(ClinicalKey 2012.) Tang, Jin Bo - Tendon Surgery of The Hand (2012) - Opt

TENDON SURGERY
OF THE HAND
Editor-in-Chief
Jin Bo Tang, MD
Professor of Surgery, Founding Chair, Department of Hand Surgery,
Affiliated Hospital of Nantong University; Founding Chair, The Hand
Surgery Research Center, Nantong University, Nantong, Jiangsu, China
Editors
Peter C. Amadio, MD
Lloyd A. and Barbara A. Amundson Professor of Orthopedics, Consultant,
Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
Jean Claude Guimberteau, MD

Scientific Director, Aquitany Hand Institute, Pessac, France
James Chang, MD
Chief, Division of Plastic & Reconstructive Surgery, Professor of Surgery
(Plastic Surgery) and Orthopedic Surgery, Robert A. Chase Hand Center,
Stanford University Medical Center, Palo Alto, California, USA
Contributing Editors
David Elliot, MA, FRCS, BM, BCh

Hand Surgery Department, St Andrew’s Centre for Plastic Surgery, Broomfield
Hospital, Chelmsford, Essex, United Kingdom
Judy C. Colditz, OT/L, CHT, FAOTA
HandLab, Raleigh, North Carolina, USA
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
TENDON SURGERY OF THE HAND ISBN: 978-1-4377-2230-7
Copyright © 2012 by Saunders, an imprint of Elsevier Inc.

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Library of Congress Cataloging-in-Publication Data

Tendon surgery of the hand / editor-in-chief, Jin Bo Tang ; editors, Peter C. Amadio, Jean Claude
Guimberteau, James Chang ; contributing editors, David Elliot, Judy Colditz. – 1st ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4377-2230-7 (hardcover : alk. paper)
I. Tang, Jin Bo, 1963-
[DNLM: 1. Hand–surgery. 2. Tendons–surgery. WE 830]
617.5’75059–dc23
2012002534
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DEDICATION
I dedicate this book to my parents, Cheng Hua Tang and Xiou Feng
Zhao; my wife, Xiao Tian; and my daughter, Yu-Qing. Their support,
understanding, and sacrifice are the most fundamental to my past work
and completion of this book.
I also dedicate this book to my colleagues all past and present members of
the Research Center and the Department. In particular, it is dedicated to
an inspiring professor and tendon enthusiast: Seiichi Ishii, who mentored
me in my first work on tendons.
Jin Bo Tang, MD
This book is dedicated to my wife, Bari, for her continuous emotional

support and understanding; to my clinical colleagues at Mayo Clinic, for
their daily inspiration and for their generosity in accommodating the
many demands that the creation of this book has required; and to my
many mentors in tendon surgery over the years, especially James M.
Hunter, MD, whose high standards of tendon surgical skill and creativity
I can only hope to emulate.
Peter C. Amadio, MD
I would like to thank two illustrious colleagues, Harold Kleinert and

Claude Verdan, for influencing my way of thinking in tendon surgery
and for lighting the path for me to perform vascularized tendon grafts.
They never wavered in their support for my work, and they encouraged
me to continue investigations.
I wish to thank my family—James Sr., Lily, Anthony, Barbara, and

Cecilia Chang; Harriet Roeder; and Julia, Kathleen, and Cecilia Roeder
Chang—for their constant love and support. I also wish to honor all the
research fellows, residents, and hand fellows at Stanford who have worked
so tirelessly; and my surgical mentors, Vincent Hentz, Neil Jones, and Roy
Meals, who have taught me so much about the hand.
James Chang, MD
PREFACE
This book, Tendon Surgery of the Hand, is intended to investigators, surgeons, and therapists to author the text.
address the lack of a comprehensive and up-to-date text- These chapters are contributed by respected surgeons/
book on the basic science and clinical practice of tendon investigators from renowned centers and innovative sur-
surgery in the hand. geons who offer unique and insightful techniques.
Tendon surgery is one of the most important topics It is our essential goal to offer comprehensive cover-
in hand surgery; its importance to hand function and age of international perspectives and techniques cur-
its allure to hand surgeons are well-reflected in the vast rently used in tendon surgery of the hand. In particular,
number of investigations and publications devoted to the section on primary flexor tendon repair and reha-
this topic. Surprisingly, however, no comprehensive bilitation is a genuinely international collaboration,
book on tendon surgery of the hand (or of other parts highlighting methods and protocols of different units;
of the body) has been published in the last 25 years, it is sure to provide readers with an abundance of infor-
despite revolutionary changes in the treatment of tendon mation, allowing them to judiciously plan their own
injuries and disorders. The only landmark book on treatments based on the surgical and post-surgical care
tendons is Hunter’s Tendon Surgery in the Hand, from principles described in the chapters. Extensor tendon
1987. Therefore, we organized a group of international injuries are another topic with various treatment options.
experts in tendon surgery to produce a new volume. The Considering the variety of techniques and rehabilitation
idea of compiling such a textbook was initiated during protocols currently used, we have planned the related
a conference in Manchester, UK, in 2006 and was sub- surgical and rehabilitation chapters to reflect diverse
sequently reshaped, with updated media technology, by approaches to the injuries. Further, multiple therapy
Elsevier with publication of both print and online protocols were contributed from the leading hand units
versions. across the world; these protocols are published online
Since the mid-1980s, the clinical practice of tendon to provide the readers with rich and authoritative refer-
surgery has evolved considerably, and a great number of ences for deciding on treatment course for extensor
innovative techniques have emerged. They include a tendon injuries.
myriad of novel repair techniques, use of new suture We are greatly indebted to the contributors from 15
materials, novel tendon sheath and pulley treatments, countries spanning four continents; their high quality
vascularized tendon grafts, and the development of contributions are the cornerstones of this book. Notably,
various postoperative rehabilitation methods. With we should give our earnest gratitude to Dr. David Elliot
regard to the basic science, a wealth of new knowledge and Ms. Judy Colditz, our guest editors. Not only are
has been accumulated. Our knowledge of tendon both eminent educators with vast experience on tendon
biology and biomechanics has increased greatly, and a problems—as a surgeon and a therapist, respectively—
number of new research fields—such as gene therapy, but they are also keen editors who have tirelessly devoted
tissue engineering, stem cell delivery, and gene silenc- their effort to this book. Dr. Elliot contributed his own
ing—have emerged. Advancements in updated clinical crystallized experience in seven chapters of this book
techniques and cutting-edge technologies in the basic and also edited a portion of the primary and secondary
science of tendon surgery are comprehensively summa- repair chapters. Ms. Colditz coordinated and helped edit
rized in this book. the chapters relating to rehabilitation. Furthermore, we
This book contains a total of 46 chapters (41 print greatly appreciate the surgeons and therapists who con-
and online chapters and 5 web-only chapters), orga- tributed therapy protocols in the online appendix and
nized in five sections: basic science, primary flexor video clips to enhance the contents of this book.
tendon surgery, secondary flexor tendon surgery, exten- Finally, we feel obliged to express our appreciation to
sor tendon repair and reconstruction, rehabilitation the Elsevier staff and editors, especially Dan Pepper,
of tendon surgery, and the future of tendon surgery. acquisition editor; Don Scholz, senior content strategist;
We have aimed to include a worldwide selection of Mary Beth Murphy, developmental editor; Heather
iv
Preface v
Krehling, content development manager; and Brandilyn master key concepts and techniques of tendon surgery
Tidwell, project manager. Without their advice on of the hand and aids in treatment planning of the
content and careful copyediting, it would not have been often worrisome problems relating to the tendon of
possible to accomplish this project. We also give our the hand.
great appreciation to the Elsevier art team for providing
superb color illustrations for this book, helping us Jin Bo Tang, MD
present our readers with a complex surgical topic in an Peter C. Amadio, MD
easily readable way. Jean Claude Guimberteau, MD
We hope that this textbook helps practitioners, James Chang, MD
fellows, residents, and medical students understand or
CONTRIBUTORS
Roberto Adani, MD Philip E. Blazar, MD

Chief, Department of Hand Surgery, Azienda Ospedaliera Assistant Professor of Orthopaedic Surgery, Department
Universitaria Integrata Verona, Verona, Italy of Orthopaedic Surgery, Brigham and Women’s Hospital,
Harvard Medical School, Boston, Massachusetts
Peter C. Amadio, MD
Lloyd A. and Barbara A. Amundson Professor of Lance M. Brunton, MD
Orthopedics, Consultant, Department of Orthopedic Assistant Professor of Orthopaedic Surgery, Department
Surgery, Mayo Clinic, Rochester, Minnesota of Orthopaedic Surgery, University of Pittsburgh Medical
Center, Pittsburgh, Pennsylvania
Kai Nan An, PhD
Professor of Biomedical Engineering, Department of Robert E. Bunata, MD
Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota Assistant Professor, Department of Orthopaedic Surgery,
Bone and Joint Research Center, University of North Texas
Rohit Arora, MD Health Science Center, John Peter Smith Hospital, Fort
Associate Professor of Trauma Surgery, Department of Worth, Texas
Trauma Surgery and Sports Medicine, Medical University
Innsbruck, Innsbruck, Austria Yi Cao, MD
Fellow, The Hand Surgery Research Center, Nantong
Morad Askari, MD University, Nantong, Jiangsu, China
Assistant Professor of Surgery, DeWitt Daughtry Family
Department of Surgery, University of Miami, Miami, Francesco Catalano, MD
Florida Associate Professor, Hand Surgery Division, Department
of Orthopedics, Gemelli Hospital of Rome, Catholic
Joseph Bakhach, MD University, Rome, Italy
Clinical Assistant Professor of Surgery, Plastic and
Reconstructive Surgery Department, Hand and James Chang, MD
Microsurgery Department, American University of Chief, Division of Plastic & Reconstructive Surgery,
Beirut Medical Center, Beirut, Lebanon Professor of Surgery (Plastic Surgery) and Orthopedic
Surgery, Robert A. Chase Hand Center, Stanford
Pierre-Yves Barthel, MD University Medical Center, Palo Alto, California
Department of Hand and Reconstructive Surgery,
Emile Galle Surgical Center, CHU Nancy, Nancy, Chuan Hao Chen, PhD
France Professor, Department of Anatomy, Bengbu Medical
College, Bengbu, Anhui, China
Alexandros E. Beris, MD
Professor in Orthopaedics, Department of Orthopaedic A. Bobby Chhabra, MD
Surgery, University of Ioannina School of Medicine, Charles J. Frankel Professor and Vice Chair, Department
Ioannina, Greece of Orthopaedic Surgery, University of Virginia Health
System, Charlottesville, Virginia
Nada Berry, MD
Assistant Professor, Department of Plastic Surgery,
Southern Illinois University, Springfield, Illinois
vi
Contributors vii
Alphonsus K.S. Chong, MBBS, MRCS(Ed), Robert R.L. Gray, MD

MMed(Orth), FAMS Assistant Professor, Department of Orthopaedic Surgery,
Consultant Hand Surgeon, Assistant Professor, Miller School of Medicine, University of Miami, Miami,
Department of Orthopaedic Surgery, Yong Loo Lin School Florida
of Medicine, National University of Singapore, National
University Hospital, Singapore Heather Griffiths, mscot(regnb), CHT
Certified Hand Therapist, Horizon Health Network,
Sean P. Clancy, OTR/L, CHT Moncton, New Brunswick, Canada
Program Coordinator, Hand Therapy, University of
Chicago Medicine, Chicago, Illinois Jean Claude Guimberteau, MD
Plastic, Hand Surgeon, Aquitany Hand Institute, Pessac
Judy C. Colditz, OT/L, CHT, FAOTA France
HandLab, Raleigh, North Carolina
Hiroyuki Kato, MD, PhD
Monina Copuaco, OTC, CHT Professor and Chairman, Department of Orthopaedic
Hand Therapist, Robert A. Chase Hand Center, Stanford Surgery, Shinshu University School of Medicine,
University Medical Center, Palo Alto, California Matsumoto, Japan
Massimo Corain, MD Ioannis Kostas-Agnantis, MD

Department of Hand Surgery, Azienda Ospedaliera Department of Orthopaedic Surgery, University of
Universitaria Integrata Verona, Verona, Italy Ioannina School of Medicine, Ioannina, Greece
Brandon E. Earp, MD Armin Kraus, MD

Department of Orthopedic Surgery, Brigham and Division of Plastic and Reconstructive Surgery, Stanford
Women’s Hospital, Boston, Massachusetts University Medical Center, Palo Alto, California
David Elliot, MA, FRCS, BM, BCh Richard D. Lawson, MBBS, FRACS
Hand Surgery Department, St Andrew’s Centre for Plastic Director of Hand Surgery Research, Department of Hand
Surgery, Broomfield Hospital, Chelmsford, Essex, United Surgery and Peripheral Nerve Surgery, Royal North Shore
Kingdom Hospital, University of Sydney, Sydney, Australia
Andrew E. Farber, DO Fraser J. Leversedge, MD

South Island Orthopaedic Group, Cedarhurst, New York Assistant Professor, Co-Director, Duke Hand and Upper
Extremity Surgery Fellowship, Department of Orthopaedic
Felicity G.L. Fishman, MD Surgery, Duke University, Durham, North Carolina
Department of Orthopaedic Surgery, Duke University,
Durham, North Carolina Beng-Hai Lim, MD
Center for Hand and Reconstructive Microsurgery
Kristen E. Fleager, MD (CHARMS), Singapore
Department of Orthopaedic Surgery, Stanford University
Hospital and Clinics, Stanford, California Paul Y. Liu, MD
Clinical Professor and Chair, Department of Plastic
Markus Gabl, MD Surgery, Brown University Alpert Medical School,
Department of Trauma Surgery and Sports Medicine, Providence, Rhode Island
Medical University Innsbruck, Innsbruck, Austria
Marios G. Lykissas, MD
Leesa M. Galatz, MD Division of Orthopaedics, Cincinnati Children’s Hospital
Associate Professor, Shoulder and Elbow Service, Medical Center, Cincinnati, Ohio
Washington University Orthopedics, Barnes-Jewish
Hospital, St. Louis, Missouri Mollie O Manley, MD, MS
Department of Orthopedics, University of Pittsburgh
Emily Grauel, MS Medical Center, Pittsburgh, Pennsylvania
Virginia Commonwealth University School of Medicine,
Richmond, Virginia
viii Contributors
Michel Mansat, MD Mark A. Rider, MBChB, FRCS, FRACS

Professor of Orthopedics and Traumatology, Department Department of Hand Surgery, SW Sydney Regional Hand
of Orthopaedics and Traumatology, Toulouse University Institute, Sydney, Australia
Hospital, Toulouse, France
Lorenzo Rocchi, MD
Pierre Mansat, MD, PhD Hand Surgery Division, Department of Orthopedics,
Professor of Orthopedics and Traumatology, Department Gemelli Hospital of Rome, Catholic University, Rome, Italy
of Orthopaedics and Traumatology, Toulouse University
Hospital, Toulouse, France Mario Igor Rossello, MD
Professor, Chief of Hand Surgery, Ospedale San Paolo,
Renzo Mantero, MD Savona, Italy
Professor, Former Chief of Hand Surgery (Retired),
Ospedale San Paolo, Savona, Italy Serge Rouzaud
Physiotherapist, Institut Aquitain de la Main, Bordeaux,
Daniel P. Mass, MD France
Professor of Surgery, Department of Orthopaedic Surgery,
University of Chicago, Chicago, Illinois Michel Saint-Cyr, MD, FRCS(C)
Associate Professor, Department of Plastic Surgery,
Antonio Merolli, MD, FBSE University of Texas Southwestern Medical Center at
Assistant Professor, Department of Orthopedics, Dallas, Dallas, Texas
Universita Cattolica del Sacro Cuore, Rome, Italy
Robert Savage, MB, FRCS, FRCS Ed Orth, MS
Arash Momeni, MD Trauma and Orthopaedic Department, Royal Gwent
Division of Plastic and Reconstructive Surgery, Stanford Hospital, Newport, Gwent, Great Britain
University Medical Center, Palo Alto, California
Ton A. R. Schreuders, PT, PhD
Steven L. Moran, MD Rehabilitation Medicine, Erasmus University Medical
Professor and Chair of Plastic Surgery, Professor of Center, Rotterdam, the Netherlands
Orthopedics, Division of Hand Surgery, Mayo Clinic,
Rochester, Minnesota Ombretta Spingardi, MD
Hand Surgery Department, Ospendale San Paolo,
Nash H. Naam, MD, FACS Savona, Italy
Clinical Professor, Plastic and Reconstructive Surgery,
Southern Illinois University and Southern Illinois Hand Yu-Long Sun, PhD
Center, Effingham, Illinois Assistant Professor of Biomedical Engineering,
Department of Orthopedic Surgery, Mayo Clinic,
Lori Niemerg, OTR/L, CHT Rochester, Minnesota
Certified Hand Therapist, Department of Working Hands,
Southern Illinois Hand Center, Effingham, Illinois Jun Tan, MD
Associate Professor of Surgery, Department of Hand
Fiona H. Peck, MCSP Surgery, Affiliated Hospital of Nantong University,
Burns and Plastic Surgery Department, Wythenshawe Nantong, Jiangsu, China
Hospital, Manchester, Great Britain
Jin Bo Tang, MD
Yeong-Pin Peng, FRCS Professor of Surgery, Founding Chair, Department of
Department of Hand and Reconstructive Microsurgery, Hand Surgery, Affiliated Hospital of Nantong University;
National University Hospital, Singapore Founding Chair, The Hand Surgery Research Center,
Nantong University, Nantong, Jiangsu, China
Karen M. Pettengill, MS, OTR/L, CHT
Clinical Coordinator, NovaCare Hand and Upper Luigi Tarallo, MD
Extremity Rehabilitation, Springfield, Massachusetts Department of Orthopaedic Surgery, Azienda Ospedaliera
Universitaria Policlinico Modena, Modena, Italy
Brian C. Pridgen, BS
Department of Plastic and Reconstructive Surgery,
Stanford University Medical Center, Palo Alto, California
Contributors ix
Shian Chao Tay, PhD Esther Vögelin, MD, PhD

Associate Professor, Department of Orthopaedic Surgery, Chief and Codirector, Department of Orthopaedic, Plastic,
Associate Professor, Department of Biomedical and Hand Surgery, Division of Hand and Peripheral
Engineering, Washington University, St. Louis, Missouri Nerve Surgery, Inselspital, University of Bern, Bern,
Switzerland
Stavros Thomopoulos, PhD
Associate Professor, Department of Orthopaedic Surgery, Xiao Tian Wang, MD
Washington University, St. Louis, Missouri Assistant Professor, Department of Surgery, Brown
University Alpert Medical School, Providence, Rhode
Michael A. Tonkin, MD, FRCS Ed Orth, FRACS Island
Professor of Hand Surgery, Head of Department,
Department of Hand Surgery and Peripheral Nerve Ya Fang Wu, MD
Surgery, Royal North Shore Hospital, Sydney Medical Lecturer, The Hand Surgery Research Center, Nantong
School, University of Sydney, Sydney, Australia University, Nantong, Jiangsu, China
Ghislaine Traber-Hoffmann, MD Ren Guo Xie, MD

Department of Ophthalmology, University Hospital Associate Professor of Surgery, Vice Chair, Department of
Zurich, Zurich, Switzerland Hand Surgery, Affiliated Hospital of Nantong University,
Nantong, Jiangsu, China
Shigeharu Uchiyama, MD
Associate Professor, Department of Orthopaedic Surgery, Hiroshi Yamazaki, MD, PhD
Shinshu University School of Medicine, Matsumoto, Japan Chief, Department of Orthopaedic Surgery, Aizawa
Hospital, Matsumoto, Japan
Véronique van der Zypen, BSC PT
Certified Hand Therapist, Department of Orthopaedic, Jeffrey Yao, MD
Plastic and Hand Surgery, Division of Hand and Assistant Professor, Department of Orthopaedic Surgery,
Peripheral Nerve Surgery, Inselspital, University of Bern, Stanford University Medical Center, Palo Alto, California
Bern, Switzerland
Chunfeng Zhao, MD
Robert J. van Kampen, MD Associate Professor of Orthopedics and Biomedical
Department of Plastic, Reconstructive and Hand Surgery, Engineering, Department of Orthopedic Surgery, Mayo
University Medical Centre, Utrecht, the Netherlands Clinic, Rochester, Minnesota
Gwendolyn Van Strien, LPT, MSc

Director, Hand Rehabilitation Consultancy, Den Haag,
The Netherlands, Director, Hand Therapy Unit, Lange
Land Hospital, Zoetermeer, the Netherlands
CHAPTER
1
ANATOMY OF THE TENDON
SYSTEMS IN THE HAND
Robert J. van Kampen, MD, and Peter C. Amadio, MD
OUTLINE reinforced by the pisiform-hamate ligament. On the

radial side, the retinaculum firmly inserts into the volar
This chapter describes the anatomy of the flexor and ridge of the trapezium (trapezial tuberosity) and the
extensor apparatus in the hand and wrist, supple- tubercle of the scaphoid. Occasionally an insertion into
mented with relevant clinical and biomechanical the styloid process of the radius can be seen.1,2
features. It emphasizes the key importance of the reti- Controversial terminology surrounds this strong,
nacular structures of the wrist and fingers and reviews fibrous band that crosses the volar side of the carpus.
both normal anatomy and common variations of the According to the Terminologia Anatomica, the term flexor
flexor and extensor tendons in the hand. Special atten- retinaculum carpi should be used. However, in textbooks,
tion is given to the vincula tendinea and pulleys sup- the terms flexor retinaculum, transverse carpal ligament and
porting the flexor tendons in the digital flexor anterior/volar annular ligament are used for the same
sheaths—in particular, the structure and biomechanics structure.3
of the pulley system. The key role of the A2 and A4 In hand surgery, it is often preferred to distinguish
pulleys is emphasized. Finally, a closer look is taken between the different parts of the flexor retinaculum.
at the tendons and bands contributing to the extensor Stecco et al3 investigated its histological and anatomical
mechanism, and their action on the metacarpophalan- features. Continuous with the antebrachial fascia, a
geal and interphalangeal joints is discussed. fibrous reinforcement was identified at the volar side of
the wrist. After removal of this layer, another fibrous
The hand, with the carpus, is the most complex collec- layer was found, with strong lamina and histological
tion of interconnected joints in the human body, and a similarities to those of a ligament. According to Stecco’s
large assembly of tendons carries out its extensive range group,3 “ligament derives from Latin ligare (to bind) and
of motion. Distinctive groups of muscles execute the means a sheet or band of tough fibrous tissue connecting
actions of these tendons on the hand. Together with bones.” They stated that “the role of the pulley for the
numerous aiding structures, the tendons form an inge- tendons of the flexor muscles is assumed above all” for
nious biomechanical system that gave humans the this deeper layer covering the carpal tunnel, and there-
ability to perform complicated tasks and develop dex- fore the term transverse carpal ligament was suggested to
terous professions that require sophisticated hand and be the most appropriate.
finger movement, like hand surgery. Treatment of hand In addition to the thickened continuation of the
disorders is similarly delicate and complex; therefore, a antebrachial fascia and the transverse carpal ligament,
thorough understanding is essential to provide adequate Cobb et al4 described a third, more distal segment com-
treatment. posed of an aponeurosis between the thenar and hypo-
thenar muscles. Based on their anatomical findings,
FLEXOR RETINACULUM
they advocate a more extensive release when dividing
On the volar aspect of the wrist, the carpal bones form the carpal ligament.
a deep excavation over which the flexor retinaculum Tanabe and Okutsu5 endoscopically released the
arches, creating the carpal tunnel. The tendons of the flexor retinaculum in management of carpal tunnel syn-
flexor digitorum superficialis (FDS) and profundus drome and found that the mean distance between the
(FDP) and the flexor pollicis longus (FPL) pass through ends of the retinaculum increased from 1.3 mm to 6.6
this tunnel together with the median nerve. mm if the distal fibers were also divided. They therefore
This retinaculum inserts on the ulnar side into the concluded that sectioning of the distal fibers is essential
pisiform bone and the hook of the hamate and is for endoscopic carpal tunnel release.
3
4 Section 1: Basic Science
different populations all over the world.9 In humans,

