed no active flexor tendon function at either the flexor digito-rum superficialis (FDS) or flexor digitorum profundus (FDP) of the right index finger (Fig. 34—1). Passive motion was almost full with only a mild flexion deformity

The right hand showed no active flexor tendon function at either the flexor digito-rum superficialis (FDS) or flexor digitorum profundus (FDP) of the right index finger (Fig. 34—1). Passive motion was almost full with only a mild flexion deformity

Flexor Digitorum Superficialis Tendon
Figure 34—1. Right index finger held in extended position while attempted to make a full fist even after two i

at the proximal interphalangeal (PIP) joint. Sensory nerve function was intact. The skin was relatively pliable and soft considering that he had had an injury and two prior operations. The remainder of the hand was normal.

Diagnostic Studies

Except for routine radiographs in cases with associated bone injury or arthritis, there are no diagnostic studies needed. Although there is some interest in the use of ultrasound and magnetic resonance imaging (MRI) in the evaluation of the flexor tendon system, I have not used these studies for these cases.

Diagnosis

Flexor System Laceration of Right Index Finger, Status Postoperative Repair, and Tenolysis with Loss of Flexor Tendon Function

Patients with injuries of the flexor system in which there has been marked scarring, disruption of the supporting pulley mechanism, and joint contracture not responsive to therapy measures often become candidates for tendon reconstruction using a staged approach. These patients often have a history of failed prior surgery, with adhesions preventing tendon gliding after a direct repair or tendon rupture after a tenolysis attempt. At the first stage, the scarred tendon is excised and the implant, attached only at its distal end, is placed in the flexor system of the finger. The implant as devised by Hunter and Salisbury consists of a Dacron woven tape encased in silicone rubber. The tape gives body to the implant to enhance its passive gliding and further provides a better hold for the distal sutures at its attachment to the profundus stump. Joint release, pulley reconstruction, skin revision, and nerve repair are performed at this first stage, as needed. Postoperatively the patient is placed in a passive exercise program to regain joint motion while allowing a smooth synovial-like sheath to form in response to the implant. Then at the second stage, performed 3 months later, the implant is replaced by a tendon graft. After this second stage an intense therapy program is initiated.

Nonsurgical Management

Many of these patients present with joint contractures and may benefit from pre-reconstruction hand therapy to regain full passive motion in the finger preopera-tively. This patient had almost full range of motion (ROM), so this therapy was not necessary here. There is no other nonsurgical management for this problem.

Surgical Management

The patient was an appropriate candidate for exploration, with proposed staged flexor tendon reconstruction. As is common in our service, these operations are started under local anesthesia to see whether the repair can be salvaged by flexor tenolysis, and if not, as in this case, then a staged tendon reconstruction is undertaken with implant placement at this first stage.

At exploration, it appeared that the repair had ruptured and the entire flexor system was involved in a heavy scar mass. Scarred tendon is sharply excised. Pulley destruction was noted at A2 and A3. Generally all remnants of the pulley system are saved, as even scar tissue can be used to support the implant. Even scarred pulleys are usable over the implant, but in this case A2 needed to be reconstructed. This was done by use of the technique where tendon material, which is generally available from the remnants of the discarded tendon, is wrapped two to three times around the proximal phalanx (Fig. 34-2). In reconstruction of A2, overlying the proximal phalanx, the tendon material is placed around the implant and deep (palmar) to the extensor mechanism. It is advantageous to carry out the pulley reconstruction over a temporary sizer tendon implant (Fig. 34-3). In this case the A1 pulley was preserv-able, and A4, although scarred, was salvageable. At completion of the pulley reconstruction, the sizer implant is removed and a new implant is broken out of its package, moistened in sterile solution, threaded into the flexor system, and attached distally to the stump of the profundus. In this passive program the proximal end of the implant is placed proximally in the distal forearm and not attached to any motor tendon but left free in the interval between the profundus and superficialis musculotendinous junctions in zone 5 (the distal forearm). At this first stage, scar excision and joint releases are performed as well as nerve repairs and skin revisions, as necessary. After the tourniquet is released and bleeding is controlled, wound closure is performed. The wound is dressed and the extremity is placed in a dorsal splint with the wrist in slight flexion, and the fingers in flexion at the MP joints and in extension for 1 week, at which time a passive mobilization program is begun.

The interval between the two stages is devoted to regaining passive mobility of the involved joints while the soft tissues are healing and a synovial-like sheath is formed in response to the implant. The goal is to grade the finger up to a point

5th Finger Synovial Tendinous Sheath
Figure 34—2. Exploration of the finger at stage 1 revealed loss of the A2pulley. The sizer implant is in place and tendon material has been wrapped around the proximal phalanx and tendon implant to reconstruct the pulley.
Reconstruct Tendon Pulleys

Figure 34—3. The pulley has been completed and rotated so that the sutures are lateral and will not be near the graft.

where it will accept a tendon graft at the second stage with a reasonable chance to succeed. Three months is sufficient to allow the sheath to form and the finger to heal completely.

