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Late Reconstruction of Flexor Tendons
Overview
• Tenolysis • Acute Free Tendon Graft • Single Stage Flexor Tendon Grafting with FDP
disrupted, FDS intact • Two Staged Flexor Tendon Reconstruction • Thumb Flexor Tendon Reconstruction • Secondary Reconstruction in Zones 3,4,5 • Flexor Tendon Reconstruction in Children • Complications of Flexor Tendon Reconstruction
Flexor Tendon Reconstruction
• Satisfactory function difficult • Treatment of choice in the past
– Typically waited > 3 weeks !
• Now secondary repair less common
Aspects of Reconstruction
• Tenolysis • Staged Reconstruction • Tendon Transfers • Pulley Reconstruction
Aspects of Reconstruction
• Fall-Back – Arthrodesis – Amputation – No Operation
May be more Prudent
The Key
• Patient Selection – Rigorous post-op physical therapy – Possibly no improvement
• Possibly worse function
– Expense – Age – Functional status
Management Ladder
• Initial consideration: adhesions? • Capsulodesis? • Tendon/ pulley integrity? • Tendon Transfer • Primary graft • Pulley reconstruction
More Procedures = More Scars
• Factors influencing outcome of multi-stage procedure
• Age – Young (except vy young) do better – Motivation – Strength – Postop care
Other Factors
• Mechanism – Clean laceration vs crushing injury – # of ass. Injuries decreases final function
• Level – Outside sheath do better than inside
• Innate healing response
Tenolysis
• Adhesions Occur anywhere the epitenon is violated !– Failed 1* repair – Crush injuries – Fractures – infections
Indications for Tenolysis
• Plateau in progress with physical therapy
• Significant difference between active and passive ROM
Post Op Tenolysis
• Maximal function demands immediate mobilization
• Any concommitant procedure requiring imobilization will decrease end result – Common
• Capsulotomy • Pulley reconstruction • Nerve repair
Tenolysis
• Timing – < 3 months
• Soft wound • Nutrition via diffusion
– <9 months • Contracture
– Most active function achieved by 22 weeks
Tenolysis
• Steroids – As much evidence shows benefit as not – Some show increase scarring
• Birnie and Idler – <11 y.o. à minimal gains – Older children benefitted up to one year after
original procedure
Technique
• Neuroleptanesthesia – Pt cooperation
• Post op – AROM started within days – CPM if combined with contracture release
Single Stage Flexor Tendon Grafting
• Direct early repair is usually treatment of choice
• Some instances when free tendon grafting is the treatment of choice – 1) segmental tendon loss – 2) delay in definitive repair (3-4 weeks) ends are
degenerative, scar fills sheath – 3)dalayed presentation of some FDP avulsion
Single Stage Acute Free Tendon Grafting
• Principals – 1) Injured tendon is excised – 2) distal anastamosis to FDP insertion – 3)proximal anastamosis in palm or forearm – 4)preffered in digits with FDP + FDS injury – 5) never sacrifice intact FDS – 6) one graft / finger
Distal Anastamosis
• Created first – Easier to adjust tension on the proximal ‘mosis
Proximal Juncture
• Goal – Early: withstand early muscle pull – Resist gap formation
• Weave – Most people prefer if outside sheath
Technique
• Zig-zag • Minimal resection of injured tendon
sheath • 1cm distal FDP stump ideal • Sharp excision FDP à lumbrical • In palm if FDP of poor quality can
anastamose to FDS
Technique Cont’d• In cases where FDP + FDS stump are
injured à FDS stump transected and can retract
• If FDS is resected à 1 cm stump provides favorable dorsal border – FDS (-) finger à hyperextension at PIPJ
• Graft obtained • Atraumatic graft handlling/ passing
Technique:Distal Juncture
• Prolene criss-crossed thru end of graft (Bunnell)
• Tendon braider used to place graft thru distal stump
• Sutures are placed around or thru P3 and thru nailbed
• FDP jnctn reinforced • If stump is short, simply split
Technique:Distal Juncture
• Other Distal Techniques – Can bring thru the pulp – Classic Bunnell tendon to bone attachment – Can also place transversely oriented drill holes
Proximal Juncture Technique
• If in palm à make distal to lumbrical • Lumbrical left alone unless involved in scar
– Significant scarring is criteria for two staged procedure
• Graft is braided thru a fish-mouth distal split • Estimate tension in an awake pt
– At rest each digit is more flexed than radial border digit
Post Operative Treatment
• Past: 3 weeks of immobilization – Splint: WRIST: 35* flexion – MCPJ : 60* flexion – IPJ : full extension – Spint worn for three weeks – AROM at 3 weeks – 2 more weeks in splint when not exercising – Pullout removed at 6 weeks
Post Operative Treatment
• With 1* repair early motion beneficial – Has been extrapolated to the post op course of
2* repair
Post Operative Treatment
• Typical Early Motion Protocol – Post-op splint = static dorsal block – Splint: wrist in nuetral – MCPJ @ 45* flexion – IPJ in nuetral – Splint worn for 6 weeks – PROM 2-3 days post-op – 2 weeks: gentle place and hold – Active short-arc
Post Operative Treatment – Cont’d
• Blocked flexion exercises – Puts increased tension on anastamosis – Initiated at 4 weeks – Against resistance at 6 weeks !!