EXTENSOR RETINACULUM
this tendon is seen as rudimentary, and for that reason,
On the dorsal side of the wrist, a thickened part of the and its easy accessibility, the palmaris longus is often
deep antebrachial fascia is found, holding the tendons used as a tendon graft.
of the extensor muscles in place. It works in continuity To the radial side of the median nerve, the FPL tendon
with the volar carpal ligament and for the previous can be found; to the ulnar side, the superficial flexor
stated reasons the term dorsal carpal ligament or posterior tendons. When coursing through the carpal tunnel the
annular ligament could also be suggested. However, the superficial flexor tendons are arranged in pairs, the
term extensor retinaculum is most commonly used. tendons to the middle and ring finger form the superfi-
As studied by Taleisnik et al,6 the deep antebrachial cial pair, and the little and index finger tendons form
fascia begins to thicken proximal to the radiocarpal the deep pair. Dorsal to the superficial tendons lie the
joint and becomes the dorsal annular ligament, a compo- flexor profundus tendons.2,8
nent of the extensor retinaculum of the wrist. Distally, In the case that the palmaris longus tendon is absent,
this supratendinous layer is continuous with the pretendi- the tendon of the flexor superficialis indicis can some-
nous fascia of the hand. On the ulnar side, it inserts in times be found between the superficial flexor tendon to
three distinct places: proximal around the flexor carpi the middle finger and the median nerve. In other varia-
ulnaris tendon, the middle part into the triquetrum and tions, the palmaris longus tendon can separate into two
pisiform bone, and distally onto the fascia of the abduc- or three tendons, the muscle can be doubled, the muscle
tor digiti quinti and base of the fifth metacarpal. can be reversed or inverted, and partial or complete
The retinaculum attaches to ridges on the radius, insertion in the antebrachial fascia can be seen. Addi-
forming septa that divide the space below the extensor tionally, insertion into the pisiform bone, scaphoid,
retinaculum in six compartments through which the flexor carpi ulnaris tendon, and muscles of the thenar
extensor tendons pass. The six compartments are further has been observed.8
described in the section about extensor tendons. Accessory slips for the FDS and FDP are frequently
Within the supratendinous layer, at the floor of the observed, especially to the index finger. Slips arise from
fourth and fifth compartment, lies the infratendinous the ulnar tuberosity to the superficialis tendon of the
layer, from which circular fibers form a tube around the index and middle finger, and from the annular ligament
tendons within the compartments. In the sixth compart- to the superficialis tendon of the little finger. The super-
ment, a duplication of the infratendinous layer forms a ficialis tendon to the little and index finger can be absent
tube around the extensor carpi ulnaris (ECU) tendon and the index finger’s deep flexor tendon can divide into
from the ulnar styloid to the triquetrum. This subsheath two tendons or have a shared origin with the FPL.8
stabilizes the tendon along the groove in the distal ulna The flexor carpi radialis (FCR) tendon courses through
and contributes to the stability of the distal radioulnar its own synovial sheath that forms a narrow osteofi-
joint. Proximally, longitudinal fibers form the linea brous tunnel when passing the trapezium. The radial
jugata that reinforces the tendon to prevent subluxation side of the tunnel is formed by the body of the trape-
during full supination. The ECU subsheath is frequently zium and the volar side by the trapezial tuberosity. On
injured, typically in young athletes who play racket or the ulnar side, the tunnel is separated from the carpal
stick sports, which can result in recurrent subluxation of tunnel by a thick septum. Distally, the FPL tendon pivots
the ECU tendon.7 around this septum. At the floor of the tunnel, the
tendon sheath lies in contact with the volar capsule of
FLEXOR TENDONS IN THE HAND
the scaphotrapeziotrapezoid (STT) joint. The narrow
The tendons in the wrist have a relatively constant tunnel induces a higher risk of primary stenosing teno-
arrangement with the median nerve. This arrangement synovitis; however, because of the close relationship
varies mainly when muscle or tendon anomalies are with surrounding structures, tenosynovitis can also
present. It is important to keep these variations in mind, occur secondary to traumatic or degenerative changes.
because it can be confusing even for the experienced Tenosynovitis of the FCR tendon is not an uncommon
surgeon. Usually, the median nerve can be found directly finding in arthritis of the STT joint, which can cause
under the tendon of the palmaris longus. Sometimes, additional pain to the baseline osteoarthritic pain.10,11
the nerve lies more superficial, next to the palmaris The FCR tendon is also suggested to play a role in
longus tendon. The median nerve is also frequently stabilizing the scapholunate joint through its close rela-
observed to split in the forearm.8 tionship between the FCR tendon sheath and the liga-
The palmaris longus tendon lies completely enclosed ments attached to the tuberosity of the scaphoid. The
in the deep fascia of the forearm between the superficial tendon was thought to use the distal pole of the scaph-
veins and cutaneous nerves. The presence of this tendon oid as a pulley to increase its mechanical advantage and
is highly variable, as its absence has been reported from prevent the scaphoid from rotating into flexion. Unlike
0.6% to 63.9% (either bilateral or unilateral) among in previous hypotheses, Salvà-Coll et al12 found that
Chapter 1: Anatomy of the Tendon Systems in the Hand 5
loading the FCR tendon rotated the scaphoid in flexion

and supination, while rotating the triquetrum in flexion SM SF PT SM SF SSCT
and pronation. These opposite rotations are attributed
to relax the dorsal scapholunate ligament. Tendon
The FCR tendon inserts into the base of the second
metacarpal and gives off a strong, tendinous slip to the Intrasynovial Extrasynovial ?
third metacarpal. Frequently a small slip to the trapezial Tendon Tendon
tuberosity can be seen. Other variations are insertions Zone 2 Zone 3 Zone 4
in both the trapezium and scaphoid and in the base Figure 1-1 Nutritional microenvironment of the flexor
of the second, third, and fourth metacarpals. The FCR tendon. In zone 2 the tendons are intrasynovial within the
muscle can even be absent. Insertion in the transverse digital flexor sheath. Zone 3, in the palm of the hand, is
carpal ligament can also be seen and may cause confu- extrasynovial tendon. In the carpal tunnel, zone 4, the
sion with the palmaris longus tendon.8 tendon is surrounded by a hybrid of both intrasynovial and
The flexor carpi ulnaris (FCU) encloses the pisiform extrasynovial tissue. SM, Synovial membrane; SF, synovial
bone, which can be seen as a sesamoid bone for this fluid; PT, paratenon; SSCT, subsynovial connective tissue.
tendon. The FCU attaches to the base of the fifth meta-
carpal and hamate, via the pisohamate and pisometa-
carpal ligaments. The pisohamate ligament creates an connected. In case of an infection within the sheath, the
additional tunnel, Guyon’s canal, between the hook of communication between the ulnar and radial bursa can
the hamate and pisiform bone through which the ulnar result in the “horseshoe abscess.”
artery and nerve pass. Occasionally, the FCU tendon In the carpal tunnel, the subsynovial connective
doubles before inserting in the pisiform bone. The FCU tissue (SSCT) connects the flexor tendons with the syno-
can also merge with the flexor superficialis or profundus vial membrane of the ulnar bursa. It consists of fibrous
tendon.8 bundles parallel to the tendons, which in turn are inter-
The FPL tendon passes through its own osseo- connected by smaller microfibrillar fibers. By acting as
aponeurotic canal and inserts at the distal phalanx of a sliding unit, the SSCT reduces friction and maintains
the thumb. Sometimes an additional tendon to the the integrity of the vascularity around the tendons. Non-
index finger is found. The FPL tendon can be absent, in inflammatory fibrosis of the SSCT is the most common
combination with a significant smaller thumb. Another histological finding in carpal tunnel syndrome, which
variation is splitting of the tendon into two or three slips suggests injury to the SSCT to be an important etiologic
that insert into the scaphoid or flexor retinaculum.8 factor14 (Figures 1-1 to 1-4).
Structure of the Digital Flexor Sheath

FLEXOR TENDON SHEATHS
The tendons of the FDP and FDS lie deep in the palm
Structure of the Sheath at Wrist and Palm of the hand, beneath the superficial palmar arch and the
In the wrist, synovial sheaths allow the flexor tendons superficial branches of the median and ulnar nerve.
to glide through the carpal tunnel. The sheaths begin There, the tendons are surrounded by several layers of
approximately 2.5 cm proximal to the transverse carpal loose connective tissue. Vessels emerging from the
ligament and extend distally to the neck of the metacar- palmar arches traverse through this tissue toward the
pals. In the fingers, the flexor tendons are also sur- tendons, forming the paratenon.
rounded by sheaths. A considerable level of variation in In a histological study of the flexor tendon sheath by
communicating patterns between these sheaths and the Cohen and Kaplan,15 two vascular systems are observed
digital flexor sheaths is observed.13 to become organized in the paratenon; one adjacent to
As reported by Fussey et al,13 the most common the tendons, the other more peripheral. The develop-
pattern shows one common flexor tendon sheath or ulnar ment of a “synovial-lined cleft” between these systems
bursa surrounding the tendons of the FDS and FDP. A creates a separation into a visceral and a parietal
second sheath, forming the radial bursa, envelopes the synovium.
FPL tendon. The parietal layer lines the wall of the tunnel through
In most cases the little finger flexor sheath works in which the tendon glides. As the layer continues distally,
continuity with the tendons along the phalanges. Like- the layer was found to be uninterrupted and reinforced
wise, the FPL tendon sheath accompanies the tendon externally by dense bands of collagen. By maintaining
along the thumb as far as its insertion.13 the tendons close to the bone and joint surface, these
Occasionally communications between the common bands act as a system of pulleys, facilitating efficient
flexor tendon sheath and the second, third, and fourth finger movement. Between these reinforcements, the
digital tendon sheaths are observed in the palm. Fur- thickness of the parietal synovium is greatest and is
thermore, the ulnar and radial bursa can be found to be called the membranous part of the tendon sheath.
I
I Flexor
I retinaculum
Parietal synovium
I Visceral synovium
II Subsynovial
connective tissue
I
Tendon
II
III
III Figure 1-3 Sliding unit in the carpal tunnel region has
both structures (i.e., paratenon and synovial sliding
mechanism). All layers from the flexor retinaculum to the
IV IV tendon are shown. The tendons in the carpal canal have a
subsynovial connective tissue and a bursa, containing
synovial fluid between the parietal and visceral synovium
(hematoxylin-eosin; original magnification, ×400). (From
Ettema AM, Amadio PC, Zhao C, et al: Changes in the
V
functional structure of the tenosynovium in idiopathic carpal
tunnel syndrome: a scanning electron microscope study,
Plast Reconstr Surg 118:1413-1422, 2006.)
Figure 1-2 Flexor tendon zones. The zones are numbered
from distal to proximal. Zone 1 contains a single tendon, the
flexor digitorum profundus tendon. Zone 2 is the critical area
of the digital flexor sheath. It contains both the profundus
and superficialis tendons, and the area where the profundus Several variations in the vincula tendinea have been
tendon penetrates the superficialis at the chiasm of Camper. observed. Ochiai et al16 studied the distribution patterns
In the extrasynovial zone 3 the lumbrical muscles arise. Zone of the vincula in the fingers of 35 human hands. Their
4, the carpal tunnel, contains mixed intra/extrasynovial study showed that four transverse communicating
tissue. Zone 5 is also extrasynovial, without the lumbrical branches arising from the digital arteries enter the flexor
muscles. In the thumb, although we have marked zones 1 to tendon sheath through openings in the pulleys, travel-
5, one may consider that zones 2 and 3 do not exist, ing toward the vincula. The sites of entry are at the base
because there is only a single tendon, and no lumbrical.
of the proximal phalanx, the neck of the proximal
phalanx, the base of the middle phalanx, and the neck
of the middle phalanx (Figure 1-5).
Two kinds of vincula were found within each digital
The visceral layer or epitenon adheres to the tendon, flexor tendon sheath: vessels arising from the transverse
creating a synovial space between the two layers. It was communicating arteries protrude through the meso-
found to be supported by a thin cover of laminated col- tenon forming short, triangle-shaped folds (vincula
lagen. All structures entering the tendons are surrounded brevia) and long, slender vincula longa (Figure 1-6).
by epitenon. In the opposite direction along these struc- The vincula brevia were found consistently in all dis-
tures, the visceral layer works in continuity with the sected fingers. The vinculum brevis superficialis (VBS)
parietal layer. The synovial layers extend distally to the arises from the volar plate of the proximal interphalan-
insertion of the FDP tendon, where they become geal (PIP) joint and attaches to the decussation of the
confluent. superficialis tendon. The thin, triangle-shaped meso-
tenon of the vinculum brevis profundus (VBP) arises at the
VINCULA TENDINEA
distal third of the middle phalanx and attaches near the
On the palmar osseous side of the tunnel, vessels pro- insertion of the profundus tendon.
trude through the synovial layers, forming mesenterial In contrast, several variations in the long vincula can
folds or mesotenon. These vascular bands connect the be found. Ochiai et al16 found the vinculum longum
dorsal side of the flexor tendons with the palmar side superficialis (VLS) to have a radial, ulnar, or two-sided
of the flexor sheath. In consideration of their tendinous origin at the base of the proximal phalanx. Absence of
structure, these bands are named vincula tendinea (vin- the VLS was also observed, mainly in the middle and
culum derives from Latin and means “bond or link”). ring fingers. They also mentioned that the vascularity of
the profundus tendon is less in adults than in fetuses.

These findings can be a possible explanation for the
higher incidence of triggering in the middle and ring
fingers and in older patients.
For the vinculum longum profundus (VLP), Ochiai
et al16 found five types, named distal, middle, mixed,
A5
Distal C3
transverse
digital artery A4
Intermediate
C2
transverse
digital artery A3
Proximal C1
transverse
digital artery
A2
Branch to
vincular longum
superficialis (VLS)
Figure 1-4 Top, Loose vertical fibers join adjacent layers

in the subsynovial connective tissue (scanning electron A1
microscopy; original magnification, ×1100). Bottom, The
loose vertical fibers between adjacent layers are stretched
during flexor tendon movements (scanning electron Common
microscopy; original magnification, ×1000). (From Ettema digital artery
AM, Amadio PC, Zhao C, et al: Changes in the functional
structure of the tenosynovium in idiopathic carpal tunnel
syndrome: a scanning electron microscope study, Plast Figure 1-5 The tendon sheath contains the annular
Reconstr Surg 118:1413-1422, 2006.) pulleys A1 to A5 and the cruciate pulleys C1 to C3.
Flexor digitorum Vinculum longum Vinculum brevis

profundus profundus (VLP) profundus (VBP)
Dorsal
Flexor digitorum Vinculum Vinculum

superficialis longum brevis
superficialis superficialis
(VLS) (VBS)
Figure 1-6 The blood vessels enter the flexor tendons through the vincular system.
proximal, and absent to refer to the site of insertion at pulleys (termed annular proximal and annular distal)
the profundus tendon. and two cruciate ligaments (cruciate proximal and
The distal type was found to be very rare; the middle distal). The first annular proximal (AP1) pulley origi-
type was most commonly found and travels through the nates just proximal to the metacarpophalangeal (MCP)
decussation. The proximal type arises between the two joint and ends at the middle of the proximal phalanx.
slips of the superficialis tendon and passes through the There it is overlapped by the proximal cruciate ligament,
bifurcation. The mixed type is similar to the proximal, which extends over the distal third of the same phalanx.
but no VLS is found. The second annular proximal (AP2) pulley is positioned
The index finger most often had a radial or two-sided at the PIP joint; the third annular distal (AD1) pulley is
VLS, and the middle type of VLP. In the long finger, no over the proximal third of the middle phalanx, where it
predominant type was found. Most long fingers had the was overlapped by the distal cruciate ligament. At the
middle type of VLP combined with the radial type of distal interphalangeal (DIP) joint is the second annular
VLS or a middle and proximal type of VLP in combina- distal (AD2) pulley; the third annular distal (AD3)
tion with two-sided VLP. pulley is at the base of the distal phalanx.
In the ring finger, the VLS was most commonly A more commonly accepted description was given by
absent, often in combination with mixed type VLP or Doyle.20 After dissecting 80 digits, Doyle concluded
both mixed and middle types. The predominant type there are five annular (termed A1 to A5, from proximal
for the little finger is the middle type of VLP and a broad to distal) and three cruciate (C1 to C3, from proximal
ulnar-sided mesotenon forming the VLS. to distal) pulleys (see Figure 1-5). The A2 pulley is the
The area in which the vincula can be found is often largest pulley in the fingers, approximately 1.5 to 1.7 cm
referred to as “no-man’s land” as surgical treatment of long, which are located in the proximal part of the
flexor injuries often have poor outcome (see Figure proximal phalanx. This pulley has a distinct semilunar
1-2). One possible explanation for these poor results and thick leading edge and the annular fibers are over-
could be the disruption of the vincula, and thus blood laid with circular fibers. The second largest annular
supply to the tendons. Amadio et al17 investigated the pulleys are A4 pulley at the middle of the middle
relationship of the vincular status on final total active phalanx and A1 pulley (at the level of the MCP joint);
motion after primary tendon repair and early mobiliza- the A3 pulley (at the PIP joint level) is rather narrow,
tion. This study showed a statistically significant decrease about 3 mm in length. The A5 pulley at the DIP joint
in total active motion when the vincular system was level is very small and sometimes indistinguishable.
injured. Disruption (or absence) of vincula could there- Strauch’s most distal annular structure (AD3), a
fore be an important prognostic factor of the outcome pulley distal to the DIP joint, is not described by other
of flexor tendon repair. investigators, including Doyle.20 The second and fourth
In the thumb, the vinculum breve forms a continuous annular pulleys were found to be always present—A3
band with the FPL tendon proximal to its insertion. After and A5, respectively—in 80% and 90% of the speci-
complete laceration of the FPL tendon at the interpha- mens. The cruciate pulleys sometimes are single oblique
langeal joint, the intact vinculum produces some flexion bands or Y-shaped.
of the joint by its connection with the volar plate.18 Lin et al21 further differentiated between pulleys that
attach to the bony floor of the digital canal formed by
THE PULLEY SYSTEM
the phalanges and pulleys that insert into the volar
The strengthening elements of the digital flexor sheaths, plates covering the joints. The two annular bony pulleys
called pulley, are condensation of dense connective over the shaft of the proximal (A2) and middle phalanx
tissue and segmentally distributed along the digital (A4) are the longest and strongest. These pulleys remain
sheath. They serve to restrain the tendons from bow- nearly constant to the joint axis and shorten the least in
stringing and to accommodate maximum mechanical finger flexion.
efficiency of tendon excursion. In contrast, the distance between the volar plate
Several descriptions of these pulleys have been pulleys (A1, A3, and A5) and the joint axis showed a
reported.19-21 The popularly used nomenclature is based significant increase in flexion of the fingers. The volar
on Doyle’s classic anatomical work.20 plate pulleys also tend to have a greater shortening com-
Strauch and de Moura19 investigated the pulleys in 72 pared to the bony pulleys. The cruciate pulleys attach at
fingers and found that a “complex synovial lined tube” one end to bone and at the other end to the palmar
surrounds the flexor tendons to the central three rays. plate. They show the most anatomical variation and
At either edge two main “cul-de-sacs” enclose the shortening.
tendons. Between the pulleys are smaller cul-de-sacs, Due to the concave shape of the volar shaft of the
which tend to flatten in extension, allowing for adjust- phalanges, absence of the bony pulleys leads to bow-
ment in length of the sheaths in finger motion. Strauch stringing of the flexor tendon over this curvature. A
and de Moura19 described two sets of three annular second form of bowstringing occurs over the joint, when
in flexion. The A2 and A4 are not at an equal distance single pulley, loss of function increased significantly
on both sides from the PIP joint; the reason for this may when this pulley was the final pulley to be cut.
be to optimally control a combination of both joint and
INTRINSIC MUSCLES: THE LUMBRICALS
bony bowstringing.21
AND INTEROSSEI
The volar plate pulleys only restrain bowstringing
over the joint, and the cruciate pulleys seem to mainly An unusual muscle originates in the palm of the hand.
modulate force transmission, by increasing the moment Instead of attaching to bone, the lumbrical muscle arises
arm in flexion beyond 45 degrees. Absence of the A2 from a movable medium, namely the FDP tendon and
and A4 pulleys has the greatest effect on joint motion, inserts distally, after crossing the MCP joint, into the
even when only the bony type of bowstringing is per- extensor expansion.26 Although their origin is at the
mitted, by preserving the other pulleys that keep the profundus tendon, the lumbrical muscle covers a great
tendons close to the joint axis. The absence of the A3 part of the superficialis tendon. The first and the second
pulley alone has minimal effect on joint motion.21 lumbrical muscles are unipennate muscles and arise
By remaining in close contact with the tendons that from the palmar surface and radial sides of the tendons
glide through them, the pulleys generate friction. Zhao of the index and middle fingers, respectively. The third
et al22 found that the A3 pulley contributes to reducing and the fourth are bipennate muscles that originate at
the gliding resistance of the tendons against the A2 and the contiguous side of the profundus tendons of the
A4 pulleys. By keeping the tendons close to the PIP joint middle and ring fingers and the ring and little fingers,
axis, the A3 pulley reduces the angle between the edges respectively. All pass at the radial side of the finger in
of the pulleys and the tendons, which reduces gliding which they insert at the dorsal side of the MCP joint.26
resistance. This occurs mainly in greater angles of PIP The lumbricales are found to vary in number between
flexion. The presence of this pulley may prevent a two and five. The most frequent variation can be seen
tendon repair site from buckling under the A2 pulley. in the third lumbrical, as two tendons originate and
Two other structures also contribute to the pulley insert in the middle and ring fingers. Another variation
system of the flexor tendons: the transverse carpal liga- shows only one tendon from the third lumbrical to the
ment and the palmar aponeurosis. ulnar side of the middle finger.26
The transverse carpal ligament arches over the flexor The main action of the lumbrical muscles is to keep
tendons as they traverse toward the palm of the hand the fingers stretched as the MCP joint flexes. They act as
and performs a pulley function by keeping the flexor a moderator band between flexor and extensor mecha-
tendons in proximity of the wrist. After transsection of nism in the finger. When the flexor tendon is pulled, the
the transverse carpal ligament in fresh-frozen cadavers, origin of the lumbrical muscle moves proximally, this
Kline and Moore23 demonstrated that flexor tendons way the muscle is stretched. With the MCP joint in
move an additional 5.5 mm forward from the joint axis, flexion the lumbrical muscle pulls the interphalangeal
when flexing the wrist. The motion of the wrist required joints into extension, by moving the extensor mecha-
a 25% increase of excursion for the FDP tendons and a nism proximally.27
20% increase for the FDS tendons. As Kline and Moore The interosseous muscles are numbered from radial to
stated, this increase in excursion could clinically result the ulnar side of the hand. According to their relative
in decreased grip strength by reducing the remaining position to the intermetacarpal spaces, three palmar
tendon excursion over the other joints. Consequently, and four dorsal interossei arise between the metacarpal
the total active finger motion could decrease if maximal shafts. The palmar interossei are unipennate muscles that
muscle contraction is reached. arise on the opposite side relative to the middle finger
At the level of the MCP joints, the fibers of the palmar metacarpal and insert on the same side into the proximal
aponeurosis and intertendinous septa form an archway phalanx; therefore, the palmar interossei produce adduc-
over the flexor tendons. By anchoring in the deep trans- tion of the fingers relative to the third ray.26
verse carpal ligament, this archway keeps the tendons The dorsal interossei are composed of two muscle
near the axis of the MCP joint and can therefore be seen bellies arising from the adjacent metacarpals. The
as an additional pulley—palmar aponeurosis (PA) tendons on the ulnar side of the axis of the third ray
pulley.24 Manske and Lesker25 sequentially cut the PA insert on the ulnar side of the proximal phalanx; on the
and the first and second annular pulleys in various orders radial side of the middle finger, the tendon inserts on
and studied the influence on joint motion. Cutting only the radial side of the proximal phalanx. In this way, the
one of these pulleys resulted in minimal loss of function. action of the dorsal interossei is abduction of the fingers
Increased loss of flexion was observed when one of the relative to the middle finger.26
annular pulleys was cut in combination with the PA Variations in the interossei are seen in the number of
pulley. The A2 pulley was found to be the most impor- muscle bellies and insertions of the tendons. The palmar
tant as a single pulley, followed closely by the A1 pulley. interossei can be bipennate with two tendons inserting
Although the PA pulley was the least important as a in each corresponding side. One or even all palmar
interossei can be absent. The dorsal interossei are some-