Stage 2, 3 months later, is actually a simplified tendon graft in that little dissection is needed or desired so as to do as little injury to the new sheath that has been created. The distal and proximal ends of the incision are opened to expose the ends of the implant. A long tendon graft is usually needed to bridge the gap between zones 1 and 5 and the palmaris longus is usually not long enough. The plantaris is excellent when available and can be removed through one incision at the medial ankle. If not present, and it is not possible to determine this without exploration, then the use of one of the toe extensors is a second choice.

In this case the plantaris was used. It is sutured to the tendon implant and drawn into the sheath. The graft is attached distally to the distal phalanx and profundus stump using the Bunnell pullout technique and tied over a button on the nail. The tourniquet is released, bleeding controlled, and the distal (finger) wound closed. The tourniquet is reinflated and the proximal juncture performed in this case using the flexor digitorum profundus of the index finger as the motor. The suture technique is an interweave as described by Pulvertaft. When reconstructing the ulnar sided flexors the profundus mass of the third, fourth, and fifth fingers is usually used to motor the finger or fingers being reconstructed. A suture is placed in the fingernail for the postoperative mobilization program. The tourniquet is again removed and the proximal wound is closed. After the dressing is applied, a posterior molded splint is made with the wrist placed in flexion of 30 degrees, the fingers at

Metacarpal Phalangeal Joint Pulley

70 degrees at the metacarpophalangeal (MP) joints, and the interphalangeal joints in extension. A protected mobilization program is started under the supervision of the hand therapist 2 or 3 days postoperative. Immobilization is continued for 3 to 4 weeks, and the pullout suture and button are removed at 4 weeks. Active flexion is started at 3 to 4 weeks with blocking techniques added as feasible but not before 4 weeks. Exercises are continued for ~12 weeks. Full resistance is allowed at ~8 to 12 weeks. Generally patients with good range of motion are protected from full resistance longer as they are more likely to rupture. This patient achieved an excellent recovery of active motion at 6 months after stage 2 tendon grafting (Fig. 34—4).

Fdp And Fds Tendons Action
Figure 34—4. Range of motion achieved 6 months after stage 2 tendon grafting.

Complications

Complications of note include reaction to the implant at stage 1, which creates a synovial reaction with fluid building up in the forming sheath. This now rare reaction, synovitis, was thought to be secondary to contaminants or breakdown of the distal juncture. The fluid is sterile and is treated by slowing down the passive motion program. Other problems include infection, which, if not controllable by antibiotics, usually requires removing the implant and redoing the procedure in the future. Joint contractures that are persistent after stage 1 need to be treated by hand therapy protocols but portend a reduced prognosis.

After stage 2, problems encountered include juncture ruptures, which are attributable to technical problems and resistant joint contractures. Rupture of a juncture should be treated by repair as soon as feasible. Although many of these reconstructions go smoothly, the most frequent problem seen is restricted motion secondary to adhesions, which, again, limit active pull-through of the tendon graft. The use of trained hand therapists helps keep this problem to a minimum.

Suggested Readings

Byron P, Berger-Feldscher S. Post-operative therapy for flexor tendon repair. In: Taras JS, Schneider LH, eds. Atlas of Hand Clinics. Philadelphia: Saunders; 1996: 163-188.

Hunter JM, Salisbury RE. Flexor tendon reconstruction in severely damaged hands, A two stage procedure using silicone Dacron reinforced gliding prosthesis prior to tendon grafting. J Bone Joint Surg [Am] 1971;53A:829-858.

Mackin EJ. Therapist's management of staged flexor tendon reconstruction. In: Hunter JM, Schneider LH, Mackin EJ, Callahan AD, eds. Rehabilitation of the Hand. 2nd ed. St. Louis: CVMosby; 1984:314-323.

Schneider LH. Staged flexor tendon reconstruction using the method of Hunter. Clin Orthop 1982;171:164-171.

Schneider LH. Staged tendon reconstruction. Hand Clin 1985;1:109-120.

Schneider LH. Complications in tendon injury and surgery. Hand Clin 1986;2: 361-371.

Schneider LH. Flexor tendons—late reconstruction. In: Green DP, Hotchkiss RN, Pederson WC, eds. Green's Operative Hand Surgery. New York: Churchill Livingstone; 1998:1898-1949.

Wehbe MA, Hunter JM, Schneider LH, Goodwyn BL. Two-stage flexor-tendon reconstruction. Ten year experience. J Bone Joint Surg [Am] 1986;68A:752-763.

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Responses

  • Clara
    Is numbness after a2 pulley reconstruction surgery normal?
    7 years ago
  • annett friedmann
    Is tenolysis effective for fdp?
    4 years ago
  • Leonie
    How long should you hold on active motion post A2 pulley reconstruction?
    4 years ago
  • pedro
    How long for a2 pulley injury to heal?
    4 years ago

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