!
Long Term Graft Integrity
• If explored at 6 months – Histologic replica of the original
• Is it the original graft or a new creation built on a scaffold of collagen ?
• Lindsay and McDougal – Initial nutrition thru synovium – Later nourished via adhesions
Single Stage Flexor Tendon Grafting with FDP disrupted, FDS intact
• Primary Indication: repair has been delayed > 3-4 weeks
• Occasionally short vinculum remains intact and can do 1* repair
Single Stage Flexor Tendon Grafting with FDP disrupted, FDS intact
• Potentially Dangerous – Most function intact when FDS intact – Minimal gain if DIPJ does not hyperextend – Significant chance of injury to FDS
Single Stage Flexor Tendon Grafting with FDP disrupted, FDS intact
• “It should not be advised unless the Pt is determined to seek perfection and the surgeon is confident of his ability to offer a reasonable expectation without the risk of doing harm”
• -Pulertaft
Single Stage Flexor Tendon Grafting with FDP disrupted,
FDS intact• Technique is similar • Attempt to pass graft thru FDS decusation • Can detach one FDS limb • Never fully detach intact FDS • If difficult and FDS injuredàconsider
staging • Can also consider passing around the FDS
Single Stage Flexor Tendon Grafting with FDP disrupted,
FDS intact
• Post Operatively • 1’st week :
– short arc active flexion/ extension – Gentle place and hold – Straight fist flexion
Two Staged Flexor Tendon Reconstruction
• Principal: – active or passive tendon implant followed by a
replant graft
• Pts more suited for 2 stage: – Severe crush with Fx or skin damage – Failed first procedure with scarred bed – Damage to pulley – Both digital nerves injured – Contracted joints
Two Staged Flexor Tendon Reconstruction
• Patient Selection – Understand that in some you are starting with a
bad finger – Can you justify subjecting finger to 2+
procedures? – Arthrodesis? – Amputation?