times found to originate more proximal at the base of
the metacarpals or even at the carpalia. The insertion of
the tendon of the second dorsal interossei can be on the
ulnar side of the second metacarpal so that the abduc-
tion of the fingers is relative to the axis of the second
ray, instead of the third.26
CHIASMA TENDINUM OF CAMPER
After leaving the carpal tunnel, the flexor digitorum JT
tendons diverge and spread out to the fingers. As in EIP
logical accordance with their names, the superficialis
tendon lies on top of the profundus. However, after
the tendons pass distal to the MCP joint, the profundus
tendon starts to penetrate through the bifurcated super-
ficialis tendon. At the middle part of the proximal ECRB
ECRL
phalanx, the superficialis tendon divides into two slips EDC EDM
that rotate laterally.27 The most dorsal fibers of the APL
rotated slips emerge to the other side and, after crossing
EPL
each other, they finally insert at the lateral volar crest of
EPB
the middle phalanx. The other fibers of the lateral slips III IV V VI
continue on the lateral side and insert on the lateral Lister’s I II
tubercle
crest on the volar surface of the middle phalanx, where
they unite with the crossed fibers. The superficialis Retinaculum
tendon has a long insertion from the base of the middle
phalanx toward the neck.27 Figure 1-7 The extensor retinaculum and extensor
The profundus tendon passes through the tunnel tendons. Extensor tendons gain entrance in the hand from
formed by the superficialis tendon at the level of the the forearm through a series of six canals. The extensor
proximal phalanx. The tunnel is narrowed by the vincu- tendons are covered with a synovial sheath. APL, Abductor
lum breve superficialis. The FDP tendon passes the volar pollicis longus; EPB, extensor pollicis brevis; EPL, extensor
capsule of the DIP joint, to which it is firmly connected. pollicis longus; ECRL and ECRB, extensor carpi radialis longus
and brevis, respectively; EIP, extensor indicis proprius; EDC,
More distally, the tendon spreads out to insert widely
extensor digitorum communis; EDM, extensor digiti minimi.
into the volar base and fat pad of the distal phalanx.27
Note the junctura tendinea (JT) connecting to the extensor
This intersection of fibers of the FDS tendon forms a tendon of the ring fingers.
plate beneath the flexor profundus and is called the
chiasma tendinum of Camper, named after the Dutch phy-
sician Petrus Camper, who gave a detailed description
of this structure in his book on the anatomy of the arm dorsal side of the distal radius in six compartments
and hand. The chiasma tendinum is an essential biome- formed by the extensor retinaculum (Figure 1-7).
chanical element of the gripping function of the hand. Most radial in position, the abductor pollicis longus
When longitudinal tension is applied to the deep flexor (APL) tendon passes through the first compartment,
tendon, the volar surface of the superficial tendon is together with the extensor pollicis brevis (EPB) tendon.
pushed against the A2 pulley. As grip is sustained, the It inserts on the radial side of the first metacarpal and
profundus tendon is compressed by the two slips of the thereby induces abduction of the first ray of the hand.
superficialis tendon. These mechanisms provide stabili- Usually the APL has multiple slips. Common insertions
zation of the interphalangeal joint, which aids in obtain- of these slips are the trapezium and the origin of the
ing grip on an object.28 abductor pollicis brevis or opponens muscle. In 71% of
100 dissections, Brunelli and Brunelli29 found that one
EXTENSOR TENDONS AT THE WRIST
or two extra tendons in the first compartment belong
A detailed description of the extensor tendons and its to a musculotendinous unit. By inserting in the trape-
variations can be found in the anatomical textbooks zium, the main function of this unit is abduction of
of Standring2 and Kaplan1 and Hunter.26 By passing the carpus and it was therefore named the “abductor
the wrist joint, the extensor tendons assist in extending carpi” muscle. Brunelli and Brunelli consider that the
the wrist and, depending on their position toward the absence of this muscle, which was seen as abnormal,
median axis, provide radial or ulnar deviation. From leads to a higher risk of instability and arthritis of the
radial to ulnar, the tendons pass through grooves on the trapeziometacarpal (TM) joint, because of the loss of a
force to balance the other abducting forces that pull the The sixth compartment contains the ECU tendon,
base of the first metacarpal and cause a shearing effect which runs through a groove between the head and
on the TM joint. styloid process of the ulna; after “encapsulating” the
Other studies did not show a significant relationship pisiform bone, it attaches to the base of the fifth meta-
between supernumerary tendon insertions and TM joint carpal. Frequently, a slip extends from the insertion to
arthritis. However, the presence of a septum within the the capsule of the MCP joint or the proximal phalanx
first extensor compartment does seem to play a role in of the fifth digit.
the pathogenesis of TM arthritis.30
VARIATIONS IN EXTENSOR TENDONS
The EPB inserts into the base of the proximal phalanx
TO THE FINGERS
of the thumb. The tendon can be fused with the extensor
pollicis longus (EPL) or absent. It often has its own Numerous variations exist in the extensor tendons to
subsheath within the first compartment. This may be an the fingers. Zilber and Oberlin33 studied the pattern of
important factor in de Quervain disease. The tendons of extensor tendons of 50 hands to determine the statisti-
the extensor carpi radialis longus (ECRL) and brevis cal distribution, combined with the results of previous
(ECRB) pass under the muscle bellies of the abductor studies. In the most frequently encountered pattern, the
pollicis longus (APL) and EPB before passing under- EDC provided one tendon to the index and middle
neath the dorsal carpal ligament, in the second com- finger, two to the ring finger, and none to the little finger.
partment. Repetitive resisted extension of the wrist can In this pattern there is a single extensor indicis tendon
cause inflammation of the tenosynovium at this inter- and a double extensor digiti minimi tendon. A septum
section, which is therefore called “intersection syn- is seen between the extensor digiti minimi tendon and
drome.” It was thought to be caused by friction of the the EDC after they have emerged from the extensor reti-
muscle bellies at the intersection; however, Grundberg naculum. Always observed is the extensor indicis tendon
and Reagan31 demonstrated this inflammation is based lacking a junctura tendinum.
on stenosing tenosynovitis of the sheath of the radial After reviewing the literature on variations in the
wrist extensors within the second compartment. The fingers extensor tendons, Zilber and Oberlin33 stated
radial wrist extensor tendons attach at the dorsal radial that the different descriptions have certain contraindica-
aspect of the base of the second and third metacarpal, tions, especially regarding the ring finger. A large varia-
respectively. Variations exist in the number of tendons tion was seen in the number of EDC tendons, ranging
arising from the muscle bellies and cross slips between from 5 to 12 tendons. The absence of a tendon to the
these tendons. Occasionally, an extensor carpi radialis index finger is exceptional. The EDC tendon to the little
accessorius can be seen with insertion into the bones or finger is often replaced by a structure arising from the
muscles in the thenar region. ring finger that joins the tendon of the extensor digiti
In the third compartment, EPL obliquely crosses the minimi at the level of the MCP joint. Some authors
long and short extensor carpi radialis tendons and describe this structure as a tendon and others as a junc-
inserts into the base of the distal phalanx of the thumb. tura tendinum. This may lead to differences in results
The tendons to the thumb form a triangular interval reported with respect to the EDC tendons to the fourth
(anatomical snuffbox), wherein the radial artery can be and fifth fingers.33
found. The EPL tendon goes around Lister’s tubercle, The absence of the extensor indicis tendon is a rare
which is a frequent site of chronic tenosynovitis. This finding. An extensor medii digiti or extensor medii pro-
could eventually lead to “drummer boy’s palsy,” when prius has been reported as a tendon for the middle
the EPL tendon ruptures. finger arising from the extensor indicis. The extensor
The extensor indicis proprius passes through the digiti minimi tendon can be absent with or without
fourth compartment together with the extensor digito- substitution of a tendon from the EDC or ECU to the
rum communis (EDC) tendons and joins the common little finger. The EDM can also be formed by two distinct
extensor tendon to the index finger, on the ulnar side. muscles or by one muscle with up to three tendons. The
Occasionally an extensor digitorum brevis manus two-tendon pattern is seen as the normal pattern. The
(EDBM) muscle can be found in the fourth compart- EDM can be identified by two tendons running in
ment, which can be confused with a ganglion. The the same sheath on the ulnar aspect of the wrist in 60%
EDBM has the same insertion as the extensor indicis to 90% of cases. This is important to know because this
proprius and could therefore be seen as variant of that extra tendon is useful for tendon transfers.33
muscle.32 Asymmetry is often seen between the right and the left
Through the fifth compartment, distally to the distal hand. Especially with respect to the EDM, this shows one
radioulnar joint, runs the tendon of the extensor digiti tendon favoring one hand more than the other in 20%
quinti proprius or extensor digiti minimi. It merges at of cases. It is necessary to have thorough understanding
the proximal phalanx with the little fingers extensor of these arrangements of the multiple extensor tendons
expansion. when performing tendon surgery33 (see Figure 1-7).
On the dorsum of the hand, the extensor tendons are

interconnected by tendinous bands called junctura ten- Central slip
dinea. The presentation of the juncturae shows several
variations. Most often an oblique slip branches off the
tendon of the ring finger to insert distally in the tendon Sagittal band
of the little and middle fingers. A thin transverse band Interosseus
can be found between the middle and index fingers.
There are three types of juncturae: a filamentous trans- TRL Lateral
ORL band Lumbrical
verse or oblique band, a much thicker and well-defined
junctura, and a “y”- or “r”-shaped tendon slip.34
With the fingers in flexion, the juncturae restrict the
neighboring fingers from extending independently. This
especially accounts for the ring finger as the juncturae Figure 1-8 Extensor mechanism lateral view. ORL, Oblique
originate at the tendon of the ring finger and course retinacular ligament; TRL, transverse retinacular ligament.
distally35 (see Figure 1-7). Sagittal band locates dorsal and lateral to the MCP joint of
the finger. The tendons of the interosseus and lumbrical
EXTENSOR MECHANISM OF THE FINGERS muscles insert in the proximal phalanx and form the lateral
Kaplan and Hunter26 and Smith35 thoroughly describe bands, which is interconnected with the central slip by the
the extensor mechanism of the fingers. As the common sagittal band at the MCP joint.
digital extensor tendons approach the distal end of the
metacarpals, they spread out to form an aponeurosis
over the MCP joint and proximal phalanx, the extensor At the base of the proximal phalanx the extensor
expansion or dorsal hood. The tendon is fixed at the tendon infiltrates the dorsal lamina; the tendon trifur-
midline of the MCP joint by a band of sagittal fibers cates and spreads out over the PIP joint. At the distal
that arises volarly at the deep transverse metacarpal liga- end of the proximal phalanx, fibers from the lateral
ment and the volar plate of the MCP joint. These sagittal bands join the middle band or central slip. After cross-
bands aid in the extension of the proximal phalanx and ing the PIP joint, the central slip is fused with the
restrict the tendon from moving proximally.26 capsule and inserts at the base of the middle phalanx26,36
Between the sagittal bands and the MCP joints run (Figure 1-9).
the tendons of the interosseus muscles that insert at the The central slip particularly extends the middle
lateral tubercles on the base of the proximal phalanx. phalanx, unless the MCP joint is in hyperextension.
These tendons allow for lateral deviation of the fingers. When the PIP joint is flexed, the central slip contributes
By its connection with the extensor expansion, the inter- to the extension of the proximal phalanx by dorsal dis-
ossei can flex the MCP joint. Fibers between the lateral placement of the middle phalanx on the head of the
ligaments and the extensor expansion prevent the inter- proximal phalanx.36
osseus tendons from luxating dorsally in extension. The A narrow, tendinous band arises at the volar aspect
radial side of the proximal phalanx, slightly distal to the of the distal end of the proximal phalanx. This oblique
lateral tubercles, normally also receives the insertion of retinacular ligament (ORL) courses obliquely to the
the lumbrical tendon.26 dorsal side of the middle phalanx, where it joins the
Distally, lateral bands formed by a continuation of lateral bands to the distal phalanx. It helps stabilizing
the interossei and lumbricales course to the sides of the lateral bands and is also attributed to extend the DIP
the PIP joint and the middle phalanx (Figure 1-8). joint in harmony with the extension of the PIP joint;
Oblique slips attach to the base of the middle phalanx however, biomechanical investigations have refuted
and merge with the central tendon. The remaining this. This “link” ligament passes volar to the PIP joint
portion of the lateral bands continues at the sides of axis only when the joint is flexed; the same applies, in
the middle phalanx and turns dorsally near its head. greater extend, to the DIP joint. The oblique retinacular
There the bands unite and continue as a wide band over ligament was observed only to aid in extension when
the DIP joint that inserts at the base of the distal the DIP joint was flexed more than 70 degrees.37,38
phalanx.36 At the PIP joint a homologue to the sagittal bands
Between the lateral bands of the interossei, distal to originates from the volar aspect of the PIP joint. The
the sagittal bands, transverse fibers arch over the dorsal transverse retinacular ligament maintains the extensor
side of the proximal phalanx. The fibers of this interten- mechanism in position and pulls the lateral bands
dinous lamina gradually change from horizontal to volarly, in flexion of the PIP joint.26
oblique from distal to proximal. The lamina courses Distal to the insertion of the central slip the dorsal
from the extensor tendon to the volar plate of the MCP hood continues toward the distal phalanx as a thin
joint and acts as a flexor of the proximal phalanx.35 membrane between the lateral bands. This area covering
A2
Oblique pulley
A1
LB
Central
slip
Triangular
ligament
Adductor pollicis
Flexor pollicis brevis, deep head
Synovial sheath
Figure 1-10 The flexor pollicis longus (FPL) pulley system

differs from the finger pulley system in that there is a strong
fibrous oblique pulley between the A1 and A2 pulleys. There
Figure 1-9 Extensor mechanism dorsal view. LB, Lateral are no cruciate pulleys in the thumb.
band. The connections between the central slip and lateral
band are illustrated. The triangular ligament connects the
lateral bands over the dorsum of the middle phalanx.
of the FPB as one of the palmar interossei.2,39 The oppo-

nens pollicis inserts along the entire length of the lateral
side of the metacarpal bone of the thumb. It flexes the
the middle phalanx is called the triangular ligament (or metacarpal at the CMC joint and therefore contributes
triangular lamina). It retains the lateral bands close to to opposition of the thumb; a combination of actions
each other by bonding them over the dorsum of the that brings the tip of the thumb and the other fingers
middle phalanx (see Figure 1-8). together. The abductor pollicis brevis, FPB, and oppo-
nens pollicis form the thenar muscles.2,39
TENDONS IN THE THUMB
The adductor pollicis tendon inserts in the first
The FPL tendon courses through a groove on the volar annular pulley and the ulnar sesamoid at the MCP joint.
side of the first metacarpal, in its own flexor sheath. In The volar plate is firmly attached to the proximal
the volar capsule of the MCP joint, two sesamoid bones phalanx, what gives the adductor pollicis the ability to
are embedded, which firmly wedge the FPL tendon. directly act on the phalanx. The adductor pollicis also
Distally the tendon inserts widely in a deep excavation has an extension to the ulnar lateral tubercle and the
in the volar surface of the distal phalanx. It flexes the dorsal aponeurosis of the thumb. Its actions are adduc-
interphalangeal joint of the thumb, as well as the MCP tion of the thumb and flexion of the MCP joint2,39
and carpometacarpal (CMC) joint.2,39 (Figure 1-10).
The abductor pollicis brevis is inserted by a thin, flat Some controversy exists about the pulleys of the
tendon into the lateral aspect of the MCP joint capsule thumb. An annular pulley arises from the volar plate of
and unites with the fibers of the flexor pollicis brevis the MCP and interphalangeal joint. At the level of the
(FPB) to the radial sesamoid. It moves the thumb ante- shaft of the proximal phalanx an oblique pulley can be
riorly (abduction) and also contributes to opposition found. The proximal part of the oblique pulley shows
and extension of the thumb.2,39 The FPB forms a tendon variation and is suggested to be seen as a separate trans-
near the MCP joint, to which it adheres, and inserts into verse pulley. These pulleys arising from the proximal
the lateral sesamoid bone and the lateral tubercle of the phalanx are most important in preventing bowstringing
proximal phalanx. It flexes the thumb towards the palm of the FPL tendon. However, the oblique part alone does
of the hand. Some anatomists describe the medial part not prevent bowstringing.40
On the dorsal side of the thumb the EPL tendon base of the proximal phalanx. Frequently an insertion
courses over the ulnar side of the MCP joint. From there in the distal phalanx is observed. By acting on the CMC
it broadens, crosses the interphalangeal joint and inserts and MCP joints the extensor pollicis brevis extends and
widely into the base of the distal phalanx. It extends the abducts the thumb.2,39 The extensor mechanism of the
distal phalanx of the thumb and contributes to abduc- thumb shows similarities with the expansion over the
tion and extension of the wrist.2,39 fingers MCP joints. It is formed by EPL and EPB, and
The EPB tendon is concealed by the dorsal aponeu- the extensions of the abductor brevis on the radial side
rosis as it crosses the MCP joint and inserts in the dorsal and adductor on the ulnar side.2,39
References
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(Am) 18:717–721, 1993. (Am) 27:628–635, 2002.
CHAPTER
2
TENDON NUTRITION
AND HEALING
Peter C. Amadio, MD
OUTLINE TENDON NUTRITION
This chapter will review current knowledge on tendon Vascular Sources

nutrition and healing. Tendon obtains nutrition from Tendons have two sources of vascular nutrition. Extra-
both vascular sources and synovial fluid. The extracel- synovial tendons are supplied by circumferential vessels
lular matrix is the principal component of tendon in the paratenon, a multilayered system elegantly
tissue, and is responsible for its material properties. described by Giumberteau7 and illustrated in Chapter
The major constituents are type I collagen; proteogly- 31. Intrasynovial tendons, such as those in zone 2 in
cans, principally decorin, but also aggrecan in the the hand, are supplied through the segmental vincular
gliding regions; fibronectin; and elastin. This matrix is system.8-10 This segmental system results in predictable
synthesized by tendon cells, or tenocytes. After tendon watershed zones within the flexor tendon (Figure 2-1),
injury, the extracellular matrix undergoes significant with intercalated regions on the palmar aspect of the
changes, due to synthesis of new elements by the teno- tendon with little in the way of blood supply. The
cytes, such as type III collagen, degradation of existing number and location of these zones also varies by digit,
elements by various matrix metalloproteases, and with the ring finger generally having the fewest vincula.10
remodeling of the resulting combination, under the
influence of cytokines as well as mechanical forces. Synovial Fluid
Physical factors, such as motion, loading and friction Intrasynovial tendons have a second source of nutrition,
affect the results of tendon repair. The concept of “safe of course—synovial fluid. This mechanism is especially
zone” was proposed to define the range of external important in avascular and hypovascular regions of the
loading which does not disrupt the tendon repair tendon3,11-14 and is dependent on the pumping effect of
when the tendon is loaded during motion. Pharmaco- digital motion. Tendons whose vincula are absent or
logical manipulation of tendon healing, such as use damaged and that do not move are therefore deprived
of 5-fluorouracil, may reduce adhesion formation of nutrition, an important consideration for tendon
during tendon healing, and supplying stem cells or repair and rehabilitation.
cytokines may augment intrinsic healing capacity of
the injured tendon. Critical points are as follows. TENDON HEALING
Regarding nutrition, both synovial and vascular routes
are important; vascular route is affected by age and Biology of Tendon Healing
injury, and the synovial route is affected by mobiliza- The extracellular matrix (ECM) is the principal compo-
tion. In healing, motion aids healing and reduces nent of tendon tissue and is responsible for its material
adhesions. There is little evidence that loading, in the properties.15-17 The major constituents of the ECM are
absence of motion, is helpful, or that, once the tendon type I collagen; proteoglycans, principally decorin, but
is moving, more loading helps healing. We do know also aggrecan in the gliding regions18-21; fibronectin; and
that loading may lead to failure of the repair. The “safe elastin. This matrix is synthesized by tendon cells, or
zone” involves enough loading to initiate motion but tenocytes. These cells are surrounded by the dense
not enough to risk the repair. matrix; thus, although they are metabolically active,
they do not participate much in the tendon healing
Traditionally, tendons have been thought of as being process. Instead, undifferentiated cells in the epitenon
inert, hypovascular structures.1,2 However, subsequent do the heavy lifting for tendon healing, proliferating,
research has shown that tendons are active metaboli- migrating into the gap between the tendon ends, and
cally, that tenocytes can replicate and heal experimental finally uniting the cut tendon ends22,23 (Figure 2-2).
injuries, and that adhesions, while common, are not Unfortunately, this is a two-edged sword; if these same
necessary for healing.3-6 This chapter will review current cells migrate away from the tendon, toward the tendon
knowledge on tendon nutrition and healing. sheath, they form adhesions, which restrict tendon
16
Chapter 2: Tendon Nutrition and Healing 17
transforming growth factor (TGF)β as well as mechani-

cal forces. Manipulation of these processes, to augment
their action between the tendon ends while reducing
them at the tendon’s gliding surface, is the goal of much
research, as described later.
Healing of flexor tendons in zone 2 depends on the
ability of the injured tendon to recruit fibroblasts and
other cellular components to the site of injury.31 Nor-
mally these are circulating or locally derived undifferen-
tiated (i.e., stem) cells that are recruited to the injury
site by the expression of cytokines in the wound.24,27,32-34
Cytokine stimulation is also important in converting
these undifferentiated cells into the tendon phenotype,
characterized by the expression of markers such as
tenomodulin and scleraxis.35,36 Bone marrow–derived
stem cells (BMSCs) can also enter and participate in soft
tissue healing.37-39
EFFECT OF PHYSICAL FACTORS

Motion
Lacerated tendons that are immobilized, unless
extremely well nourished, will heal with adhesions.40-42
While these adhesions can remodel, especially in an
extrasynovial environment, in the region of the tendon
sheath such adhesions are invariably associated with
Figure 2-1 Tendon blood supply. loss of motion. Thus, motion of flexor tendon repairs
in critical. Duran and Houser43 suggested observing
the repair intraoperatively and maintaining passive
motion sufficient to cause 4 mm of tendon gliding, and
separation of the profundus and superficialis repairs, if
both tendons are injured. Evans has discussed similar
concepts of limited active motion of repaired tendons.44
Loading
Clearly, some load must be applied to a flexor tendon
if it is to move. The loads applied to a tendon by passive
motion of a digit tend to be small, and tendons may
buckle instead of glide, especially if the tendon repair
has a high friction.45 A modification of the usual syner-
gistic passive motion protocol in which the metacarpo-
Figure 2-2 Epitenon cells migrating into the repair site 3 phalangeal joints are maintained in extension in both
weeks after injury in a canine model of tendon injury the flexion and extension phases of motion seems to
(hematoxylin-eosin, magnification ×100). provide better pull, on the order of 100 g, in both the
flexion and extension directions, and may be useful in
some cases.46,47 The use of higher loads, with active
motion. Often this is indeed the case, as the relatively motion protocols, is somewhat controversial.48-50 My
ischemic tendon is surrounded by better vascularized philosophy has been to tailor the loading to the stage
tissue, which sends out vascular buds under the stimula- of healing, as emphasized by Groth,51 as further
tion of vascular endothelial growth factor (VEGF).24-27 described later.
After tendon injury, the extracellular matrix under-
goes significant changes, due to synthesis of new ele- Effect of Friction on the Results
ments by the tenocytes, such as type III collagen,28-30 of Tendon Repair
degradation of existing elements by various matrix Animal studies over the past decade have shown
metalloproteases, and remodeling of the resulting com- convincingly that high friction repairs with knots and/
bination, under the influence of cytokines such as or many loops on the surface, such as the modified
A B
Figure 2-3 A, Abrasion of sheath 6 weeks after MGH repair in an in vivo canine model (scanning electron microscopy,
magnification, ×300). Compare with B, a similar image from a tendon repaired with a modified Kessler suture.
Becker/MGH or Tsuge repairs, result in abrasion of the sufficient to overcome the forces of friction. It is for this
tendon sheath (Figure 2-3) and adhesion formation, reason that low friction repairs are important—they
even when factors such as rehabilitation method are minimize the load needed to initiate movement. Fric-
optimized.52-54 Thus, the goal should be to use a high- tion, though, is not the only concern. The force needed
strength, low-friction repair construct, such as the modi- to overcome joint stiffness and to flex traumatized,
fied Kessler, Tajima, or Pennington repairs, and a edematous tissues must also be considered, as well as
low-friction suture material, of which there are many. the weight of the distal digit itself; often these latter
Most recently, I have been using 3-0 polyester suture and forces will far outweigh the frictional ones in magni-
a modified Pennington design. tude, especially in an injured digits. So the minimum
force needed to load the tendon will be a combination
Impact on Postoperative Management: of the frictional force and the force needed to move the
Concept of the “Safe Zone” joints and soft tissues. The energy needed to flex the
Until the mid 1960s, most flexor tendon repairs were digit is often called the “work of flexion”.69,77,78
immobilized postoperatively for three weeks. This One might imagine that the maximum load that
policy was based on the research of Mason and Allen,55 could be applied is the load that represents the breaking
who had shown that canine flexor tendon repairs strength of the tendon, but that would be incorrect: long
decreased in tensile strength for three weeks postopera- before the tendon breaks, it begins to gap, and gapping
tively. Subsequent clinical work by Verdan,56 Kleinert also increases friction, setting up a vicious circle that can
et al,57 and Duran et al58 showed that human flexor lead to later rupture. So, really, the upper bound is not
tendon repairs could be safely mobilized with a combi- breaking strength but the force needed to create a gap,
nation of active extension and passive flexion. which is usually much less.50,62,79-87 The difference
The use of early mobilization after tendon repair has between the two forces—the force to initiate unloaded
resulted in improved outcomes for flexor tendon inju- digital flexion and the gapping force—represents the
ries.56,58-62 In animal models,45,53,63-67 earlier mobiliza- “safe zone” in which rehabilitation can occur88 (Figure
tion results in better final tendon gliding and tensile 2-4). Early on, this safe zone will be bounded by strictly
strength. More recently, the fine details of mobilization mechanical parameters, related to the anatomy and bio-
have been studied, specifically the effect of timing68-70 mechanics of the repair. Over time, though, the effects
and the effect of differential motion of the wrist and of tendon healing are added in; the general effect is
finger joints on tendon loading and tendon gliding usually to gradually widen the safe zone, enabling the
during the healing period.49,53,71 Active motion protocols rational use of a graded resistance program as outlined
have also been used, although, interestingly, the clinical by Groth.51 The details of such programs are reviewed
results are not reliably better than passive protocols.72-75 in Chapter 38.
Moreover, the addition of loading to motion in animal Unfortunately, in some cases, early mobilization after
models has been shown to have little effect on the final tendon repair is not possible by any method. Common
result in terms of strength and motion.49,67,76 Thus, the examples include situations with complex hand injury,
available evidence suggests that motion, not load, is the in which motion might jeopardize bone, skin, nerve
critical factor. or vascular integrity; patients who are uncooperative
Of course, there must be some load on the tendon if due to age or mental status; or situations where the
it is going to move; at the very least, the load must be tendon repair is deemed to be too tenuous to tolerate
Lubricated surface
Max strength
In Vitro
40N Initial strength of the repair
Max strength
1 wk. In Vitro
30
Patch containing cells,

2 mm gap Initial “safe zone” growth factors and collagen
20
Figure 2-5 Conceptual model of stem cell patch to
Initial gap Effect augment tendon repair.
10 of time
Friction 5
of the In Vitro
repair 0.2 Repair effects appear to be focal to the site of application and
titratable in terms of length of action.96-98 A 5-minute
Figure 2-4 The “safe zone” concept. exposure to 5-FU has been shown to significantly
decrease postoperative flexor tendon adhesions in
chicken and rabbit models.99,100 This beneficial effect is
mobilization. In such cases, adhesions have been, up to thought to be due to the downregulation of TGFβ and
now, inevitable. It is possible, though, that the applica- modulation of matrix metalloproteinase (MMP)-2 and
tion of a tissue engineered, biocompatible adhesion MMP-9 production.101,102 The effect on surface lubrica-
barrier that is porous to nutrients might allow an immo- tion is unknown. No adverse effect was noted on tendon
bilized tendon to heal without adhesions. We are cur- healing in these studies. It is presumed therefore that
rently pursuing research to address this issue, using the topical 5-FU does not penetrate to affect the cells
carbodiimide derivatized hyaluronic acid and lubricin, below the tendon surface. Topical application of 5-FU
linked to collagen, as the proposed barrier, and hope to may well have a role in improving the outcomes in
have an update in time for the next edition of this book. selected cases of tenolysis.
PHARMACOLOGICAL MANIPULATION
OF TENDON HEALING AUGMENTATION OF INTRINSIC
TENDON HEALING
Various pharmacological agents have been used in the
past in an attempt to modify adhesion formation. Ste- Stem Cells
roids, antihistamines, and beta-aminoproprionitrile BMSCs delivered on collagen sponges improve healing
have not been shown to clinically decrease scar forma- in animal models of tendon repair,103,104 and stem cells
tion.89,90 Ibuprofen and indomethacin have been found from other origins have been shown to be effective
to have a small beneficial effect.91 in enhancing repair in several other tendon injury
The ideal pharmacological agent should have no models.105-108 Current research is focused on optimizing
systemic side effects, should be limited to a single the isolation and differentiation of stem cells into the
application, and should be directed at growth factor tendon phenotype. In the future, it is likely that cells
expression and ECM production. 5-Fluorouracil (5-FU) derived from the patient’s own bone marrow, fat, skin,
may be such a drug. 5-FU is an antimetabolite that or muscle will be used as a “patch” to augment tendon
is used not only as a cancer chemotherapeutic agent repair (Figure 2-5). My colleagues and I are pursuing
but also to prevent adhesions in glaucoma filtration one such option in our laboratory now: a mixture of
surgery. The exposure of a surgical field to 5-FU procollagen, growth factors, and stem cells from the patient’s
duces a focal inhibition of scarring. Blumenkranz own tissues and lubricated with an engineered surface
et al92,93 has found that 5-FU is able to inhibit the pro- containing hyaluronic acid and lubricin.109-112 Such a
liferation of fibroblasts in cell cultures and reduce retinal graft could also be used to bridge flexor tendon defects,
scarring. Single exposures to 5-FU, for as short duration and, finally, replace like with like.
as 5 minutes, can have antiproliferative effects on fibro-
blasts for several days. The suppression of fibroblast Cytokines
proliferation has been observed for up to 36 hours Growth factors are the chemical signals that direct the
without signs of cell death.94,95 This time frame may be migration and proliferation of the tendon fibroblast
adequate to inhibit tendon adhesions prior to begin- during the healing process. The role of growth factors
ning postoperative motion protocols. Reversible pro- has been examined extensively in cutaneous wounds
longed inhibition of fibroblast function is attributed to and other soft tissue processes, yet we are only begin-
the drug’s inhibition of DNA and mRNA synthesis ning to known the specifics involved in flexor tendon
through thymidylate syntheses. More important, these healing.17,113 The factors that appear to be involved
include TGFβ, platelet-derived growth factor (PDGF), adhesions in a rabbit tendon model.122-125 TGFβ levels
basic fibroblast growth factor (bFGF), insulin-like can remain elevated for up to 8 weeks after tendon
growth factor (IGF), epidermal growth factor (EGF), injury.126,127
and VEGF.27,114,115 These same growth factors have also Neuropeptides may also play a role in tendon
been shown to optimize tissue-engineered constructs healing.128-131 During the early phases of healing, tendons
used for tendon repair.27,104,114-117 Growth differentiation exhibit nerve fiber ingrowth.128 This nerve ingrowth is
factor-5 (GDF-5), a member of the TGFβ superfamily, associated with the temporal release of substance P
has also been shown to accelerate tendon healing in (SP). SP promotes tendon regeneration through the
multiple animal models.118-120 stimulation and proliferation of fibroblasts.132-135 Further
TGFβ stimulates the formation of the ECM. It signals studies have found that tendon motion helps to modu-
fibroblasts to produce collagen and fibronectin, late the release of SP.129 The injection of SP into the
decreases protease production, and increases the forma- peritendinous region of ruptured rat tendons improves
tion of integrins, which promote cellular adhesions and healing and increases tendon strength.136 Similarly,
matrix assembly. In normal tissue, TGFβ becomes inac- growth and differentiation factor-5 (GDF-5), a member
tivated once wound healing is complete; however, it of the TGF superfamily, have a potential to stimulate
may remain active in tendon adhesion formation, con- BMSC proliferation and regulate BMSC differentiation
tinuing the cycle of matrix accumulation.121,122 Modula- to tenocytes.137 Recent experiments have some beneficial
tion of TGFβ has been reported to reduce peritendinous effect of GDF-5 on tendon healing as well.25,119,138
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123. Chang J, Thunder R, Most D, et al: Studies in flexor tendon 138. Dines JS, Weber L, Razzano P, et al: The effect of growth
wound healing: Neutralizing antibody to TGF-beta1 differentiation factor-5-coated sutures on tendon repair in a
increases postoperative range of motion, Plast Reconstr Surg rat model, J Should Elbow Surg 16(Suppl 5):S215–S221,
105:148–155, 2000. 2007.
CHAPTER
3
TENDON FRICTION,
LUBRICATION, AND
BIOMECHANICS OF MOTION
Chunfeng Zhao, MD, Peter C. Amadio, MD, and
Kai Nan An, PhD
OUTLINE fingers, frictional force must be encountered. An et al1

developed a tendon/pulley gliding model to measure
Both physiological and pathological conditions the frictional force and calculate the frictional coeffi-
regarding tendon friction, lubrication, and motion are cient (Figure 3-1). If the impending motion of the cable
discussed in this chapter. Tendon friction and lubrica- is from F1 to F2, then F2 is greater than F1 due to the
tion mechanism vary according to tendon type. Intra- friction f, and f = F2 − F1. F2 is also related to F1 as F2
synovial tendon, regularly located in high abrasion = F1eµø, where µ is the frictional coefficient. If a loga-
areas, has less frictional force and greater durability rithm is taken, LnF2/F1 = µø. If the values of F2, F1, and
than the extrasynovial tendon. The lubrication mecha- ø are known and natural logarithms of F2/F1 are plotted
nism of the intrasynovial tendon is similar to that of against angles in radians, the frictional coefficient can
the articular cartilage. Proteoglycan, hyaluronic acid, be calculated as the slope of a line designed according
and phospholipid are the major lubricating compo- to the least-squares method.2
nents. Extrasynovial tendon relies on the paratenon The assessment of frictional force at the tendon–
sequential gliding phenomenon to reduce the direct pulley interface with this method is an ideal model.
abrasion of the tendon with surrounding tissues. However, tendon gliding is far more complicated. In
However, this gliding unit is fragile. A hybrid of intra- classical theory, for friction without a lubricant, three
synovial and extrasynovial tendon occurs in the carpal laws have been postulated3: (1) The frictional force is
tunnel. Adequate tendon excursion is essential to directly proportional to the applied load; (2) frictional
maintain normal muscle and joint function. An force is independent of the apparent area of contact; and
increased tendon moment arm (such as bowstringing) (3) the kinetic frictional force is independent of the
will affect both strength and excursion of the tendon. sliding speed. However, these rules must be modified in
tendon, for several reasons. First, the tendon is a visco-
A healthy tendon is essential to maintain the normal elastic tissue. Its properties are affected by the velocity
functional performance of muscles and joints. Since the of tendon motion, and its surface deforms in response
tendons transmit both force and displacement from to contact pressure. In addition, tendon is lubricated, at
muscle, the tensile strength of the tendon must be least normally.
strong enough to bear the range of anticipated loading, Moriya et al4 investigated three parameters that may
and the tendon displacement must be long enough to relate to tendon friction: temperature (4°C, 23°C, and
achieve full joint motion. Lose of either property would 36°C), gliding velocity (2, 4, 6, 8, or 12 mm/sec), and
not only jeopardize the tendon functional performance load (250, 500, 750, 1000, 1250, and 1500 g) applied
but also affect muscle and joint function. Therefore, an to the tendon using a flexor digitorum profundus
understanding of tendon friction, lubrication, and bio- tendon and A2 pulley model. They found that the
mechanics, in both physiological and pathological con- tendon friction was proportional to load, but not,
ditions, is essential for clinicians who diagnose and treat within the ranges studied, to gliding velocity (Figure
tendon disorders. 3-2A and B). The temperature also affected the tendon
friction; the friction at 4°C was significantly higher than
TENDON FRICTION that at body temperature, 36°C. This information is
useful to guide the experiments that relate to tendon
Tendon Friction in Physiological Conditions frictional testing. Some studies have also demonstrated
When tendons glide against surrounding tissue, espe- that tendon frictional force is dependent on joint posi-
cially when passing through a series of pulleys in the tion or the direction of motion. Zhao et al5 found that
24
Chapter 3: Tendon Friction, Lubrication, and Biomechanics of Motion 25
80 85 90 85 80 7
75 5 70
70 65
65 60
60
55
55
50
50
45
45
40
40
35
35
30
25
F1
20 F2 A2
15
pulley
10
10
5
5
α β
0
0
Mechanical
actuator FDP
and linear tendon
potentiometer
Load
Figure 3-1 Illustration of the tendon–pulley frictional measurement system, consisting of a mechanical actuator with a
linear potentiometer, two tensile load-transducers connecting distal (F1) and proximal (F2) to the A2 pulley, a mechanical
pulley (right), a Dacron cord, and a weight. FDP, Flexor digitorum profundus.
the friction at the flexor tendon–transverse carpal liga- a lower friction repair technique, the modified Kessler
ment interface was significantly higher in wrist flexion repair, had fewer adhesions after 6 weeks compared to
compared to the neutral position. Heers et al6 studied a higher friction technique, the modified Becker repair.
the frictional force of the long head of the biceps tendon However, these positive adhesion outcomes were com-
during shoulder motion and found that the frictional bined with higher rates of gap formation and rupture.
force during abduction was significantly higher than To balance the tensile strength and friction, several
that of adduction. studies have studied suture techniques with higher
tensile strength and lower friction. Momose et al16 used
Tendon Friction in Pathological Conditions a looped suture with a modified Kessler suture tech-
The normal tendon frictional force is small. The fric- nique to repair flexor tendons and achieved high tensile
tional coefficient of flexor tendon in zone 2, where two strength with relative low friction. Later, Tanaka et al17
flexor tendons are enveloped by flexor sheath with syno- demonstrated that the modified Pennington technique
vial fluid between, is comparable to that of cartilage.7-9 possesses low friction and high strength.
However, the frictional force after tendon injury and Some alternative surgical techniques have been devel-
repair dramatically increases, which impairs tendon oped to minimize bulk after tendon repair. Resection of
function. Sutures create roughness of the tendon surface one slip of the flexor digitorum superficialis (FDS)
and increase friction. Sutures also increase the volume tendon decreased the repaired flexor digitorum profun-
of the tendon, and postinjury edema can increase fric- dus (FDP) tendon gliding resistance.18 Pulley plasty also
tion as well. Afterward, the biological healing between reduces friction.19 Trimming the pulley edge on an
tendons and surrounding tissue forms adhesions, which oblique, rather than perpendicular to the long axis of
increase the frictional force and may in some cases the bone, may also help the repaired tendon pass
totally impede tendon gliding. through with less risk of triggering.20
Strategies to reduce the fictional force after tendon The frictional force of a repaired tendon with a gap
repair have been studied.7,10-12 Surface friction of a has also been studied. The friction of repaired tendons
repaired tendon can be reduced by burying knots without gap mainly comes from surface roughness.
between tendon ends, or locating the knots away from However, with gap formation, plowing friction, related
the anterior tendon surface, choosing low friction suture to surface shape, becomes dominant, which dramati-
materials, and using fewer suture loops and strands.13,14 cally increases the resistance. If a repaired tendon has a
Using a canine in vivo model, Zhao et al15 found that 3-mm or larger gap, the plowing frictional force may
increase sharply due to the trapping of the repaired to increase, as in rheumatoid arthritis, also increase fric-
tendon edge on the pulley, eventually leading to repair tional force.22 Trigger finger is another example where
failure if the applied load exceeds the repair strength.21 increased bulk and decreased lubrication hamper
The tendon frictional force may also increase in cir- tendon gliding through the pulley. The integrity of the
cumstances not related to tendon injury or repair. Joint flexor pulley system is also important to maintain
deformities that cause the tendon pulley gliding angle normal frictional force during finger motion. Resection
of the A3 pulley increases the gliding resistance between
tendon and A2 pulley.23 Increased carpal tunnel pres-
FRICTION VS LOAD sure also increases tendon frictional force.24
1
Tendon Friction in Different Tendon
0.8
Surroundings
Frictional force (N)
Tendons can be classified as intrasynovial and extrasy-

0.6 novial tendons based on their surrounding environ-
ment.25 Intrasynovial tendons are defined as tendons, or
0.4 parts of tendons, enclosed within a synovial sheath.
These tendons are lubricated by synovial fluid, and the
0.2 tendon surface is covered by a thin visceral synovial
membrane, the epitenon (Figure 3-3). The epitenon
0 cells are similar to synovial cells and secrete lubricants.
A 250 500 750 1000 1250 1500 (g) This unique structure effectively decreases friction,
reduces abrasion, and eliminates wear. Flexor tendons
FRICTION VS VELOCITY
in zone 2 area are typical intrasynovial tendons. Exten-
0.5
sor tendons in the dorsal wrist area, the long head of
0.4
the biceps brachii tendon, and the posterior tibial
Frictional force (N)
tendon at the medial malleolus are other examples of

0.3 intrasynovial tendons. In contrast, the tendons located
within subcutaneous soft tissues are extrasynovial
0.2 tendons. These tendons are covered by loose connective
tissue, called paratenon (see Figure 3-3). In addition,
0.1 some tendons have a hybrid type. Ettema et al26 reported
that flexor tendons in zone 4 (within the carpal tunnel)
0 have a unique structure, in which the subsynovial con-
2 4 6 8 10 12 nective tissue (SSCT), a paratenon-like structure, covers
B Gliding velocity (mm/s)
each flexor tendon. The SSCT and tendon are in turn
Figure 3-2 The frictional force of tendon is proportional to encased in a synovialized bursa. Therefore, the flexor
load applied to the tendon (A) but independent of the tendons in this region include both intrasynovial and
gliding velocity (B). extrasynovial gliding mechanisms (see Figure 3-3).
Figure 3-3 Left, Intrasynovial tendon region, Surrounding

the tendon surface is covered by epitenon, tissues
which includes several layers of epitenon cells
seeding on the surface (top, hematoxylin-
eosin stain). Middle, Extrasynovial tendon that Tendon
is wrapped by loose connective tissue,
paratenon (top, hematoxylin-eosin stain). Synovial
Epitenon Paratenon SSCT Bursa
Right, Hybrid region of the tendon that sheath
wrapped by paratenon and synovial sheath
bursa (top, hematoxylin-eosin stain).
Intrasynovial Extrasynovial Hybrid

portion portion portion
0.8
2.0 0.7 PL tendon
FDP FDP tendon
0.6
PL
Friction force (N)
Friction (N)
0.5
0.4
1.0 0.3
0.2
0.1
0
0 0 200 400 600 800 1000
0 4 8 12 16 Number of cycles
Load (N)
Figure 3-5 The friction of the extrasynovial tendons rises
Figure 3-4 The slope of friction versus load for the up rapidly with cyclic motion. The intrasynovial tendon
extrasynovial tendon (palmaris longus [PL]) was higher than remains at the same level of frictional force even after 1000
that for the intrasynovial tendon (FDP). (Data from Uchiyama cycles of tendon motion.
S, Amadio PC, Coert JH, et al: Gliding resistance of
extrasynovial and intrasynovial tendons through the A2
pulley, J Bone Joint Surg Am 79:219–224, 1997.)
why tendons may form adhesions, increased friction is
certainly one of the major factors to consider, which
can be ameliorated if an intrasynovial graft is available.
Although the gliding ability of the paratenon is not Unfortunately, there are few intrasynovial tendons that
as durable as the epitenon, it serves as a cushion and can be sacrificed for the purpose of tendon grafting. The
sliding sleeve to protect the tendons from surrounding development of a tissue-engineered intrasynovial graft
tissues, such as muscle, bone, and neurovascular struc- is one object of our research.
tures. It also serves as a network to protect the vessels
and nerves that provide the nutritional supply of
TENDON LUBRICATION
tendons.27
Due to the differences of anatomy and structure Lubrication has been the focus of intense study in
between intrasynovial and extrasynovial tendons, the articular cartilage, since cartilage degeneration is associ-
frictional force of extrasynovial tendons is much higher ated with mechanical abrasion and wear.32-34 Although
than that of intrasynovial tendons.28,29 Uchiyama et al tendon does not bear as much compressive loading as
found that the frictional force of the palmaris longus cartilage, the number of motion cycles experienced by
tendon increased with increasing loads. In contrast, the tendons is comparable to that of joints and was esti-
frictional force of FDP tendon was nearly independent mated at over 1 million cycles per year.35,36 Therefore,
of the load applied to the tendon (Figure 3-4). Several tendon lubrication is very important, especially for the
studies have demonstrated that the frictional force of intrasynovial tendons in the hand, which experience
extrasynovial tendons increases rapidly with cyclic the most cyclic motion. Since the gliding structure of
motion,29-31 while intrasynovial tendons maintain a the intrasynovial and extrasynovial tendon structure is
constant frictional force even after 1000 cycles of tendon different, the lubrication mechanism is also totally
motion (Figure 3-5). different.
Tendon surface morphology has been studied with
the use of electron microscopy. These studies show that Intrasynovial Tendon Lubrication Mechanism
the intrasynovial tendon surface has a smooth surface, As the intrasynovial tendon glides within a synovial fluid
with no collagen fibrils exposed on the surface. After environment, its lubrication mechanism is similar to
cyclic motion, this smooth surface is maintained. In the cartilage in the articular joint, which associates two
contrast, the paratenon on the extrasynovial tendon lubricating phenomena (i.e., boundary lubrication and
surface wears off with cyclic motion, exposing increas- fluid-film lubrication). Boundary lubrication mainly
ing amounts of collagen fibrils with increasing number relies on the tendon surface structure. The intrasynovial
of motion cycles (Figure 3-6). One could argue that tendon surface is covered by a highly resistant, tenacious
extrasynovial tendon rarely glides against a pulley, but epitenon layer acting as a living boundary support load
this is only true normally. When an extrasynovial tendon and avoiding collagen wear. These cells also secrete
is used as a graft to reconstruct an intrasynovial tendon, lubricants into the synovial fluid. In addition, some of
which is a common clinical situation, then the tendon the secreted lubricants are bound to the intercellular
does glide against a pulley. While there are many reasons matrix, and thus remain adherent to the epitendinous
FDP tendon Before testing After 1000-cycle After 1000-cycle
A B C
PL tendon
D E F
Figure 3-6 The morphological appearances under scanning electron microscopy (SEM) of the intrasynovial tendon
(A, normal tendon before testing; B, after 1000 cycle motion in low magnification; and C, after 1000 cycle motion in high
magnification) display a smooth surface compared to the extrasynovial tendon (D, normal tendon before testing; E, after
1000 cycle motion in low magnification; and F, after 1000 cycle motion in high magnification paratenon on the extrasynovial
tendon surface wears off with collagen exposed under tendon cyclic motion against pulley).
surface. The extracellular matrix of the epitenon layer Core protein

has similar components and structure as the superficial
zone of the cartilage, including collagen, hyaluronic
acid, proteoglycans, and phospholipids. The structural Chondroitin
collagen in tendon is type I collagen. Hyaluronic acid sulfate
(HA) is an important component on the tendon surface.
Keratan
Proteoglycans bind to HA in the presence of HA binding sulfate
protein (Figure 3-7),37,38 forming large highly negatively HA
harged aggregates. These aggregates imbibe water to HA–binding
form a highly viscous layer to decrease friction and wear domain
during tendon motion. The major lubricating proteogly-
can on the tendon surface is lubricin.39,40 Phospholipids,
existing on the cell surface and extracellular matrix, are
also important for lubrication.41,42 These three compo- Proteoglycan
nents (i.e., HA, lubricin, and phospholipid) are present Hyaluronic
in the synovial fluid as well. acid (HA)
The removal of any of these three lubricating sub-
stances results in increased friction.43 Conversely, exog- Epitenon cell
enously applied lubricants on the tendon surface
decrease the frictional force, especially in combination, Collagen
and when chemically bound to the tendon Phospholipids
surface.29-31,44 Figure 3-7 Intrasynovial tendon surface structure.
Extrasynovial Tendon Lubrication
In contrast to intrasynovial tendon, the extrasynovial moves, the paratenon layer closest to the tendon starts
tendon has no synovial fluid environment. The lubrica- to move. This stretches the collagen fibers crosslinking
tion mechanism relies on the paratenon sliding unit.27 between the paratenon layers, leading to the next layer’s
The paratenon gliding mechanism of extrasynovial subsequent motion. This sequential small motion
tendon has been well studied recently, using flexor among paratenon layers effectively reduces the total
tendon in zone 4 as a model.26,45,46 When the tendon tendon excursion related to the surrounding tissue
Outer paratenon
displacement
A B
Tendon displacement
Paratenon
Tendon
Figure 3-8 Extrasynovial tendon gliding mechanism. When a tendon moves from A to B, the paratenon layer that closes to
the tendon moves first and then transmit to the next layer by the connecting collagen fibers shown by the scanning electron
microscopy (SEM) left (relaxed) and right (stretched). This sequential motion of the multi–paratenon-layer motion decreases
the relative motion between tendon and surrounding tissue.
and decreases abrasion during tendon motion (Figure