Historical Aspects of Staged Reconstruction
• ’65 Hunter published personal experience • ’71 Hunter + Salisbury published 10 yr
experience • Their tec. Involved excision of tendon
and rebuilding of pulley system around silicone graft
Historical Aspects of Staged Reconstruction
• Attached implant dstally • Left proximal end in forearm unattached • Post-op à PROM • Found that in a previously scarred bed the
graft would create a smooth well organized pseudosheath
• 2’nd stage performed at 3 months
Historical Aspects of Staged Reconstruction
• ’69 Paneva- Holevich alternative staged technique – 1’st stage : proximal cut FDS sutured to proximal
cut FDP • Can place a silicone rod if neccessary
– 2’nd stage : FDS cut as far proximal as possible and this is sutured to the distal phalanx
Historical Aspects of Staged Reconstruction
• Peacock and Hueston – Described using a homograft consisting of the
entire flexor system, tendon and supportive structures
– Obtaining grafts was difficult
Historical Aspects of Staged Reconstruction
• ’74 Chacka – Used autologous composite grafts from the toe – Modest results only
Historical Aspects of Staged Reconstruction
• Recently – Many permanent active tendon implants have
been attempted – No reliable with either the proximal or distal
anastamosis
Technique of TWO Stage Flexor Tendon Reconstruction
• Zig-zag or mid-lateral • All pulley material is preserved • Flexors excised
– 1 cm FDP stump – 1 cm FDS stump – Set aside tendon for possible pulley repair
• If lumbrical scarred à excise
Technique of TWO Stage Flexor Tendon Reconstruction
• Check for static joint deformities – ? Volar plate incision – ?col. Lig. incision
• FDS excised at 2’nd incision prox. To flexor retinaculum
• Silicone implant sized and placed • Asses pulley system
Technique of TWO Stage Flexor Tendon Reconstruction
• Handling the implant – Smooth forcep – talc
• Suture distal graft • Test for smooth gliding
– Buckle à dilate pulley
Technique of TWO Stage Flexor Tendon Reconstruction
• Post-OP regimen – Splint : wrist 35* flexion mcpj 60* IPJ extension PROM POD 2 Wait 3 months
Technique of TWO Stage Flexor Tendon Reconstruction (stage II)
• Use previous incision • Expose distal attachment • Expose proximal graft • Select motor
– S,R,M F’s àprofundus mass – IF à FDP of IF
Technique of TWO Stage Flexor Tendon Reconstruction (stage II)
• Select Graft – Palmà tip : palmaris – Forearm à tip : plantaris or toe extensor – Select Graft
• Graft sutured to implant, pulled thru • Distal followed by proximal
anastamosis
Technique of TWO Stage Flexor Tendon Reconstruction (stage II)
• One Motor Used : end weave • Profundus mass used: inter-weave • Post-op Splint
– Wrist : nuetral – MCPJ : 45* flexion – IPJ : neutral
Inter-Weave
Technique of TWO Stage Flexor Tendon Reconstruction (stage II)
• Post-OP Care • Immediate
– Protected PROM
• Two weeks – Short arc active extension/ flexion – Place and hold
• 4-6 weeks – Add resistance
• >6 weeks – +/- dynamic splinting
Tissue Response to Silicone Implant
• Dogs in 60’s – early : Nutrition provided thru diffusion – Later : nutrition thru mobile, vascular adhesions
• Electron Microscopic Studies – Psuedosheath and synovium similar
• ’76 Rayner – Pseudosheath = fibroblastic (not mesothelial in origin) – + fluid secreted – Lesson: wait for adhesions (mobile) to form before 2’nd
stage
Tissue Response to Silicone Implant
• Later histologic studies: mainly connective tissue (F.B. reaction)
• Unknown exact nature of sheath • Unknown origin but reliable results
Thumb Flexor Tendon Reconstruction
• Flexor system is less complicated • one less joint • 30* will give excellent result • Primary repair can be done within 6
weeks • Indication for Reconstruction:
– Good ROM but unable to do 1* repair
Thumb Flexor Tendon Reconstruction
• Options for Reconstruction – Free tendon graft – FDS transfer – Staged reconstruction – Nothing (especially if MCPJ and CMCJ are nl.) – Arthrodesis (require string pinch)
Thumb Flexor Tendon Reconstruction
!
• Thumb Free Tendon Graft – Same indications as for fingers – Can use FPL or FDS as motor – If > 1 cm tendon loss à IPJ deformity
Thumb Flexor Tendon Reconstruction
• Technique (similar to fingers)
– Zig-zag : distal phalanx àMCPJ – divide tendon – Preserve pulley – Curvilinear distal forearm incision – FPL musculotendinous jnctn – Excise tendon – Obtain graft – Distal jnctn with pullout – Tension adjusted
• Wrist in neutral • Thumb palmar abducted in front of IF MC • IPJ at 30*
Thumb Flexor Tendon Reconstruction
• Post-Op Splint – Wrist neutral – 30* abduction at CMCJ – MCPJ and IPJ 30* flexion
Thumb Flexor Tendon Reconstruction
• Post - Op Protocol • 1’st week
– Full passive flexion, fully extend to limit of splint
• 2-6 weeks – Active flex/ ext out of split
• >6 weeks – Pull-out removed – Start blocking techniques
Thumb Flexor Tendon Reconstruction
• FDS Transfer – Alternative to grafting – Consider if FPL m. not functional – FDS of RF transferred
Thumb Flexor Tendon Reconstruction
• Technique of FDS Transfer – Zig-zag over thumb – Curved distal forearm – Transverse at base of RF – FDS divided 2 cm proximal to PIPJ – Pull into forearm wound – Passed antegrade into thumb flexor system
Thumb Flexor Tendon Reconstruction
!