3-8).47 Any pathological changes of the paratenon, such Toe region Linear region Failure region
as fibrosis, could alter this sequential motion pattern,
which in turn may lead to clinical problems. Indeed, a
Sress (N/ma)
disruption of this mechanism has been suggested as a

cause of carpal tunnel syndrome.26
BIOMECHANICS OF TENDON MOTION
Flexor tendons cross over multiple joints, including the
wrist, metacarpophalangeal (MCP) joint, proximal
interphalangeal (PIP) joint, and distal interphalangeal
(DIP) joint. Therefore, a large excursion is needed to
Strain
achieve full joint motion. Flexor tendons also bear large
tensile loads during forceful hand motion and experi- Figure 3-9 Tendon mechanical properties can be typically
ence a huge number of repetitive motion cycles during presented by its stress-strain curve, which includes three
routine activities. It is essential therefore to understand phases: a toe region, a linear region, and a failure region.
the mechanical properties and motion characteristics of
the flexor tendons.
collagen molecules form a microfibril, and groups of
Mechanical Properties of Tendon microfibrils assemble a subfibril, which then combine
Mechanical properties of tendon are determined by its to form larger fibrils. Fibrils are packed in parallel
basic structure, molecular organization, cellular arrange- bundles with proteoglycans and water to form the fas-
ment, and extracellular crosslinking. The tendon con- cicles. The numbers of fascicles, which are wrapped by
sists of 60% to 80% water in its wet weight. The major the endotenon, compose a tendon bundle.48,49 Some
extracellular matrix is type I collagen, which is estimated tendons have only one tendon bundle; others have
to comprise about 80% of the tendon’s dry weight. several. For example, the canine flexor digitorum pro-
Proteoglycans and elastin make up 1% to 5% and 2% fundus tendon in zone 2 has two bundles.50
of the dry weight, respectively.48 Collagen’s hierarchical The tendon stress-strain curve includes three phases:
structure has been well described. The collagen mole- a toe region, a linear region, and a failure region (Figure
cule itself is a triple helix of polypeptide chains linked 3-9). The toe region is the initial loading phase, in
by covalent and hydrogen bonds. Five crosslinked which a small axial load can reach a large elongation.
Biomechanics of Tendon Motion

Creep The flexor tendon excursion depends on the range of
joint motion and applied tension.58-60 In the pathologi-
Elongation
cal condition, there are other factors, such as tendon
Load
Constant load adhesions, joint contracture, bone shortening, or pulley
Elongation resections, that also affect excursion.61-63 Wehbe et al58
Load measured tendon excursion radiographically in 36
hands in which the flexor tendons were tagged with
A Time (load control) buried wire sutures. The flexor digitorum profundus
tendon excursion averaged 32 mm and the flexor digi-
Constant elongation torum superficialis tendon averaged 24 mm with the
wrist in the neutral position. With wrist range of motion
Stress
Elongation
relaxation added, the amplitude of the profundus tendon excur-
Load
sion increased to 50 mm and the superficialis tendon to
Elongation
49 mm.58
Load The correlation between tendon excursion and joint
motion has been well studied.64,65 For single joint
motion, the ratio of the joint motion and tendon excur-
B Time (displacement control)
sion is determined by the joint moment arm. Since the
Figure 3-10 A, Creep is the time-dependent elongation of moment arm is different for different joints, the relation
the tendon under a constant load. B, Stress relaxation of tendon excursion and joint motion is different at
presents the concomitant decrease in load as the tendon is different joints. The larger the moment arm, the greater
subjected to a constant elongation. the tendon excursion must be to produce a given angle
of joint rotation. For example, at the DIP joint, every 10
degrees of motion requires 1.2 mm of FDP tendon
This behavior is attributed to the collagen at the molecu- excursion, while at the MCP joint every 10 degrees of
lar level unfolding from an initial relaxed state. The motion requires 2.2 mm of FDP tendon excursion.59
linear region demonstrates the fundamental tendon The tendon excursion also can be mathematically
mechanical properties, in which the tendon elongation calculated based on the joint moment arm.61,64,65 The
is constant under a given load. The slope of the stress moment arm is defined as the perpendicular distance
to strain represents Young’s modulus of elasticity. In between the joint center rotation and the central longi-
the failure region the collagen crosslinks gradually tudinal axis of the tendon (Figure 3-11). To best under-
break until complete disruption occurs. Since the stand the relationship between tendon excursion, joint
tendon is a viscoelastic tissue, the mechanical behavior angular motion, and moment arm, the geometric
of tendon can be also characterized by creep and stress concept of the radian has been introduced (Figure
relaxation. Creep is a time-dependent elongation of the 3-12).64 The basic concept is that the joint is like a
tendon under a constant load (Figure 3-10A). Stress wheel, and the tendon is like a rope going around the
relaxation represents the concomitant decrease in load outer edge of the wheel. As the rope is pulled, the wheel
as the tendon is subjected to a constant elongation turns. For one complete rotation of the wheel (360
(Figure 3-10B). degrees) the rope must move the full circumference of
In the normal tendon, Young’s modulus ranges from the wheel, which is 2πr. The moment arm, or distance
1200 to 1800 Mpa, the ultimate strength ranges from from the center of rotation to the closest point on the
50 to 150 MPa, and the ultimate strain to failure ranges tendon, is also the radius of the circle, or r, which means
from 9% to 35%.48 However, the true strain is probably that when the joint moves roughly 57.29 degrees
less. The strains noted in publication are measured from (360/2π), the tendon will have moved a distance equal
the places where the tendon is gripped. More detailed to r. This angular rotation, 57.29 degrees, is called a
studies of strain within the tendon suggest that there is radian.
always some slippage at the grips, and the intratendi- The moment arms of the hand joints have been
nous true strain to failure is less. reported with 12.5 mm at the wrist, 10 mm at the MCP
Tendons are rarely subjected to within 30% of the joint, 7.5 mm at the PIP joint, and 5 mm at the DIP
tendon ultimate force and stress values, even for the joint.64,66 Based on the angular motion of the finger
most vigorous activity.51,52 This high safety factor may joints (MCP, 85 degrees; PIP, 110 degrees; DIP, 65
explain why tendon rupture is usually at the muscle– degrees), the excursion was calculated as 14.8 mm in
tendon conjunction or tendon–bone insertion, rather the MCP joint, 14.4 mm in the PIP joint, and 5.7 mm
than within the tendon substance,53,54 unless the tendon in the DIP joint (see Figure 3-12). These results indeed
is damaged by disease or trauma.55-57 were similar to excursion that was experimentally
Figure 3-11 The moment arm is the

perpendicular distance between the joint
center rotation and the central
longitudinal axis of the tendon.
Moment
arm
110° ~ 14.4 mm
85° ~ 14.8 mm
140° ~ 30 mm
65° ~ 5.7 mm
1 Radian = 57.29°
5 mm 7.5 mm 10 mm 12.5 mm
DIP PIP MP Wrist
Figure 3-12 The FDP tendon excursion can be calculated by the joint moment arm and its range of motion based on the
principle that the excursion is equal to moment arm when joints move 57.29 degrees (1 radian).
measured using human fingers.58,59 This mathematical arm, leading to a need for more tendon excursion to
calculation model provides a useful tool for the valida- produce a given arc of motion.
tion of in vivo measurement of tendon excursion.67-69 The flexor tendon–pulley system elegantly balances
Tendon excursion is also dependent on the force the force generation and tendon movement.66 Tendon
applied to the tendon. The excursion with active motion excursion has an upper limit, so moment arms need to
is longer than the excursion with passive motion due to be small to affect the most motion. However, tendons
the difference of the force applied to the tendon.60,70,71 transmit force, so moment arms should be big to apply
Although joint passive motion can induce a pushing more force. The volar plate–based annular pulleys, A1,
force from distally towards proximally which is able to A3, and A5, provide this flexibility, because the moment
create tendon motion, this passive tendon excursion is arms begin short with the finger extended and then
limited by tendon buckling, if the resistance to passive gradually increase as the finger flexes, and the volar plate
motion exceeds the passive force applied to the bows away from the joint center of rotation. Using this
tendon.71,72 In contrast, active motion not only elimi- concept, many postoperative rehabilitation protocols
nates this tendon buckling effect but also elongates the have been developed.71,73-76
tendon viscoelastically, to create more tendon excursion The tendon motion or excursion can also be affected
even without joint motion. In addition, the active force by the tendon friction within the flexor sheath. This
on the tendon boosts the bowstring effect, especially effect may not be obvious since the normal frictional
when the joint is in flexion position (Figure 3-13). This force is very small. We have already discussed some
bowstring effect will increase the tendon–joint moment pathological conditions that cause the friction to
599% for high-friction repair technique, which then

make up 24% and 31% of total work of flexion, res
pectively.81 External resistance can also dramatically
increases after trauma and surgical procedures due to
soft tissue edema, joint swelling, and pain-induced
antagonist muscle contraction. As the total resistance
increases, more tendon force is needed to move the
finger during active motion. Therefore, the tendon repair
strength has to be strong enough to bear the loading
without gapping or rupture of the tendon during active
Moment arm
motion. With passive motion, however, since the exter-
nal resistance is overcome by the passive manipulation,
motion of the tendon only needs to overcome the inter-
Figure 3-13 Moment arm of the PIP joint increases with nal resistance between the tendon surface and surround-
the joint flexion due to bowstring effect when a tension (10 ing tissues. However, the force applied to the tendon
Newton) is applied to the FDP tendon. with passive motion is also small. Therefore, the fric-
tional force of the repaired tendon becomes an impor-
tant issue if a passive rehabilitation is chosen. A low
increase, potentially hindering tendon motion, such as frictional repair technique should be considered if a
trigger finger or tendon repair.7,17,74,77-80 passive rehabilitation is used clinically.
Mechanical resistance to tendon gliding is composed In summary, tendon friction, lubrication, and the
of external sources of resistance and internal sources of biomechanics of tendon motion are the fundamental if
resistance. The external sources of resistance consists of a hand surgeon is to understand hand function and
joint stiffness, surrounding soft tissue resistance, mass pathological alterations. Normally, the tendon in zone
of the digit, and resistance of antagonist muscles. The 2 is almost frictionless, because of its unique structure
internal resistance includes surface friction between and effective lubricating surface. However, any patho-
tendon and sheath, the bulk friction due to the fit of logical disorders that disrupt tendon lubrication could
the tendon within the flexor sheath, and biological jeopardize the tendon motion. A better understanding
adhesions. The energy expended by internal resistance of the evolution of resistance to finger motion, tendon
in only a small portion (10%) of total work of flexion. strength after repair, and postoperative rehabilitation
However, the internal resistance after tendon repair will guide future improvement in treatment of these
increases 274% for low-friction repair techniques and complex injuries.
References
1. An KN, Berglund L, Uchiyama S, et al: Measurement of fric- 8. Morooka T, Miura H, Higaki H, et al: A new friction tester of
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CHAPTER
4
BIOMECHANICS OF CORE AND
PERIPHERAL TENDON REPAIRS
Jin Bo Tang, MD, and Ren Guo Xie, MD
OUTLINE The end-to-end repair commonly consists of two

parts: (1) core sutures that provide essential strength and
Surgical sutures with core and epitendinous stitches (2) peripheral sutures (also called epitendinous sutures)
are the mainstay of tendon repair. Adequate mechani- that serve to “tidy up” the tendon approximation.
cal strength is essential for a repair to resist gapping Strength of the repairs relates to the tendons’ resistance
and failure. A repair using conventional two-strand to gapping at the repair site and to complete failure
core sutures is weak; repairs using four- or six-strand during tendon movement, which consequently relates
core sutures are stronger. To ensure surgical repair closely to adhesions and ruptures of the tendons. The
strength, a sufficient number of strands (four or more) essential goal of a surgical repair is to provide the tendon
passing through the repair site, an optimal core suture with strength sufficient to withstand early active tendon
purchase (0.7 to 1.2 cm), appropriate suture calibers motion postsurgery but offering minimal resistance to
(4-0 or 3-0), and optimal size (2 mm) of locking or tendon gliding. A surgical repair should also be simple
grasping anchors are essential. Maintaining a certain (or at least uncomplicated) for most surgeons to learn
baseline tension on the core suture during surgery and to practice. Therefore, understanding the biome-
greatly benefits gap resistance. It should be realized chanics of tendon repairs is imperative not only to
that repair strength decreases considerably as the design and planning of an optimal repair technique but
finger flexes, and traumatized tendon ends tend to also to its appropriate application to clinical cases and
soften during the first 2 weeks postsurgery, thus reduc- to guide postoperative rehabilitation. Surgeons or thera-
ing the holding power of the suture. The innately weak pists should also be aware of the mechanical properties
and slow biological healing creates a “no gain” lag of surgical repairs when establishing postoperative
period in tendon strength during the first 3 to 4 weeks therapies.
after surgery. We should ensure that the strength of
surgical repairs is greater than the forces generated
ESSENTIAL MECHANICAL REQUIREMENTS
during unresisted active finger flexion (1 to 35 N for
OF A SURGICAL REPAIR
a normal adult) plus a certain safety margin.
Forces generated during normal hand action range from
The gap resistance, ultimate strength, and stiffness of 1 to 35 N, except tip pinch, according to in vivo mea-
repaired tendons are the primary parameters that define surements.1 Schuind et al1 measured tendon forces up
the mechanical properties of a surgical repair. To evalu- to 6 N during passive mobilization of the wrist, up to 9
ate a surgical repair, the tendon is usually tested under N during passive mobilization of the fingers, and up to
a single cycle load-to-failure or under cyclic loading; 35 N during active unrestricted finger motion. There-
both generate load-displacement curves. The cycle fore, a surgically repaired tendon should be able to
numbers at which gapping occurs and the repair com- withstand at least 40 N, with power sufficient to resist
pletely fails indicate performance of the repair. gap formation. The repair should be able to withstand
Surgical repairs of the tendon are divided into end- cyclic loads under both linear and curvilinear load con-
to-end repairs (for acutely lacerated tendons), repairs of ditions. In vitro laboratory tests have shown that a con-
tendon–bone junctions, and tendon repairs by other ventional two-strand core repair plus running peripheral
methods (such as interweave repairs for tendon grafting sutures yields a maximal strength of 20 to 30 N2; this is
or transfer). This chapter will be devoted to end-to-end lower than forces generated during normal hand actions
repairs for primary tendon surgery. These repairs have and explains why some such repairs are disrupted during
received the most attention, and their success is most postoperative motion exercise. Studies have shown that
dependent on repair mechanics. Strong surgical repair forces necessary to cause failure of four-strand repairs
is the mechanical basis of early tendon mobilization are around or beyond 40 N3-5; six-strand repairs fail with
and a prerequisite for biological healing. loads over 50 to 60 N.6,7
35
Clinically, patients are encouraged to start moving mechanical properties of the repairs. Human and porcine
the tendons in the first few days after surgery. Edema of tendons are the most common materials used in in vitro
traumatized tissues (tendons, subcutaneous tissue, tests of repair strength,2-5 though tendons from sheep,
sheath, and pulleys), bulkiness of the tendons, and the rabbits, monkeys, and cows are also reported.7,8 Canine,
normal healing responses of tissues increase the resis- rabbit, and chicken are used in in vivo investigations.9-12
tance of the tendons. In the first 1 to 2 weeks, the tendon
CURRENT TENDON REPAIR TECHNIQUES
ends tend to soften, which decreases their power to hold
the sutures. Therefore, a certain safety margin should be Techniques currently available are, first, repair with core
maintained by increasing the baseline surgical repair and peripheral sutures. Core suture repairs are further
strength. Taking these points into consideration, one divided according to the number of strands passing
expects a baseline ultimate strength of 40 to 50 N and through the repair site: two-strand (conventional) and
the capacity to resist gapping of 20 to 30 N for a surgi- multistrand (including four-strand, six-strand, and
cally repaired tendon. eight-strand) repairs.2-8,13,14 Alternatively, suture repairs
can be categorized by type of tendon–suture junctions:
HISTORICAL REVIEWS
grasping, locking, and mixed grasping-locking repairs.
The main body of information regarding the biome- A repair is often referred to using the type of tendon–
chanics of tendon repair was accrued over the past few suture junctions and the number of strands (e.g., a
decades; the principal contributing research groups are locking four-strand repair). Peripheral sutures include
summarized in Box 4-1. The investigatory topics interrupted, simple running, locking running, cross-
included (1) development of new repair methods; (2) stitch (Silfverskiöld),15 locking cross-stitch (Dona),16
comparisons of existing repairs; (3) factors affecting interlocking horizontal mattress (IHM),16 and horizon-
strength; and (4) new means to test or to record the tal mattress (Halsted) sutures.17 Second, repair can be
Box 4-1 Groups Contributing to Major Information of Tendon Repair Biomechanics

(Listed in Alphabetic Order of the Leading Investigators)
Amadio-Mayo Group: In vitro model: human, canine tendons; in vitro model: canine tendons
Gliding friction of the tendon against sheath and pulley (Uchiyama et al), gapping and resistance of grasping and locking
repairs (Tanaka et al), partial tendon repairs (Zobitz et al), effects of different repairs, knot sizes and locations (Momose
et al), and relation of gap sizes and gliding resistance (Zhao et al).
Gelberman–St Louis Group: In vitro and in vivo models: canine tendons

Significance of gap formation on adhesion and repair failure (Gelberman et al), effects of forces of rehabilitation on the
healing strength (Boyer et al), zone 1 flexor tendon repair including tendon–bone junction (Silva, Dinopoulos, et al), and
development of eight-strand repair (Winster et al).
Manske–St Louis Group: In vitro model: human, canine tendons; in vivo model: canine, chicken tendons
Development of tendon splint repair (Aoki et al), knot locations (Pruitt et al), cyclic loading (Pruitt et al), differences between
grasping and locking loops (Hotokezaka and Manske), effects of area of locking loops, suture sizes, and development of
the modified Pennington locks (Hatanaka and Manske), and tendon strength during early mobilization (Kubuta, et al).
Mass-Chicago Group: In vitro model and in vivo models: human tendons

In situ tendon repair strength in curvilinear test model using cadaveric hands (Komanduri et al), comparison of repair
strength of different techniques (Angeles et al), repair strength during cyclic load (Choueka et al), and partial tendon
repairs (Manning et al)
Tang-Nantong Group: In vitro model: human, porcine tendons; in vivo model: chicken tendons
Development of four- and six-strand repairs (Wang et al), effects of sizes and configurations of locks (Xie et al), core suture
purchase (Cao et al) and oblique or partial tendon cuts (Tan et al), effects of tension direction and tendon curvature
(Tang et al), strength of the healing tendon (Wu et al), and effects of a major pulley on strength (Cao and Tang).
Trumble-Seattle Group: In vitro model: human tendons

In situ test of repair strength in cadaveric hands and cyclic loading (Thurman et al), zone 1 tendon repairs (McCallister
et al), and repair with Fiberwire (Miller et al and Hwang et al).
Wolfe–Yale–New York Group: In vitro model: human tendons

Development of the cruciate repair (McLarney et al), cyclic loading test of locked repairs and gap formation (Barrie et al),
effect of peripheral suture purchase (Merrell et al), and comparisons of four-strand repairs with Teno Fix (Wolfe et al)
Chapter 4: Biomechanics of Core and Peripheral Tendon Repairs 37
completed with devices. The use of devices is not

common; methods include tendon splints,18 barbed
repair devices,19,20 and the Teno Fix device.21,22
Surgical repairs using sutures are the mainstay of
current clinical practice. In experimental settings, repairs
with use of the above-mentioned devices have yielded
impressive strength. The Teno Fix system, a stainless
steel rod connecting stainless steel soft tissue anchors
with screw threads in each end, was tested in vitro and
shown to have strength similar to or greater than a four-
strand repair.21 Clinical use of Teno Fix to repair zone 2
flexor tendons has been reported with good outcomes.22
However, Teno Fix is likely to make the tendon bulky
and may even impinge upon the already narrow and
swollen pulleys, which is a concern. Implanting a stain-
less steel rod not only risks increasing the volume of the Locking loop Grasping loop
tendon but also may require another operation to
Figure 4-1 Locking and grasping tendon-suture junctions
remove. A barbed suture device was reported to produce
have different interactions between the suture and tendon
strength equal to a four-strand core suture.19,20 There are fibers. Locking repairs tighten around tendon fibers under
similar concerns regarding repair bulkiness. The idea of tension, but grasping repairs tend to pull through tendon
placing a splint inside the tendon to bridge the cut ends fibers under tension.
was tested experimentally by Aoki et al,18 but this
method has not yet been used clinically.
TYPES OF TENDON–SUTURE JUNCTIONS
AND THEIR STRENGTH
In a broader sense, all parts of any sutures embedded
within tendon stumps constitute tendon–suture junc- Circle-lock Loop-lock
tions. However, the tendon–suture junction usually
refers to the site where the suture forms a “locking” or
“grasping” configuration to encompass the tendon sub-
stance. These sites are anchor points of the surgical
suture—by either grasps or locks on the tendon—that
help secure the power of surgical repairs. Cross-lock (embedded) Pennington-lock
Locking is defined as the configuration that tightens
around a bundle of tendon fibers when tensile forces
are applied to the suture ends (Figure 4-1).23 In con-
trast, grasping refers to the configuration that holds the
tendon fiber bundles but does not tighten around their
entire circumference and tends to pull through the fiber
Cross-lock (exposed) Grasp (non-lock)
bundles when tensile forces are applied to the suture
ends (see Figure 4-1). Figure 4-2 Different tendon–suture junctions: different
locking junctions and a grasping junction.
Grasping junctions are either open circle or open
loop. Locking junctions include cross-locks (either
exposed or embedded), circle-locks (looped or double- above are not met. In clinical settings, we should ensure
circled), and Pennington locks (original or modified) that the calibers of the suture are equal to or greater than
(Figure 4-2). Mechanically, the effectiveness of grasps 4-0, the suture purchase no less than 7 to 10 mm, and
or locks of a core suture is greatest when (1) suture the size of the lock or grasp equal to or greater than
materials are sufficiently strong—allowing the sutures 2 mm. These requirements are critical to the repair
to grasp or lock the tendon substance tightly without strength and are more important than whether a locking
disruption of sutures; (2) the anchor point is sufficiently or a grasping junction is used or which lock is incorpo-
distant from the tendon laceration—so grasps or locks rated into the repair.
will not slip; and (3) grasp or lock sizes are sufficient— When all the above conditions are met, grasping and
so the suture anchors to ample tendon substance. locking junctions provide reliable anchors for the suture
In other words, one should not expect a locking or in the tendon, although a locking repair is generally
grasping junction to be secure if all three requirements somewhat stronger than a grasping repair. In practice,
when the primary requirements of the repairs are met, at days 3 and 21, not at days 7 and 14, even with the
the differences in the strength between locking and 2-0 suture. In other words, modified Pennington locks
grasping repairs are actually narrow or insignificant. do not improve repair strength during the second week
Depending on the locks or grasps used, the strength of (days 7 to 14), when the tendon stumps usually soften
repairs changes (usually less than 10 N).23-29 The increase and most ruptures occur. We should be cautious in
in strength brought about by incorporation of locking relying upon Pennington locks to increase strength.
anchors is much smaller than increases in strength Recently we examined the effectiveness of the origi-
through other means—such as increasing the strength nal Pennington lock in a four-strand repair; we detected
of suture materials or the number of suture strands no differences in strength between repairs with the Pen-
passing through the repair site.2-7 From this perspective, nington locks and those with random assignment of
surgeons should pay ample attention to factors that grasping and locking. When a two-strand Kessler repair
exert the greatest influence on strengths and ensure that with original Pennington locks was compared with the
these requirements are met primarily. It is not appropri- repair with grasping anchors using 4-0 suture, our tests
ate to rely on incorporating locks, hoping that this indicated a modest difference (12%) in gap resistance
measure alone increases strength, while neglecting other but no difference in ultimate strength.29 When compar-
more influential factors. ing two grasping anchors (open circle and open loop),
Whether various locks have different mechanical we found no difference in their gap resistance and ulti-
strengths is under question. We tested the strength of mate strength. Taken together, the evidence above leads
the different locks and found they have essentially the us to believe that differences between the grasping and
same holding power.27 A cross-lock and a circle-lock are the original Pennington’s locking tendon–suture junc-
identical in holding power; an exposed cross-lock and tions may not be substantial in a clinical setting, and
an embedded cross-lock are the same as well.27 However, incorporating Pennington locks in multistrand repairs
our in vitro tests showed that the Kessler-type repairs does not appear to affect strength.
with the original Pennington locks are weaker than
repairs with cross- or circle-locks.28
STRENGTHS OF CORE SUTURES
Pennington locks are frequently incorporated in
Kessler-type repairs. Most surgeons believe that Pen- Strengths of core sutures have been tested extensively
nington locks help secure the repair. However, this con- both in vitro and in vivo and in single cycle load-to-
sideration actually lacks sufficient experimental support. failure test2-14,23-28,32-34 or cyclic test setup.35-37 Using a
According to the definitions of Pennington30 in 1979, 4-0 nylon suture, a two-strand repair has a strength of
in the locking configuration of the Kessler repair, “the about 20 to 25 N, a four-strand repair has a strength
transverse suture component passes superficial to the of about 35 to 45 N, and a six-strand repair has a
longitudinal component so that the sutures lock a strength of about 50 to 70 N. Thus we see the strength
bundle of tendon fibers when tensile forces are applied is roughly proportionate to the number of strands
to the suture.” Pennington did not present its strength (Table 4-1).2-8,13,14,32-35 Strength is greatly increased when
data when describing this repair.30 In a letter communi- suture caliber increases36-38 or stronger suture material is
cation directed to Pennington,31 Silfverskiöld com- used (see Table 4-1).38,39
mented regarding this locking repair: “As to Dr. The common core sutures are as follows:
Pennington’s claim that the locking loop design is
crucial to the tensile strength of the suture, I agree that 1. Kessler-type repair: The two-strand modified Kessler
in theory this should be true, but in actual practice this repair has been the most common over the past
may not be the case. … Another practical consideration decades. Four-strand Kessler repairs were devel-
is that even if one attempts to place the transverse part oped, either as a double Kessler or as one Kessler
superficial to the longitudinal part, to create the locking repair made with a double-stranded suture
design, it is often difficult to be certain of success.” (Figure 4-3).
Practically, we agree that it is difficult for surgeons to 2. Cruciate repair: The original cruciate repair is a
ascertain the relation of transverse and longitudinal four-strand grasping repair (see Figure 4-3).4 Locks
sutures in the repaired digital tendon clinically. can be incorporated to make a locking repair.14,35
Hatanaka and Manske9,24 modified the Pennington 3. Strickland repair: This four-strand repair consists of
locking repair by placing some of the longitudinal a Kessler-type repair (with reinforced double-circle
strands over the dorsal tendon surface, making locked locking anchors at four corners) and a simple
tendon–suture junctions confirmatively. The modified double right-angle suture (Figure 4-4).41,42
repair is stronger than the grasping Kessler repair when 4. Savage repair and modifications: Savage repair is a
the suture calibers are 2-0 and 3-0 but not 4-0.24 It is six-strand locking repair.32 Its modifications
noteworthy that in an in vivo setting,9 the strength include a six-strand single-cross repair, with one
gained by this modified locking repair was noted only cross-lock as suture anchor (see Figure 4-4).43
Table 4-1 Some Biomechanical Tests Showing Increases in the Strength With the Number of Strands and the
Strengths of Repair Devices
Suture Materials Ultimate Gap Force (N)
Investigators Tendons Methods Core/Epitendinous Strength (N) (Gap Sizes)
Savage,32 1985 Procine 6-strand (Savage) 4-0 Ethibond 60–70 44 (3-mm)
2-strand (Kessler) 4-0 Ethibond 23 10 (3-mm)
18
Aoki et al, 1994 Human Tendon splint Dacron 81–84 20–31 (initial)
2-strand Kessler 4-0 Ethibond/6-0 26 14 (initial)
Prolene
Greenwald et al,7 1995 Monkey 4-strand (MGH) 5-0 Nylon/6-0 Nylon 30
2-strand (Kessler) 5-0 Nylon/6-0 Nylon 16
Thurman et al,35 1998 Human* 6-strand (Savage) 4-0 Tricron/6-0 79 (0.3 mm)
Surgilene
4-strand 4-0 Tricron/6-0 43 (0.3 mm)
(Strickland) Surgilene
2-strand (Kessler) 4-0 Tricron/6-0 34 (2.7 mm)
Surgilene
McLarney et al,4 1999 Human 4-strand 4-0 Ethobond/6-0 56 44 (2-mm)
(cruciate) Polypropylene
Barrie, et al,14 2000 Human* 4-strand 4-0 Ethibond/6-0 70 49 (3-mm)
(cruciate, grasp) Nylon
4-strand 4-0 Ethibond/6-0 79 52 (3-mm)
(cruciate, lock) Nylon
Xie et al,6 2002 Human 6-strand (Tang) 4-0 Supramid/6-0 60 45 (2-mm)
Nylon
Wang et al,33 2003 Porcine 6-strand 4-0 Supramid/6-0 62 46 (2-mm)
(M-Tang) Nylon
Cao and Tang,34 2005 Porcine 4-strand 4-0 Supramid/6-0 43 37 (2-mm)
(U-shaped) Nylon
Lawrence and Davis,39 2005 Human 4-strand 4-0 Fiberwire/6-0 81 63 (initial)
(single-cross) Nylon
Su et al,21 2005 Human Teno Fix Teno Fix 55 47 (2-mm)
Teno Fix/5-0 67 55 (2-mm)
Polypropylene
Hirpara et al,20 2010 Porcine 2 barbed repair Nitinol 58 30 (3-mm)
devices
Wu et al,28 2011 Porcine 4-strand 4-0 Ethilon/6-0 40 32 (2-mm)
(cross-lock) Nylon
*In situ test of the repair strength and gapping of flexor tendons in cadaveric hands under cyclic tension.
5. Becker repair and Massachusetts General Hospital sutures. Two or three groups of looped sutures can
(MGH) repair: Becker et al44 used a series of cross- be used. We typically used three groups of looped
stitches to repair a beveled tendon. The MGH sutures in repairing tendons (see Figure 4-4),45
repair is its modification that uses four-strand with and fewer looped sutures in modifications of such
a series of cross-stitches (cross-locks).7 repairs (Figure 4-5).33,34,46
6. Multiple looped sutures and their modifications: These 7. Repairs with double-stranded sutures: These repairs
repairs are accomplished using Tsuge’s looped simplify surgical maneuvers (Figure 4-6). A
I I
II II
A
A III B III
Figure 4-3 Methods of making a two-strand modified
Kessler repair (A), and a four-strand cruciate repair (B). B
A
C
D
C
D
Figure 4-4 Four-strand Strickland repair (A), six-strand
E
original Savage repair (B), six-strand modified Savage Figure 4-5 Methods of making a modified six-strand
(Adelaide) repair (C), and six-strand Tang (or three Tsuge) Tang repair forming an M configuration (M-Tang repair).
repair (D). A U-shaped four-strand repair is made with one looped
suture (A-C), and another looped suture is used to complete
the six-strand repair (D and E).
number of configurations can be created and have

similar strength, except that the four-strand Kessler STRENGTH OF PERIPHERAL SUTURES
repair is a bit weaker.28
Interrupted, running, or locking running peripheral
Core suture configurations, as detailed above, vary enor- sutures are common in the clinic. These peripheral
mously. Practically, with an identical number of suture sutures are usually adequate to smooth the tendon and
strands passing through the repair site, the strength of to help resist gapping (Figure 4-7).
these sutures varies within a small range. To maintain Others are more complex, which some surgeons have
ideal strength, two factors are crucial to all core sutures: advocated to increase strength, rather than simply to
(1) adequate suture purchase: a 7- to 10-mm purchase is approximate the tendon ends. The cross-stitch suture
necessary to ensure optimal performance of a core designed by Silfverskiöld et al15 is among the most
suture, and (2) secure locks or grasps: the locks or grasps famous. Silfverskiöld’s group15 had good clinical results
should be of a diameter of 2 mm or more and of suf- with this suture combined with a two-strand modified
ficient depth. Superficial or small locks or grasps are Kessler core repair. The cross-stitch suture does provide
pulled out easily. the tendon with great strength, but we have a concern
about its massive exposure of sutures over the tendon,

which may increase gliding resistance and the likeli-
hood of adhesions. Similarly, locked cross-stitch16 and
Halsted17 sutures give the tendon great strength. Com-
A
plexity of surgical maneuvers and suture exposures are
their major drawbacks. Nevertheless, several complex
repair methods, such as cross-stitch and locking cross-
stitches, are ideal options for repairing the thin, flat
extensor tendons.
B A running peripheral suture with 2-mm purchase
generates optimal strength according to Merrell et al.47
Cross-stitch repairs usually have a purchase of 5 mm or
more. The number of runs of peripheral suture influ-
ences strength. However, increasing the number of runs
is difficult clinically, because the small diameter of the
digital tendon does not easily accommodate this
C increase. The dorsal aspect of the tendon is also harder
to access.
We prefer to use multistrand core repairs to give the
tendon strength, supplemented with interrupted or
simple running peripheral stitches. We believe that
D when a strong multistrand repair is used, supplementa-
tion of a complex peripheral suture such as cross-stitch
Figure 4-6 Methods of making a variety of four-strand
or Halsted repair is unnecessary. Giesan et al48 reported
repair using one needle carrying two suture strands (looped
or separated). These repairs achieve greater strength
not using any peripheral sutures with a six-strand core
with simplified surgical maneuvers. A, Cross-lock repair; repair in repairing flexor pollicis longus tendons.
B, U-shaped repair; C, Kessler-type repair; and D, cruciate FACTORS AFFECTING THE STRENGTHS
repair. In A, B, and D, one needle carrying two separate OF TENDON REPAIRS—SUMMARY
strands are used.
Factors affecting the strength of a surgical repair are as
follows (Figure 4-8): (1) the number of suture strands
across the repair sites—strength is roughly proportional
to the number of core sutures2-8,13,14,32-35; (2) the tension
of repairs—most relevant to gap formation and stiffness
of repairs46; (3) the core suture purchase2,3,49-51; (4) the
types of tendon–suture junction—locking or grasp-
ing14,23-29; (5) the diameter of suture locks in the
A
tendons—a small diameter of locks diminishes anchor
power5; (6) the suture calibers (diameter)36-38; (7) the
material properties of sutures39,40; (8) the peripheral
sutures15-17,52; (9) the curvature of tendon gliding paths—
the repair strength decreases as tendon curvature
B increases53,54; and (10), above all, the holding capacity
of the tendon, affected by degrees of trauma and post-
traumatic tissue softening, is vital to strength. Following
are five important factors affecting the strength of
tendon repair.
C
IMPORTANT FACTOR 1—TENSION OF SUTURE
REPAIR AFFECTS GAP FORMATION
Peripheral sutures prevent tendon gapping. However,
another factor of perhaps equal importance and closely
D related to gap formation has rarely been discussed:
Figure 4-7 Methods of making peripheral sutures: initial tension of the core suture. In repairing a tendon,
A, simple running; B, running locking; C, Silfverskiöld we suggest that surgeons maintain a certain tension
(cross-stitch); and D, locking cross-stitch. across the repair site, rather than leaving the repair
Core sutures Curvature of the tendon

• Suture strands:
4 or 6 strands suggested Material properties of sutures
TENDON REPAIR
• Suture purchase lengths: STRENGTH Peripheral sutures
0.7 to 1.0 cm purchase suggested
• Tension of the repairs: • Number of runs:
Slight tension (10% shortening 6–8 runs suggested
of tendon segment) suggested • Suture purchase lengths:
• Suture calibers: 3–0 or 4–0 1–2 mm suggested
• Locking/grasping: locking preferred • Tension: slight tension

Holding capacity of the tendon
• Sizes of the locks or grasp: >2 mm (tendon trauma, softening, etc.) • Suture calibers: 6–0 or 5–0
Figure 4-8 Summary of factors determining the strength of surgically repaired tendons.
tension-free. We tested the gap formation forces of the four-strand repairs (double-modified Kessler, locking
repair under varying tension, which resulted in 0%, cruciate, and modified Savage) had gained significant
10%, or 20% shortening of the sutured tendon segment. resistance to gapping and ultimate strength as the length
The tendon with tension causing 10% shortening of core sutures increased from 0.4 to 1 cm. We deter-
reduced the chance of repair gapping, with significantly mined that the optimal core suture purchase for a trans-
increased gap formation forces. Increasing the tension versely cut tendon is between 0.7 and 1 cm (Figure 4-9).
to cause 20% tendon shortening did further increase In obliquely cut tendons, increasing the purchase
gap resistance forces, but by a much smaller amount. A length to 1.2 cm improved the strength of a two-strand
four-strand core repair tensioned to cause 10% tendon modified Kessler repair and a four-strand locking cruci-
shortening, regardless whether a simple peripheral ate repair.49
suture is added or not, had identical gap resistance. The importance of core suture purchase was verified
The gap resistance of a repair closely relates to its by other investigators. Kim et al50 reported progressive
tension status. Adding a slight baseline tension to the increases in the strength of double Kessler repairs as
repair site when the proximal tendon is temporarily purchase lengthened from 0.3, to 0.7, to 1, and 1.3 cm
fixed to ease the tension during surgery results in appro- in porcine tendons; they recommend 1 cm as the
priate tension after surgery, because this counteracts the appropriate purchase length. Using cadaveric hands,
tension of muscle pull during active motion.46 Multi- Lee et al51 studied locking cruciate repairs, randomly
strand repairs are placed in different areas in the tendon assigned to placement of 0.3, 0.5, 0.7 or 1 cm from the
cross-section, which may evenly distribute tension cut edge of the tendon, with interlocking horizontal
throughout the tendon and may not require a periph- mattress sutures. The tendons repaired at 1 cm had the
eral suture. This concept of “core suture–only” multi- lowest increase in work of flexion (5.2%), the highest
strand repairs, if practiced under certain repair tension, 2-mm gap force (89.8 N) and ultimate load (111.5 N).
is proper. In contrast, the tendons repaired at 0.3 cm had the
highest increase in the work (22.1%), the lowest 2-mm
IMPORTANT FACTOR 2—SUFFICIENT
gap force (54.6 N) and ultimate load (84.6 N). In fact,
SUTURE PURCHASE AND LOCK (GRASP)
all studies suggest an optimal core suture purchase of
SIZE ARE ESSENTIAL
1.0 cm (range: 0.7 to 1.2 cm).
Length of core suture purchase is defined as the exit/entry As stated in previous paragraphs, sizes of locks and
distance of the core suture from the cut ends of the grasps are another important factor; they should be
tendon. We tested how the length of core suture pur- equal to or greater than 2 mm to guarantee anchors of
chase affects the strength of the transversely or obliquely the sutures to the tendons (see Figure 4-9).
cut tendon.2,3,49 We examined the strength of porcine
IMPORTANT FACTOR 3—STRENGTH DOES NOT
flexor tendons with two-strand modified Kessler core
INCREASE DURING EARLY TENDON HEALING
repairs with purchase of 0.4, 0.7, 1.0, and 1.2 cm and
with four-strand circle-locking repairs with purchase of Only a few investigations have been conducted of surgi-
0.4 and 1.0 cm.2 As the suture purchase increased from cal repair strength in vivo, using animal models.9-14 Data
0.4 to 0.7, 1.0, and 1.2 cm, the gap and ultimate strengths on the strength of the healing tendons in human
increased significantly. The strengths remained constant patients are not available. Urbaniak et al55 found that
with the purchase from 0.7 to 1.2 cm. The four-strand the strength of repaired canine flexor tendons decreased
circle-locking repairs with a suture purchase of 1.0 cm at week 2 postsurgery. With simulated postsurgical
were significantly stronger than those with a suture pur- motion, Boyer et al10 found no decrease in the strength
chase of 0.4 cm. In another study,3 we found that three of the canine flexor tendons. In a chicken model,
Weak
Weak
Diameter of locks: 1 mm
4 mm 4 mm
Strong
-optimal
Diameter of locks: 2 mm Stronger
Strong 7 mm 7 mm
A Diameter of locks: 3 mm
Strongest
-optimal
Three 10 mm 10 mm
locks
produce
equal Strongest
a b c power
Exposed X Embedded X Circle
B C 12 mm 12 mm
Figure 4-9 A, Sizes of the locks affect the repair strength significantly. We determined that the diameters of locks of 2 or
3 mm generate strength greater than those of 1 mm and recommend an optimal locking size of about 2 mm. B, Our
biomechanical tests of the strength of three different types of locks indicate no significant difference in the repair strength
with the three types of locks. C, We tested the strength of two- or four-strand repairs with core suture purchase lengths
ranging from 4 to 12 mm and found that repairs with the purchase lengths between 7 to 12 mm generate strength greater
than those with the purchase of 4 mm. We recommend the optimal core suture purchase of 7 to 10 mm. The purchase
length of 10 mm is optimal.
Hatanaka et al9 found no changes in the strength of the smaller. These findings imply that repair strength
healing tendons in the first 3 weeks. Our study12 using decreases as the finger flexes further, because both the
chickens showed no significant changes in the strength angles of tension on the tendon increase and the radii
of the healing flexor tendon during the initial 4 weeks. of the tendon gliding curves decrease progressively. The
The strength of the digital flexor tendons in animal dorsal part of the tendon is subjected to greater tension
models does not typically increase during the first 3 and may gap more easily during finger flexion. Placement
or 4 weeks postsurgery; under certain circumstances, of sutures dorsally may favor gap resistance.
the strength may actually decrease slightly. This “no- The clinical implications of these biomechanical
gain” lag period in strength in the initial weeks after observations are that strength decreases as the fingers
surgery is characteristic, reflecting the slow healing are flexed progressively, and that repairs are weakest
responses of the tendon. Unfortunately, the slow bio- when the finger is in marked flexion. Therefore, the final
logical healing response invites invasion of tissues part of finger flexion is when repairs are more vulnera-
outside the tendon and development of adhesions, ble to disruption. Catching of the tendon repair site by
resulting in gapping or rupture of the repairs during the sheath or pulley edges during finger flexion may
early tendon mobilization. trigger repair rupture.
IMPORTANT FACTOR 4—STRENGTH IMPORTANT FACTOR 5—SOFTENING OF
DECREASES WHEN THE FINGER FLEXES TRAUMATIZED TENDON PARTS DECREASES
HOLDING POWER
Because finger flexion is the key action of postsurgical
tendon motion exercise, the capability of a repair to resist It should be emphasized that tissue softening is crucial
gapping or failure during finger flexion is important. To to repair strength. Because most biomechanical studies
understand how flexion affects the strength of tendon were in vitro, the influence of this factor could not be
repairs, we created two models to test (1) how the direc- reflected in these studies. Tissue softening renders the
tion of tension on the tendon affects strength53 and (2) repair weaker with decreases in both gap resistance and
how tendon curvature affects strength (Figure 4-10).54 maximal strength. As the locking or grasping anchors
Strength of the repairs decreased as the angles of pulling move farther from the trauma area, tissue softening
became greater, and when the radius of the curvature is decreases. Suture purchase of the core repairs should be
Pulley
F F′
A
F
F′
A B
1
2 F
Our model F
-INSTRON 4411 F1
C D F2
B
a
b
F F
Pulley
1′ Tendon E F
2′
Repair site
c F
Clamp
C G H
Finger flexion Force analysis

Figure 4-10 Left, The changes in the tendon arcs during digital flexion. A, The digital flexor tendons follow an arc of
increasing curvature as the fingers flex progressively during digital flexion. B and C, The curvature of tendon arcs is greater in
the distal (site 1) than in the proximal (site 2). As the finger flexes, the tendon curvature increases at each site close to the
joints (for example, site 1). Middle, Our test setup of the flexor tendon undergoing load to failure testing over a curve. By
changing the diameter of the pulley, we re-created different tendon curvature during tendon loading. We recorded substantial
decreases in the repair strength when the tendon curvature becomes smaller. Right, Differential loading conditions on the
tendons according to tendon curvature. A, The tendon is subjected to a linear load when pulled straight. B, The tendon is
subjected to both a linear and a bending force when pulled to glide over a pulley. The tendon is subjected to an angular
tensile load and bending forces. The bending force on the repaired tendon segment is greater in C (of a greater curvature)
than that in D (of a smaller curvature). E–G, The gliding curvature becomes increasingly greater, with increasingly greater
bending force on the repaired tendon segment; the tendon is easier to rupture. G, When the tendon arc approximates the
length of the core suture, the bending force is loaded entirely to the suture. The repair especially is prone to failure.
H, When the tendon glides over a remnant pulley with adjacent pulleys and sheath defects, tendon curvature is especially
small, and the repair is easy to disrupt.
sufficient to minimize the negative impact of tissue soft- Increasing the caliber from 4-0 to 3-0 adds 10-15 N to
ening. Clinical evidence indicates that rupture of the the ultimate strength of two- or four-strand repairs (see
repair is most likely in the second week after surgery,56 Table 4-1; Figure 4-11).36-39 Increasing the suture strands
thought to be related to softening of traumatized tissues. from two to four is more efficient than increasing the
caliber from 4-0 to 3-0. We suggest either a 3-0 or a 4-0
TWO WAYS TO INCREASE STRENGTH—
suture for a four-strand repair, and a 4-0 suture for a
MORE SUTURE STRANDS AND LARGER
six-strand repair. However, rigidity of sutures increases
SUTURE CALIBERS
along with caliber. Sutures of 2-0 become more rigid;
Increasing the number of suture strands across the repair sutures of this or greater caliber are rarely necessary.
sites is a popular means to increase strength. Repair with Lawrence and Davis39 evaluated the mechanical prop-
four or six strands are most often used to provide proper erties of five nonabsorbable 4-0 sutures and a four-
strength for early active tendon motion. Use of double- strand locking repair with these sutures (Table 4-2). All
or triple-stranded repair simplifies surgery.26,33,34 Increas- repairs failed by suture rupture at the locking loop.
ing suture caliber is another easy way to augment Fiberwire and stainless-steel sutures and repairs were
strength. Clinically, repairs with 4-0 sutures are common. stronger and stiffer than the other sutures. The results
60
achieved by Prolene and Ethibond were similar with
Ultimate strength respect to gap and ultimate forces. The merits of Fiber-
4-0 suture
50 3-0 suture
wire have been reported by others40; knot security and
suture rigidity remain concerns. We expect to see the
40 development of strong yet flexible materials in the
Strength (N)
future.
30
2 mm gap forces TEST SETUP AND MEASUREMENTS OF
20
TENDON REPAIR BIOMECHANICS
The centerpiece of the test setup is a material testing
10 machine. Most data on tendon repair biomechanics
were generated using this machine, under either single-
0
cycle load-to-failure or cyclic loading conditions. Typi-
2-strand 4-strand 2-strand 4-strand
cally, a load-to-failure curve is generated (Figure 4-12),
Number of repair strands
which allows analysis of the failure load (called ultimate
Figure 4-11 Our test results of two-strand modified strength or maximal strength of the repair) and stiffness
Kessler repair and four-strand cross-lock repairs (using of the tendons. Stiffness is obtained by measuring the
double-stranded sutures) using 4-0 and 3-0 suture slope of the middle linear portion of the load-
(Ethilon). Increasing the suture caliber from 4-0 to 3-0 adds displacement curve. By calculation of the area under-
about 10 N to the maximal strength. Increasing the suture neath the curve, energy to failure of the repair can be
strands from two to four adds about 15 to 20 N to the obtained. The forces at which the gaps start to appear
maximal strength. The gap resistance of the repairs is or reach 2 or 3 mm are recorded as gap forces. Analyses
increased by increasing the caliber and the number of the of the curves generated when the tendon undergoes
repair strands.
cyclical loads help determine which repair tends to fail
in earlier cycles. Gap sizes can be monitored and
recorded continuously over loading cycles with a video
Table 4-2 Biomechanical Tests of Different Materials and Repairs With Varying Suture Calibers
Investigators Methods/Materials Ultimate Strength (N) Initial Gap Force (N) Stiffness (N/mm)
39
Lawrence and Davis Test of material properties of
sutures
4-0, Nylon 22 2.5
4-0, Prolene 25 5.0
4-0, Ethibond 25 8.2
4-0, Stainless steel 36 14.8
4-0, Fiberwire 37 11.0
39
Lawrence and Davis 4-strand (single-cross repair)
4-0, Nylon 46 36 6.0
4-0, Prolene 63 52 8.0
4-0, Ethibond 66 52 10.2
4-0, Stainless steel 87 66 11.9
4-0, Fiberwire 81 63 12.8
38
Taras et al 2-strand (Kessler repair)
5-0, Ethibond 16
4-0, Ethibond 22
3-0, Ethibond 31
2-0, Ethibond 41
Cyclic loading has been used rather extensively to

50 test the strength of repairs. Because this type of test
Ultimate imitates conditions of repetitive tendon loading in
40 strength
patients, it has yielded valuable information regarding
ion )
gap resistance and fatigue. One concern in interpreting
eg m
r r /m
Load (N)
30 the findings after cycling the tendon over hundreds and
ea (N
Lin ness
thousands of times continuously is that the test does
20 not simulate situations seen clinically in healing tendons
iff
St
Area = Energy
during the early period. Clinically, the tendon usually
10 moves only 20 or 30 times in each session of exercise;
to failure (J)
even ordinary daily life does not involve moving the
0 tendon over hundreds of cycles continuously. Testing the
0 10 20 30 repair strength or the gapping after more than 20 to 30
A Displacement (mm) cycles of tension appears to make more sense. We believe
that a single cycle of motion test provides the most
30 useful basic information; a test of the load-to-failure
Ultimate strength
strength after cyclic loading of a limited number (e.g.,
10 to 30) of cycles may generate information relevant to
20 Force of complete disruption
Load (N)
or peripheral sutures postsurgical exercise.