• Pitfalls of FDS Transfer to Thumb – Intertendinous connections in palm – Tension adjustment is more difficult
Staged Reconstruction in the Thumb
• Criteria – Imperative thumb flexion – Prior failed surgery – Severely scarred bed – Destruction of pulley system
• Tendon – Can use: 1) free graft 2) FDS
Secondary Reconstruction in Zones 3,4,5
• Primary and Secondary repair has more favorable results
• Principals – Large longitudinal incisions – Resultant dysfunction usually a result of
concomitant injuries – Well-healed soft wounds prior to 2’nd stage – if no proximal migration à 1* repair
Secondary Reconstruction in Zones 3,4,5
• Interposition Graft – Common to have a 2-3 cm tendon gap – Graft = intact FDS or palmaris – 1)Criss-cross proximal tendon – 2)thread graft over suture – 3)criss-cross distal tendon – Tension critical – Neuroleptanesthesia – +/- pulley incision
Secondary Reconstruction in Zones 3,4,5
!
• FDS Transfer – adjacent intact FDS tendon – Pass deep to N-V bundle
Secondary Reconstruction in Zones 3,4,5
• End To Side FDP Juncture – Distal FDP à side of an adjacent FDP – Inter-weave – Most useful in forearm – Limited in Zone III by A1 pulley
Secondary Reconstruction in Zones 3,4,5
• Splint (dorsal, to fingertips) – Wrist : neutral – MCPJ :40* flexion – IPJ : neutral
• Early – Controlled AROM
• 2 weeks – AROM
• 4 weeks – DC splint – Blocking techniques – Resisted exercises started
Obtaining Tendon Grafts
• palm à finger – palmaris
• forearm à finger – plantaris – Long extensors of 3 middle toes – EIP – EDM
Palmaris Tendon
• Pro – Same field
• Con – 15-25% absent – Length
• Technique – Wrist incision – Transect tendon – Mobilize under direct vision x 6 cm – Circular tendon stripper – Usually can do with one incision – 2’nd incision if meet resistance
Plantaris as a Graft
• Pro: – longer
• Con: – 7-20% absent – Girth – Attachments
• Technique – 5 cm vertical incision Anterior Medial of Achilles – Blunt dissection under direct vision – Tendon stripper – Knee extended – Divide when plantaris m. fills stripper – Compartent syndrome reported
Long Toe Extensors• Can use 2-4 toe extensors • Pro
– Good diameter – Up to 3 grafts – Almost always present
• Con – May fuse distal to ankle
• Technique – Transverse incision over MTPJ – Isolate and divide extensor – Tendon stripper – Stop if encounter resistance – Additional incisions – Pull tendon into 2’nd wound – Early transection of graft – Can potentially obtain graft into leg
Extensor Proprius Tendons
• Each can potentially give 1 palmà tip graft • EIP
– Lies ulnar to EDC – Transverse incision over MCPJ – Transect 1 cm proximal to hood – 2’nd incision over musculo-tendinous junction
• EDM – Harvest similar to EIP – Usually has 2 tendon slips – Only harvest the ulnar 1/2
Toe Flexors
• Studies have shown fewer adhesions verse extra-synovial grafts
• Long flexors of the 2-5’th toes minimal morbidity
• Technique – Transverse incision at base of toe – 6 cm incision over NWB mid foot – Dissect individual tendon from coalescence – Mid-foot à toe = palm à tip – Multiple grafts possible
Recontruction of the Pulley System
• Barton showed that at minimaum A2, A4 • With complete destruction: minimal
reconstruction distal to MCPJ and PIPJ • One Stage Tendon Grafting
– All uninjured tendon is retained – Earlier work suggested wide debridement except critical
bands
• Pulley Reconstruction – Criteria for 2 stage procedure
Pulley Reconstruction Using Free Tendon Graft
• During 2 stage procedure excess tendon for grafting
• 1)encircle P1 and P2 – Pro : strong – Con : bulky
• 2)Tendon is woven into remnant pulley • 3)osteotomy • 4)FDS tail
Pulley Reconstruction Using Extensor Retinaculum
• Segment of retinaculum passed around phalanx
• Pro: – Undersurface glides well – Strong enough for early motion
• Con: – Difficult – Second incision
Recontruction of the Pulley System
• Karev described using the Volar Plate • Creates slits in the volar plate • Pro: almost as strong as annular band • Con: abnormal joint motion
Recontruction of the Pulley System
• Artificial materials – Gor-tex – Dacron – Silicone – Xenograft – Fascia lata – Nylon – Porcine collagen – Peritoneum !