Gap resistance is an important measure, because a
10 repair with remarkable gaps is bound to fail, and
Tendon distraction during gapping impairs the healing process. Assessment of gap
peripheral suture disruption forces (at the gap sizes of initial appearance, 2 mm, or
0
0 5 10 15 20 3 mm) or gap sizes under a certain load is necessary.
Nevertheless, the examiners should be aware that gap
B Displacement (mm)
formation forces are easily affected by the number of
Figure 4-12 A, A typical load-displacement graph runs of the peripheral sutures and tension status of the
generated during a single cycle load-to-failure test. From the surgical repair, two factors that should be standardized
graph, we can obtain ultimate strength, the energy to failure to facilitate comparison of the gap resistance of various
(calculated from the area under the load-displacement repairs. The ultimate strength of a given repair, on the
curve), and stiffness of the repairs (the slope of the linear other hand, is rather consistent in different studies. We
middle part of the load-displacement curve). B, Form this consider both parameters—gap force and ultimate
graph, we can also determine the force at which peripheral
strength—essential measures of the mechanical perfor-
repairs fail completely and the tendon distraction during
peripheral or core suture failure. The initial, 1-, 2-, or 3-mm
mance of a repair.
gap formation forces are usually recorded to determine gap In our mechanical study settings, we load a 5-cm
resistance of the repair. These forces are measured during segment of tendon in a material testing machine and
tendon loading with the assistance of a video camera. measure 2-mm gap formation force and ultimate
strength. Sometimes we also measure the initial gap
force and tendon stiffness; occasionally we include
energy to failure as well. The distraction of the tendon
camera, allowing identification of repairs vulnerable to during failure of the peripheral or core sutures is instruc-
gapping. tive as well. We believe that findings regarding tendon
In situ testing of repaired tendons using cadaveric stiffness are inconclusive. An increase in stiffness indi-
hands, developed by Mass et al,57 Trumble et al,35 and cates greater capacity to resist tendon deformation;
Wolfe et al,14 represents another means to measure the however, tendons normally have some elasticity.
mechanical properties of repairs. This test simulates a Whether greater stiffness necessarily benefits a repaired
curvilinear loading condition of the tendon within the tendon is actually questionable.
digits. Gap formation, gap forces, ultimate strength, and
CONSIDERATIONS IN THE DESIGN AND USE
work of flexion can be measured,14,35,57 and cyclic loading
OF REPAIR METHODS
on the tendon can be simulated as well.14,35 Measuring
the resistance to tendon movement over a pulley or a Most surgeons use strong core sutures with simple epi-
segment of the sheath using a custom-designed device tendinous sutures clinically; some others favor strength-
is another innovative test setup developed by the Amadio ening peripheral sutures. Rarely, surgeons try to adopt
group.58 This test generates sensitive data on the differ- both complex core and peripheral sutures, because the
ences among different repair methods, particularly with tendon is hard to accommodate. Strength increases with
respect to surface friction of the repair. the complexity of peripheral or core sutures, but at the
cost of more difficult surgical maneuvers, tendon bulki- In recent decades, investigations have been directed
ness, and exposure of sutures or knots over the tendon. mainly to increasing surgical repair strength. However,
With these considerations in mind, one should be careful as clinical reports have indicated, repair ruptures have
in designing and advocating complex suture techniques, not been entirely eliminated by using stronger repairs.
because they would not be widely accepted clinically and Besides tension on the repaired tendon, resistance to
the strength sometimes exceeds what is actually needed. tendon gliding from the peritendinous tissue is a major
Assembling elements from existing methods to form a cause of repair gapping and failure. A decrease in resis-
complex (and “novel”) repair is not difficult. Such tance to tendon gliding can be efficient in reducing
methods may not have great practical value. repair ruptures. If we decrease the resistance to tendon
A novel and clinically acceptable repair should be gliding adequately, the demand for strength of surgical
either (1) stronger than existing repairs (with an identi- repairs may no longer be as great; the strength that
cal degree of complexity) or (2) simpler in surgical present repairs provide is thus sufficient. Currently,
maneuvers (without decreasing the strength). We favor venting of critical parts of the pulleys, as Elliot and our
use of double-stranded sutures—either a loop at the end groups have practiced, or attempts to modify the gliding
or two separate strands, carried by a single needle, to surface of the tendon, as the Amadio group is exploring,
increase repair strength, with fewer needle-suture pas- may provide alternative yet efficient ways to enhance
sages through the tendon and the same surgical surgical strength, towards the goal of minimizing repair
maneuvers. ruptures during early active motion.
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1:41–64, 1996.
CHAPTER
5
BIOLOGY AND BIOMECHANICS
OF THE TENDON–BONE
INSERTION
Stavros Thomopoulos, PhD, and Leesa M. Galatz, MD
OUTLINE
STRUCTURE AND FUNCTION OF THE
TENDON–BONE INSERTION
The repair of tendon to bone presents a major chal-
lenge due to the disparity in the mechanical properties The gradual tailoring, or “functional grading,” of mate-
of the two tissues. The uninjured insertion overcomes rial systems has been described in the engineering mate-
this mechanical mismatch by attaching the two tissues rials community as a way to minimize these stress
across a functionally graded insertion. This unique concentrations.3 A central concept to the formation of
transition develops between tendon and bone postna- a robust attachment between tendon and bone is that
tally and is driven by both biological and mechanical smooth, monotonic transitions in mechanical proper-
factors. Muscle loading, for example, is necessary for ties are necessary for minimizing stresses. The tendon–
the development of a well-organized, mineralized bone insertion site is a natural functionally graded
insertion. Tendon–bone healing does not recapitulate structure. Notably, this gradation is not maintained at
development. Healing is characterized by bone loss healing insertions, and the surgically repaired tissue is
and the formation of a fibrovascular scar, leading to a prone to rerupture.4-6 Surgical technique and treatment
repaired attachment that is prone to rupture. Current approaches should therefore seek to minimize stress
treatment approaches for enhancing tendon–bone concentrations and thereby protect the repair site from
healing focus on rehabilitation. Studies in animal rupture.
models, however, have demonstrated that a fine
MORPHOLOGY OF THE TENDON ENTHESIS
balance must be reached between too much load
(TENDON–BONE INSERTION SITE)
(which can lead to microdamage) and too little
load (which can lead to a catabolic environment) to Tendons insert into bone across broad fibrous transi-
maximize tendon–bone healing. Future treatment tions or across short fibrocartilaginous transitions.7
approaches may include delivery of growth factors Fibrous transitions are characterized by insertion sites
and/or mesenchymal stem cells to stimulate regenera- with large footprints (effectively distributing the forces
tion of a functionally graded insertion. Ultimately, a over large areas and reducing stresses) and by perforat-
tissue engineered scaffold with a gradation in proper- ing mineral fibers (“Sharpey’s fibers”). Examples of
ties and seeded with the appropriate cells and biofac- these attachments include the tibial insertion of the
tors may provide a solution to the clinical problem of medial collateral ligament and the deltoid tendon inser-
tendon–bone healing. tion into the humeral head. Examples of the more
common fibrocartilaginous insertions include the
The attachment of a compliant material like tendon to rotator cuff tendon insertions and the Achilles tendon
a relatively stiff material like bone is a fundamental insertion. The structure, function, development, and
engineering challenge.1 As is evident from the study of healing of fibrocartilaginous tendon–bone insertions
attachment of engineering materials,2 potentially dam- will be the focus of this chapter. These insertions are
aging stress concentrations can be expected to arise at characteristically short and occur across distinct fibro-
the insertion if the tissue is not tuned to this stiffness cartilage regions classically categorized into four zones
mismatch both at the macroscopic level (i.e., the (Figure 5-1).7 The first zone consists of tendon; this
outward splay of the tendon) and the microscopic level region is populated by fibroblasts and has properties
(i.e., the gradual stiffening of collagen molecules by similar to those found at the tendon mid-substance. It
mineral crystals). is composed primarily of well aligned type I collagen
49
Tendon
Insertion
site
Bone
Figure 5-1 The supraspinatus tendon–bone insertion in the rat (toluidine blue stain). Tendon attaches to bone across a
graded fibrocartilaginous transition.
fibers.8 The second zone consists of fibrocartilage; this tissue. There was a variation in gene expression along
region is populated by fibrochondrocytes and is com- the length of the insertion; tendon-specific genes were
posed of types I, II, and III collagen and the proteogly- localized to the tendon proper, bone-specific genes were
can aggrecan.8-11 The third zone is also populated by localized to the bone proper and the mineralized por-
fibrochondrocytes and is composed of mineralized tions of the insertion, and cartilage specific genes were
fibrocartilage. Here, the predominant collagen is type II, localized to the insertion.12 Collagen fibers were less
and there are significant amounts of type X collagen as oriented at the insertion compared to the tendon.12
well as aggrecan.8-11 The fourth zone consists of bone Mineral content increased linearly from tendon to
proper; this region is populated by osteoblasts and bone.13 Biomechanically, both the elastic and viscous
osteoclasts and is composed predominantly of mineral- behaviors of the tissue varied from tendon to bone.12
ized type I collagen. While the insertion site is typically The tensile properties of the tendon, for example, were
categorized into these four zones, changes in the tissue stiffer than those of the insertion. Structure-function
are gradual and continuous, minimizing stress concen- relationships were also examined at the anterior cruciate
trations between the tendon and the bone. The com- ligament–bone insertion.14 Microcompression was per-
plexity of the tendon–bone insertion, however, results formed to determine the compressive properties and
in a difficult challenge for effective healing. energy dispersive x-ray analysis was performed to deter-
mine mineral content along the ligament enthesis. The
Gradations in Biomechanical, Compositional, calcified regions of the insertion exhibited significantly
and Structural Properties Along the Tendon– greater compressive moduli than the noncalcified
Bone Insertion Site regions. Based on these results, it is apparent that there
The tendon–bone insertion contains gradients in bio- is a gradation along the tendon–bone insertion site with
mechanical, compositional, and structural properties. regard to collagen structure, extracellular matrix compo-
Between the unmineralized and mineralized fibrocar sition, mineral content, and biomechanical properties.
tilage of the enthesis is a narrow zone that darkens
markedly during tissue staining. This “line” was tradi- Composition and Microstructure of the
tionally thought to represent a mineralization front, or, Insertion Site Is Optimized to Minimize
mechanically, a boundary between soft and hard tissue. Stress Concentrations
Studies examining the supraspinatus tendon–bone Mechanical models of the insertion demonstrate that
insertions of rats, however, have demonstrated grada- the orientation of the collagen fibers and their level of
tions in properties along the enthesis rather than an mineralization are optimized to minimize stress and
abrupt change from mineralized to unmineralized strain concentrations. In one study, a finite element
Chapter 5: Biology and Biomechanics of the Tendon–Bone Insertion 51
model of the insertion was used to determine the role cell types and maturation processes are seen at both
of collagen orientation on stress and strain distribu- anatomical locations.26
tions.15 The idealized model showed that the micro- The developing growth plate contains cells that are
structure serves to reduce stress concentrations and divided into distinct zones based on morphology and
material mass and to shield the insertion’s outward mineral content.27 The zones are the reserve zone, the
splay from the highest stresses. Similarly, a model of the proliferative zone, and the hypertrophic zone. The small
medial collateral ligament femoral insertion demon- cells in the reserve zone proliferate and organize into
strated that the direction of the principal tensile stresses columns in the proliferative zone, and finally become
coincides with the direction of the collagen fibers.16 A hypertrophic chondrocytes. It is at the leading edge of
correlation was found between cell shape and mechani- the hypertrophic zone that calcium is deposited in the
cal stresses, suggesting a direct relationship between zone of provisional calcification leading to mature
the stress field and cell activity. The effect of mineral bone. Similar chondrocytes are seen at the developing
content on load transfer was modeled at the insertion insertion site; these cells eventually mineralize to form
in a separate study.17 It was demonstrated that mineral a tendon enthesis with a gradation in mineral.
content and collagen fiber orientation combine to The tendon–bone insertion site develops in the early
give the tendon–bone transition a unique grading in postnatal period.19-22 Mouse studies have elucidated the
mechanical properties, supporting the idea for a func- time course of development of the tendon enthesis
tionally graded, continuous tissue transition from using in situ hybridization.20,21 Collagens were localized
tendon to bone. An increase in mineral on collagen along the developing insertion. Collagen I was exam-
fibers provided significant stiffening of the fibers. The ined due to its prevalence in both tendon and bone.
orientation of collagen fibers was the second major Collagen II was examined due to its association with
determinant of tissue stiffness. The combination of chondrocytes, and hence the fibrocartilage region of the
these two factors resulted in a variation of stiffness over insertion. Last, collagen X was examined due to its
the length of the tendon–bone insertion similar to what reported expression by hypertrophic chondrocytes of
has been described from experimental testing.12,18 These the growth plate. Rotator cuff tendon precursors were
biomechanical models describe how tendon–bone juxtaposed to the humeral head at 15.5 days postcon-
attachment is achieved in nature through a functionally ception. A transition zone between the developing
graded material composition. tendon and bone was not apparent until 7 days after
birth. Prior to 14 days postnatally, collagen I was con-
DEVELOPMENT OF THE TENDON–BONE
sistently expressed on the tendon side of the insertion
INSERTION SITE
while collagen II was consistently expressed on the
Studying the development of the tendon enthesis may humeral side, mirroring each other during these early
provide insights into the biological processes necessary time periods. Collagen X was expressed at 14 days in
to form this complex anatomical site. These insights are association with hypertrophic chondrocytes. As the
critical for the success of biological treatments or tissue humeral head matured and mineralized, it began to
engineering solutions for tendon–bone repair. Animal express collagen I, the main collagen type in mature
models indicate that the enthesis develops into a func- bone. A mature fibrocartilaginous insertion site was
tionally graded tissue postnatally,19-22 allowing a unique formed by 21 days postnatally. This corresponded to the
opportunity to study and perturb its formation. completion of mineralization of the cartilaginous
humeral head. Similar results were seen at the develop-
Role of Biological Factors ing Achilles tendon insertion of the rat21 and human.28
Several factors are important to the development of the PTHrP has been localized to the insertion sites of
tendon–bone insertion site. Scleraxis is a transcription both tendons and ligaments.26 In the growth plate, it
factor expressed both in tenocyte progenitors and in is seen in proliferating chondrocytes, and is known to
mature tendon cells and has been associated with be part of a negative feedback loop, preventing their
tendon and insertion site formation.23 SRY (sex deter- maturation into hypertrophic chondrocytes, which
mining region Y)-box 9 (SOX-9) is associated with chon- then mineralize to form bone. Therefore, it plays an
drogenesis and has been localized in proliferating important role not only in maintaining a population
chondrocytes.24 Parathyroid hormone–related protein of cells available for growth but also for preventing
(PTHrP) and Indian hedgehog (IHH) drive chondrocyte inappropriate mineralization. It likely plays an analo-
proliferation, but also form a negative feedback loop, gous role in maintaining a barrier between mineralized
maintaining a population of proliferative cells at the and unmineralized tissues at the tendon to bone inser-
growth plate, available for further growth and differen- tion site. PTHrP works in concert with other factors.
tiation.25 These factors are seen in the growth plate of IHH is secreted by proliferative chondrocytes before
developing bones and likely play a similar role at the they become hypertrophic chondrocytes. It binds to
formation of the tendon enthesis, as many of the same the cell membrane receptor Patched 1 leading to the
accumulation of a transmembrane protein smoothened, used as controls. Many effects were observed due to
which leads to the production of PTHrP. These factors paralysis in bony development, soft tissue contracture,
are all localized to the developing tendon insertion muscle mass, and muscle force generation. Dramatic
site at 14 to 21 days, correlating to the onset of miner- changes were seen at the developing tendon–bone
alization of the humeral head. These factors are also insertion site due to unloading.
highly mechanosensitive.29 Specifically, their expression The sensitivity of bone to its mechanical environ-
is decreased when load is removed. ment was highlighted in this series of experiments.
SOX-9 and scleraxis are important factors in chon- Removal of load significantly decreases amounts of
drogenesis and tenogenesis, respectively.30 SOX-9 is bone mineral in the humeral heads of the paralyzed
localized to proliferating chondrocytes, but not in mice (Figure 5-2). These differences were not seen,
hypertrophic chondrocytes, and may play some role in however, until after the 14-day time point; large differ-
insertion site development. Serving as a marker for ences were seen comparing saline to botulinum toxin
many connective tissues, including ligaments, tendons, injected shoulders at 21, 28, and 56 days. In addition,
and joint capsules, scleraxis has been localized at the the botulinum toxin injected sides had larger numbers
developing insertion site and is required for tenogenesis. of osteoclasts lining the bone compared to the controls.
Scleraxis likewise has been shown to be highly sensitive Therefore, the decreased mineral content resulted not
to the mechanical environment, specifically, upregu- only from decreased mineral deposition, but also due
lated in stem cells exposed to tensile forces.31 to increased bone resorption.
Removal of load also impaired the formation of a
Role of Mechanical Factors graded fibrocartilaginous insertion site. At 14 days, both
A series of experiments using mice were performed to saline and botulinum toxin injected shoulders demon-
elucidate the effects of the mechanical environment on strated evidence of hypertrophic chondrocytes at the
the formation of the tendon–bone insertion site.19 Botu- insertion. However, by 21 days, the botulinum toxin
linum toxin A was injected to the shoulders of mice injected specimens showed a lack of fibrocartilage for-
within 24 hours of birth, simulating a neonatal brachial mation, disorganized collagen fibers, and persistence of
plexus injury and removing muscle load from the hypertrophic chondrocytes. The saline side, on the other
humeral head. Saline injections in the contralateral hand, had a well-developed transition zone with no
shoulders and a separate group of healthy mice were evidence of hypertrophic chondrocytes. The transition
Saline Botox
BONE VOLUME TRABECULAR THICKNESS TRABECULAR SPACING
6 0.30 0.8
Trabecular thickness (mm)
Trabecular spacing (mm)
Normal # Normal
0.25
Bone volume (mm3)
5 #
Botox Botox
Saline 0.6
4 # 0.20 # # Saline
*
3 # 0.15 0.4 #
* * #
* #
2 0.10 *
#* # Normal
*
# * # Botox 0.2
1 0.05
* Saline
# #
0 0 0
0 10 20 30 40 50 60 0 10 20 30 40 50 60 0 10 20 30 40 50 60
Time (days) Time (days) Time (days)
Figure 5-2 Bone volume and trabecular architecture were significantly altered in the Botox group compared to the Saline
and Normal groups at most timepoints during postnatal enthesis development (*significant difference Saline vs. Botox;
#significant difference Saline or Botox vs. Normal). (Adapted from Thomopoulos S, Kim HM, Rothermich SY, et al: Decreased
loading delays maturation of the tendon enthesis during postnatal development, J Orthop Res 25:1154–1463, 2007.)
zone remained disorganized and immature at 56 days examined the strength of the rabbit patellar tendon–
in the paralyzed specimens, whereas the saline group tibia insertion site after the creation of a partial defect.35
had a mature, fibrocartilaginous, tendon enthesis. The Failure strength increased and approached normal over
changes in fibrocartilage formation and bone formation a span of 12 weeks. However, the healing tissue in a
support the conclusion the mechanical environment partial defect may have been stress shielded by the adja-
plays an important role in enthesis development. cent uninjured tissue. Another group found that the
strength of healing infraspinatus insertion site in goats
TENDON–BONE REPAIR was only one third of the strength of the normal infra-
spinatus insertion at 12 weeks.36 This finding demon-
Basic Science of Tendon–Bone Healing strates that although the histological appearance may
Tendon–bone healing occurs through the generation of suggest the recreation of an insertion site, the strength
a fibrovascular scar rather than regeneration of a graded of the site may not be restored to normal. Another study
fibrocartilaginous transition (Figure 5-3).5,32-34 These examined tendon healing in a bone tunnel.32 Strength
studies have focused on morphological and composi- increased significantly between 2 and 12 weeks. After
tional evaluations of the healing tissue. In an Achilles this point, failure occurred somewhere other than the
tendon–bone healing study, surgical repair was impor- insertion site. In a rat rotator cuff model, while the
tant to allow cells to reorganize the insertion site.33 At structural properties reached two thirds of normal after
8 weeks, the tendon was attempting to recreate the 8 weeks of healing, the material properties remained an
insertion site. Low levels of type X collagen were found order of magnitude weaker than control.5 The healing
in the fibrocartilage adjacent to bone, and this protein tissue had a higher cross sectional area compared to
was important in maintaining the interface between uninjured control, but was made up of poorly organized
calcified and noncalcified fibrocartilage. Similar histo- type III collagen without a recreation of a fibrocartilagi-
logical findings were reported in a canine model of nous transitional zone. Studies on canine flexor tendon
tendon detachment.34 However, both models showed to distal phalanx repair indicated that insertion-site
that the structure and the composition of the healing healing demonstrates little improvement in repair-site
insertion did not approach normal by the longest time failure force from the time of suture through 42 days
points studied. following repair.37 A significant decrease was seen in
Investigators have also examined the mechanical insertion site ultimate strength at 10 and 21 days
properties of the healing insertion site. One group compared to time zero, indicating that a softening
NORMAL HEALING
Tendon
Bone
Interface
Bone
Tendon
Interface
Figure 5-3 A graded fibrocartilaginous transition is not regenerated at the healing supraspinatus tendon–bone insertion in
rats (toluidine blue stain). Rather, the interface is filled with fibrovascular scar tissue, forming an abrupt transition between
tendon and bone (orange lines indicate the borders of the fibrocartilaginous transition on the left and the abrupt interface
between scar tissue and bone on the right).
phenomenon occurred in the early stages after repair.37 700