• Limited experience 2* abundant 1* graft material
Recontruction of the Pulley System
• Technique • At proximal phalanx graft is placed deep to N-V
bundle and intrinsic system • Minimum of 2 wraps • 4 wraps better • At A4 2 wraps enough • 6-8 cm of graft for 1 wrap • Enter pulley system at cruciate pulley
– But blood supply to vincula enter here
• Post-op – External protective pulley ring x 2 weeks
Flexor Tendon Reconstruction in Children
• Primary repair better • Small structures à do not hold
sutures well • Post op rehab difficult • Conservative approach
– Delay graft until 7 y.o.
Technique of Flexor Tendon Reconstruction in Children
• Same as for adults except: – Do not place graft into P3 – Distally suture to FDP stump – If no stump; suture with non-absorbable thru drill holes
distal to epiphysis – Preferred graft:
• Palmaris • FDS of injured finger • Plantaris too thin
– Injured finger remains smaller
Complications of Flexor Tendon Reconstruction
• Adhesions – Most common complication – Occurs at anastamosis or anywhere epitendinous layer
disrupted – To reduce:
• Handling • Post op therapy
– Tenolysis • Salvage • Only done after plateau reached • Timing
Complications
• Mechanical Failure of Implant – rare
• Graft Rupture – Distal > proximal – 1* repair if recognized early – Salvage procedure: suture to P2
• Pulley disruption – Diagnosis: decrease in ROM with bowstringing – Rare – Continue PROM while plan repair
Complications – Cont’d• Quadregia • Decreased flexion of an adjacent nl finger 2* limitations on
FDP due to common musculotendinous origin • Flexion deformity • Occurs:
– Adhesions – FDP advancement too great – Short tendon graft – P3 ampand flexor sutured over tip of P2 – Amp and FDP adheres to proximal phalanx
• Treatment – Depends on cause
Tenolyse Lengthen Divide
Complications –Cont’d• Hyperextension of PIPJ
– Absence of FDS may cause – Difficult initiation of flexion – Can do tenodesis with 1 slip of the FDS
Complications –Cont’d• Lumbrical –Plus Finger
– If graft is too long – Excessive traction on lumbrical with flexion – Paradoxical IPJ extension – High risk if advocate wrapping lumbrical
around proximal anastamosis
Complications –Cont’d• Synovitis
– Present in 8-20% at Stage II – Increased crepitus, swelling, heat, thickened sheath – Culture negative – Expect increased adhesion formation – ? cause
• distal implant jnctn breakdown • Buckling of implant • talc
– Treatment • Decrease exercse program • Move up Stage II
Complications –Cont’d• Infection
– Disaster – Implant removal – Abx – Repeat stage one in 3-6 mo
Complications –Cont’d• Late Flexion Deformity
– Poor nutrition – Wound contracture – Splinting problems
• Treatment • Early
– Splint digits in extension between exercises and at night – Gentle stretching
• Attempt x 1 year
• Late • Capsular release • tenolysis
Complications –Cont’d• FDS Finger
– 1) DIPJ inadequate 2* intra-art damage or extensor damage
– 2)inadequate pulley –> Bowstring -> decrease excursion
– 3)rupture of distal insertion
Complications –Cont’d• Treatment of FDS finger • 1)
– Insert graft into P2 – Arthrodesis if joint unstable
• 2+3) – Same as 1) + pulley reconstruction