In all animal models, rather than regeneration of a func-
tionally graded transition between tendon and bone, 600
–21%
the interface was filled with fibrous scar tissue. These –40% –41%
500 *
findings demonstrate the considerable need for improve-
BMD (mg/cm3)
ment in the treatment of tendon–bone insertion site 400 * *
injuries.
300
Bone Loss Following Tendon or
200
Ligament Injury
Control
Bone loss following tendon or ligament injury has been 100 Injury and repair
noted in a number of clinical studies and animal models.
0
In the rotator cuff, reduced bone mineral density was
0 10 20 30 40
seen in the humerus of patients 9 years after cuff rupture
and repair.38 These changes, however, were seen only in Time (days)
patients who did not have full return of function, sug- Figure 5-4 Dramatic bone loss was observed in the canine
gesting that the bone loss was due in part to reduced distal phalanx after flexor tendon to bone repair. Decreases
joint loading. In another clinical study of the Achilles in bone mineral density (BMD) were observed as early as 10
tendon, calcaneal bone loss was seen 4 to 12 months days after injury and repair. (Adapted from Silva MJ, Boyer
after surgical repair.39 In a canine model of anterior MI, Ditsios K, et al: The insertion site of the canine flexor
cruciate ligament transsection, a significant reduction in digitorum profundus tendon heals slowly following injury
bone mineral density was seen as early as 4 weeks and suture repair, J Orthop Res 20:447–453, 2002.)
postinjury.40 Bone loss progressed through 10 weeks,
and then reached a plateau. Finally, a clinical study of
anterior cruciate ligament injury showed a 20% reduc-
tion in bone mineral density at 1-year follow-up for Increased force is beneficial to healing in a variety of
patients who had surgical repair.41 Patients with less clinical settings. Early mobilization improves healing
severe injuries who were treated conservatively (i.e., no and function after anterior cruciate ligament reconstruc-
surgery) showed only a 2% to 3% reduction in bone tion in the knee.45 Early passive range of motion
mineral density. Significant bone loss was also demon- decreases adhesions and improves strength after flexor
strated in the canine flexor tendon model.42 Decreased tendon repair.46 Controlled static stress is beneficial to
bone mineral density was seen at the distal phalanx medial collateral ligament healing in the knee.47 On the
at 10, 21, and 42 days following injury and repair, other hand, excessive force and motion can be cause
indicate that bone resorption may be a factor that con- microdamage and/or gapping and thus be detrimental
tributes to the low values of repair-site failure force to healing.5 Optimizing the mechanical environment in
(Figure 5-4).42 Similar results were reported in the rat the postoperative setting is therefore critical for improv-
rotator cuff model.43,44 Bone mineral density was signifi- ing outcomes.
cantly decreased following tendon injury and repair. In order to determine the effects of a variety of activ-
A delay between injury and repair resulted in inferior ity levels on tendon–bone healing, rotator cuff repairs
tendon–bone healing, in part due to decreased bone were performed in rats.5 Rat shoulders were then immo-
quality. bilized, allowed cage activity, or exercised. Shoulders
that were immobilized demonstrated superior collagen
Rehabilitation Based Treatments orientation and biomechanical properties compared to
As described earlier, tendon–bone healing is character- those that were exercised. The exercised rats had a greater
ized by the formation of connective tissue with vastly quantity of tissue, but the tissue was lower in quality.
inferior biomechanical properties compared to normal, The composition of extracellular matrix generated at the
uninjured tendon. A graded fibrocartilaginous transi- immobilized insertion better resembled a normal, unin-
tion between tendon and bone is not recreated. It is well jured insertion. The immobilized group was superior to
established that musculoskeletal tissues, including the cage activity group, and the cage activity group was
tendon, bone, and cartilage, respond to their mechani- superior to the exercised group. A second study using
cal environment. Similarly, as described earlier, the this animal model investigated the effect of short and
development of a functional enthesis requires mechani- long durations of these activity levels on the healing
cal loading. Therefore, significant efforts have been insertion site.48 The activity level had no effect on the
made to enhance tendon–bone healing via rehabilita- biomechanical properties of the insertion site at the
tion protocols (i.e., via control of the mechanical loads early (4 week) time point. However, decreased activity
across the healing insertion). (i.e., cast immobilization) had a positive effect on
biomechanical properties at the late (16 week) time properties and greater range of motion. There was no
point. In these studies, decreasing the activity level by difference in bone density between loaded and unloaded
immobilizing the shoulder improved tendon–bone specimens. As in the rat model, cast immobilization
healing, as measured by collagen organization and bio- resulted in a better outcome than complete removal of
mechanical properties. These results demonstrate that load. When considering these studies together, it is clear
increased activity can be detrimental to healing. that a balance between too much and too little load is
However, it was not determined whether this was a important to maximize tendon–bone healing. Closer
result of a positive effect due to low levels of loading in investigation suggests that high levels of motion are
the immobilized group or a negative effect due to high detrimental but physiological muscle loading is benefi-
levels of motion in the exercised group. cial. The role of loading is consistent with the premise
The notion of negative effects due to motion at the that musculoskeletal tissues not only respond to, but are
healing rotator cuff insertion site were substantiated in dependent on, some load for development, healing,
a subsequent study that examined tendon biomechan- and homeostasis.
ics and joint range of motion in rat shoulders after
rotator cuff repair.49 Continuous immobilization was Biologically Based Treatments
compared to two different passive range-of-motion pro- Biologically based approaches for enhancing tendon–
tocols for 2 weeks followed by a 4-week remobilization bone healing have focused on one or more aspects of
period. Both passive range-of-motion groups had less the tissue engineering paradigm—the use of signaling
joint range of motion compared to the continuous biofactors (e.g., growth factors), responding cells (e.g.,
immobilization group. All joints were stiffer compared mesenchymal stem cells), and scaffold microenviron-
to preinjury levels. No differences were found in tendon ments (e.g., collagen matrices).52 Numerous studies
collagen organization or mechanical properties in the have attempted to enhance tendon–bone healing by
three groups. delivering growth factors to the repair site. As significant
As both high levels of load and high levels of motion bone loss has been demonstrated after tendon–bone
were found to be detrimental to tendon–bone healing, injury and repair, one approach has been to target the
the effect of decreasing load below that seen in immo- bony side of the insertion for treatment. Bone morpho-
bilized repairs was examined in a recent study.50 After genetic protein 2 (BMP-2) is well established as a potent
surgical injury and repair, rat shoulders in two groups stimulator of bone formation. One experiment demon-
were immobilized. One experimental group had botu- strated that the healing of tendon in a bone tunnel
linum toxin A injected into the supraspinatus muscle to occurred through bone ingrowth into tendon.53 The
completely remove load from the healing insertion site. authors demonstrated an improvement in structural
A second group was immobilized and had saline injec- properties of the tendon healing in a bone tunnel after
tions into the muscle. A third group had botulinum application of exogenous BMP-2. Preventing bone
toxin A injections and rats were allowed cage activity resorption at the healing insertion using bisphospho-
after repair. The saline/casted group had greater scar nate treatment has also been effective in improving
volume and cross-sectional area of the repair tissue at healing.54 Promotion of fibrocartilage at the healing
the insertion site and improved structural properties insertion has also been attempted, but with limited
compared to the botulinum toxin–paralyzed groups, success. One study demonstrated that transforming
demonstrating that complete removal of load from the growth factor beta is critical for tendon–bone healing,
healing insertion site was detrimental to healing. but its modulation was ineffective in improving
Although reduced loading (e.g., through cast immobili- healing.55 A separate study showed that application of
zation) can be beneficial to healing (presumably by articular cartilage to the healing insertion increases
eliminating excessive motion at the repair site), some fibrocartilage regeneration.56 However, the partial regen-
load applied to the site via normal muscle contraction eration of a fibrocartilaginous transition did not lead to
is necessary for effective healing. improvements in the biomechanical properties of the
The beneficial role of cast immobilization coupled repair.
with physiological muscle loading was corroborated by Cell based therapies also hold great potential for
a study using a canine model of flexor tendon repair.51 enhancing tendon–bone healing. Adult mesenchymal
This study measured biomechanical properties, bone stem cells (MSCs) show excellent regenerative capacity,
density (of the distal phalanx), and gap formation after including the ability to proliferate rapidly in culture and
a flexor tendon–bone repair. In the experimental group, the capacity to differentiate into a wide range of cell
the proximal tendon was transected to remove all load types. Prior reports support the use of stem cells to
from the repair site. All repairs were immobilized post- enhance healing in multiple tissues. Recent work showed
operatively and subjected to a standard flexor tendon that MSCs transfected with a tenogenic factor were effec-
passive range-of-motion protocol. Muscle loading across tive in improving rotator cuff tendon–bone repair in a
the repair-site resulted in improved biomechanical rodent animal model.57 The addition of naïve MSCs to
the healing rotator cuff insertion site did not improve σ = 0.29MPa σ = 1.60MPa σ = 2.41MPa
healing at the tendon attachment site. However, when High mineral
the MSCs were modified to overexpress the insertion-
site specific developmental gene membrane type 1
metalloprotease prior to delivery, rotator cuff healing
was significantly enhanced. Similar repair enhance-
ments were seen with the delivery of MSCs to a patellar
tendon defect and Achilles tendon models.58,59
A review of scaffolds currently used clinically for
rotator cuff tendon–bone repair revealed that further
work is necessary to optimize scaffold properties.60 Par-
ticularly lacking in the currently available scaffolds is an
appropriate recreation of the native tissue’s gradation in
properties. To address this lack of complexity, tissue
engineering work has focused on stratified and continu-
ously graded designs. In recent work, biphasic61 and
triphasic scaffolds62 were generated and seeded with Low mineral
multiple cell types. These studies demonstrated the
importance of signaling between the various insertion- ε=
site cell types for generation of a functional insertion.
0 0.02 0.04
Recent approaches have also attempted to create con-
tinuous gradients in properties to recreate the functional Figure 5-5 Strain maps of a nanofiber scaffold with a
gradation in mineral content under uniaxial tension.
grading that is seen at the natural tendon–bone inser-
Increasing strain is seen with increasing stress, with
tion. To this end, electrospun polymer nanofiber scaf-
localization at the compliant low mineral end.
folds were synthesized with gradations in mineral,
mimicking the mineral gradation seen at the native
insertion.63 The gradation in mineral content resulted in
a spatial variation in the stiffness of the scaffold (Figure
5-5). Similar results were reported using a cell-seeded provide a solution to the clinical problem of tendon–
collagen scaffold with a gradient in retrovirus encoding bone healing. A functionally graded material implanted
an osteogenic transcription factor.64 A tissue engineered at the time of surgical repair may provide mechanical
scaffold with a gradation in properties and seeded with stability and guide the repair process, leading to a suc-
the appropriate cells and biofactors may ultimately cessful attachment of tendon to bone.
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21:420–431, 2003. 2008.
CHAPTER
6
GENE THERAPY FOR TENDON
HEALING
Jin Bo Tang, MD, Ya Fang Wu, MD, Yi Cao, MD,
Chuan Hao Chen, PhD, Xiao Tian Wang, MD, and
Paul Y. Liu, MD
OUTLINE a recent exponential expansion in available genetic

information. We have noted that biological investiga-
Weak intrinsic healing potential is the central issue tions are catching up with mechanical studies, making
underlying difficulties of tendon healing and major an increasingly greater contribution to the efforts to
clinical problems associated with tendon surgery. Bio- improve tendon repairs.9-29 From these biological inves-
logical augmentation of the healing process has long tigations, we are rapidly accruing information regarding
been sought. In the past decade, growth factor gene the molecular mechanisms and efficacy of manipula-
therapy emerged as an attractive treatment modality. tions of tendon healing, which may bear fruit in the
Our work over the past decade has not only identified future.
appropriate genes as the therapeutic target and vectors Weak healing potential is a common problem in
as gene-carrying vehicles but also assessed the effi- tissues without a rich blood supply. At present, there is
ciency of transgene expression and sustained supply a lack of effective treatment to ensure a prompt and
of the growth factors in the healing tendon. In testing strong healing of these tissues. Finding treatments to
the efficacy of growth factor gene therapy in vivo, we accelerate healing such tissues is of paramount signifi-
found that injection of adeno-associated viral vectors cance in regenerative medicine, sports medicine, reha-
harboring basic fibroblast factor or vascular endothe- bilitation, and in surgery. The treatments not only
lium growth factor cDNAs to the tendon during benefit tendon repair in the hand but also benefit repair
surgery substantially increases tendon healing strength and regeneration of tendons, ligaments, and tendon–
in a chicken tendon cut and repair model. Transgenes bone junctions throughout the body. Efforts to acceler-
were expressed from postsurgical weeks 2 to 6, cover- ate healing of those tissues are expected to bring about
ing the critical healing period. In the healing tendons, significant impacts in a number of medical specialties.
gene therapies increased the levels of growth factors, Laceration of digital flexor tendon is representative of a
promoted synthesis of extracellular matrix compo- wide spectrum of injuries that fail to heal reliably and
nents, decreased tenocyte apoptosis, and enhanced is an ideal setting for testing novel molecular therapies.
cellular proliferation. These evidences show the Work in this area holds promise for advancing the treat-
promise of gene therapies in the arena of tendon ment of tissue injuries due to trauma or sports or in
repair. Our studies also indicate the possibility of association with degeneration.
delivery of synthetic micro-RNA in limiting adhesions. Of gene therapy applications in tissue healing, the
These findings may lay the groundwork for establish- unique advantage is that this strategy necessitates
ment of methods to correct the insufficiency in intrin- production of the encoded factors for a fairly short
sic healing capacity of the tendon. period.30-32 Gene therapies traditionally aimed at curing
tumors or congenital diseases, in contrast, necessitate
Improvement in tendon healing through biological long-term transgene expression, usually over the entire
approaches, molecular manipulations in particular,1-8 is lifetime. Such prolonged transgene expression is still a
a relatively new area of investigation related to flexor difficult goal to reach reliably for chronic conditions,
tendon surgery. These biological manipulations are which constitutes an obstacle to ultimate clinical success
intended to overcome a major obstacle to success in in curing these diseases. However, for tissue repair, gene
tendon repair—low intrinsic healing potential. The therapy can establish a local, endogenous synthesis of
development of molecular treatment of tendon healing the authentically processed materials critical to the
has benefited from advances in biotechnology and healing. Long-term gene expression is neither necessary
59
nor desired.30 The required period of transgene expres-

OVERALL CONCEPTS AND METHODS
sion for tissue healing exactly fits current possibilities
OF GENE THERAPY
offered by gene therapy.
The central idea of gene therapy is the incorporation of
INNATE WEAKNESS IN INTRINSIC
genes of interest into recipient cells to modify levels of
TENDON HEALING AND “NO-GAIN”
expression of the gene, for the purpose of treating
PERIOD IN STRENGTH
disease. The disorders requiring gene therapy are usually
Tissues nourished with rich blood supplies usually refractory to conventional therapeutic approaches.
acquire mechanical strength rapidly in the first and Although the clinical utility of these technologies
second postsurgical weeks. However, the tendon healing remains in its infancy, gene therapy has been used with
process is characterized by a “no-gain” period in strength preliminary clinical success in some diseases. More trials
over the first 3 to 4 weeks (Figure 6-1)5,33-35 due to the are currently under way and may generate evidence for
weak healing capacity, yielding slow healing responses the utility of such techniques over a broader range of
after injury. The innate weakness in tendon healing medical problems. Gene therapy holds great promise
relates to the following structural facts: (1) they lack for incorporation into mainstream medicine.
sufficient blood supply, (2) have sparse cellularity, and The ideas behind gene therapy date back to the early
(3) are mainly composed of tightly packed collagen 1970s. In 1972, Friedmann and Roblin advocated intro-
bundles. The characteristic no-gain period in strength is ducing exogenous genes to cure human diseases in an
the central issue underlying the difficulties and clinical article entitled, “Gene Therapy for Human Genetic
problems associated with tendon repairs. The goal of Disease?”36 Major advances were made in the technical
present efforts through biological manipulations is to aspects of gene therapy in the 1990s. Over the past two
elicit an earlier increase in strength, helping the tendon decades, investigators have taken logical steps of using
“leap over” this lag period. Theoretically, this goal is gene therapy to pursue curing diseases caused by single-
achievable through targeting major causes of weak gene defects (e.g., cystic fibrosis, hemophilia, muscular
tendon healing, either by supplementation of cells dystrophy, and sickle cell anemia) or in the treatment
involved in healing or by increasing the activity levels of certain cancers. More recently, clinical work has
of growth factors. Because healing strength is structur- included a trial for treating Leber congenital amauro-
ally based on collagen connections across the tendon sis,37 a disease caused by mutations in the RPE65 gene.
repair site, we expect that addition of specific cells or The investigators proved the safety of subretinal delivery
growth factors will ensure speedy deposition and matu- of recombinant adeno-associated virus (AAV) carrying
ration of collagens at the healing site, resulting in an the RPE65 gene and found a modest improvement in
earlier gain in mechanical strength. vision of the patients.37 In another study, investigators
restored trichromatic vision to squirrel monkeys using
gene therapy to cure red-green color blindness.38 Other
50 investigators succeeded in treating adrenoleukodystro-
45
Further phy (ADL), a fetal brain disease, by delivering the gene
steady gain in for the missing enzyme to patients via a lentiviral vector.39
40 the strength
Various techniques have been developed to achieve
Tendon strength (N)
35
Swift gain in successful gene transfer,32 including both nonviral
30 the strength
3 methods (e.g., liposomal, electroporation, sonopora-
25
tion, shots from a “gene gun,” etc.) and viral vectors
20
(e.g., adenoviruses, AAVs, herpes simplex viruses, retro-
15 No gain period viruses, lentiviruses, etc.).
10 in the strength
2 Gene therapy is commonly considered a possible
5 treatment modality for patients with congenital defects
1
0 of key metabolic functions or patients with malignan-
0 1 2 3 4 5 6 7 8 cies. Clinical success of gene therapy for congenital
Weeks diseases and cancers is hindered by problems such as
the short-lived function of the transgenes, immune
Figure 6-1 The tendon healing process is characterized by
responses, side effects with vectors, the inability to treat
a “no-gain” period in strength over the first 3 to 4 weeks.
multigene disorders, and the risk of insertional muta-
The graph shows our data for the tendon strength obtained
from the complete cut and repair model of the FDP tendon genesis. However, these problems rarely constitute a
in chicken long toes. The tendon was repaired with a barrier to the use of gene therapy strategies for tissue
modified Kessler method using 5-0 nylon suture. The healing if gene delivery methods are appropriate. The
strength of the healing tendon can be divided into three use of gene therapy in tissue repair or regeneration may
parts: no gain, swift gain, and further steady gain periods. become “dark horses” in the field of gene therapy.
Chapter 6: Gene Therapy for Tendon Healing 61
Controlled-release drug delivery systems is another

BIOLOGICAL METHODS TO ENHANCE
way to provide the tendon with a prolonged supply of
TENDON HEALING
growth factors.7,21 Growth factors can be incorporated
Theoretically, tendon healing may be enhanced through into polymers in vitro, and the impregnated polymers
biological means other than gene therapy. Nevertheless, are then implanted into the tissues, which may deliver
none of those methods can be claimed to be of practical the growth factors continuously for a prolonged period
value until fully tested. The initial step in the test process in a controlled fashion. This system holds promise for
involves in vitro studies. The next step is in vivo experi- use in tendon repairs, but research in this area is just
mentation, which will generate preclinical data to beginning. Growth factors (bFGF and PDGF-BB) have
support the clinical trials, the last step in the test process. been incorporated into fibrin matrices and the release
One possible way to augment tendon healing is to kinetics has been tested over a 10-day-period in vitro21;
provide the tendons with exogenous cells, to ameliorate bFGF and PDGF-BB were found to release gradually
sparse cellularity. A few such attempts have been made. from the fibrin matrices and to modulate cell prolifera-
Direct delivery of bone marrow stem cells to healing tion and extracellular matrix synthesis in vitro. However,
rabbit Achilles tendons produced some evidence of this system loaded with PDGF-BB was not found to
increases in tendon strength.40 Investigators coated sur- improve the strength of the healing canine flexor
gical sutures with bone marrow stem cells and delivered tendons at days 7, 14, and 42 after surgery.7 In a canine
those cells to the tendon in vitro,6 but the in vivo effi- model, bFGF delivered through fibrin heparin–based
cacy of this method has not been reported. controlled-release system stimulated cellular prolifera-
Growth factors, such as insulin-like growth factor-1 tion, promoted neovascularization and inflammation of
(IGF-1),9,10 platelet-derived growth factor-B (PDGF-B),20 the flexor digitorum profundus (FDP) tendon in the
and basic fibroblast factor (bFGF),20,23,25 have been earliest stages after surgical repair, but it failed to improve
reported to promote tenocyte proliferation or collagen mechanical strength of the repair.43 This system remains
synthesis. Direct supplementation of growth factors to to be fully tested with respect to its effectiveness to
the healing tendons has failed to reliably improve increase tendon strength in vivo.
healing strength. Chan and colleagues41 injected bFGF
GENE THERAPY APPROACHES—THE
to rat cut patellar tendon and detected no effects on
FIRST STEP: CHOOSING GENES AND
ultimate strength of the tendon 7 and 14 days after
DELIVERY METHODS
surgery despite increases in cell proliferation and type
III collagen production. Surgical sutures can be coated Over the past 10 years, we have directed our efforts toward
with growth factors such as bFGF or growth differentia- improving tendon healing through augmentation of
tion factor-5 (GDF-5).4,42 Surgical repairs using such growth factor activity (Figure 6-2). To test the efficacy
coated sutures improved the strength of the rabbit flexor of this approach, we faced two initial questions: (1)
tendon only at a single time point (postoperative week what genes should be delivered, and (2) which are safe
3) but failed to improve strength at other time points.4,42 and efficient gene-carrying vehicles for our purposes?
FLOW CHART OF OUR INVESTIGATIONS OF TENDON GENE THERAPY
Tissue reactions In vivo study Expression of

caused by different of efficacy of molecules
Characterization Tests of effects of vectors in tendons Construction of AAV2-bFGF involved in the
of effects of plasmid vectors AAV2-bFGF, gene therapy healing tendon
growth factors on harboring growth Efficiency of gene AAV2-VEGF, and apoptosis
tenocytes in vitro factors in vitro delivery by different and In vivo study
vectors in tendons DS-AAV2-VEGF of efficacy of Test of in vitro
vectors AAV2-VEGF engineered
Efficiency of gene
gene therapy miRNA gene
delivery by different
serotypes of AAVs therapy in vitro
and in vivo
(2002–2003) (2003–2004) (2004–2006, 2008) (2005–2010) (2007–2011)
Tang, Xu Tang, Wang Zhu, Cao, Chen, Tang Xin, Wang Cao, Wu, Tang Chen, Wu, Tang
Understand molecular biology of tendon healing Increase the healing strength Limit adhesions
Figure 6-2 Flow chart of our investigations of growth factor gene therapy to enhance tendon healing and micro-RNA gene
therapy to inhibit tendon adhesions over the past 10 years.
To answer the first question, we examined levels of than liposome-mediated gene transfer. Because more
growth factors in the healing digital flexor tendons. than 10 serotypes of AAV are currently available, all with
Growth factor genes with low levels of expression in the different cellular or tissue tropism, we compared trans-
healing process are considered targets of gene therapy. duction efficiency of AAV1, AAV2, AAV3, AAV4, AAV5,
In a chicken tendon laceration model, we examined the AAV7, and AAV8 vectors containing the lacZ gene. We
levels of growth factors from day 3 to week 12 after found that AAV2, the best characterized and most
surgery. bFGF and PDGF-BB were found to have the popular AAV vector, has the highest efficacy of gene
lowest expression in the early period28; VEGF and IGF-1 transfer in tenocytes.27
were expressed in modest amounts.28 Consequently, we We then examined the duration of expression of
decided to target the bFGF gene initially, and the VEGF transgene introduced by AAV2 vectors to the healing
gene secondarily. flexor tendon. Using an in vivo chicken model, we
Our answer to the second question—how best to injected the vectors at two sites in each stump of cut
deliver the genes—was based on an essential consider- FDP tendon through lacerated tendon surfaces. We
ation: the intended therapy is aimed at the healing of found that expression of transgenes lasts beyond 4
normal tissues, requiring only short transgene expres- weeks and peaks during the second week. Through the
sion, rather than treating cancers or curing inherited presence of enhanced green fluorescent protein (EGFP)-
diseases. In this regard, safety issues of the vectors positive cells, we confirmed that injected vectors were
should be the primary concern. With these consider- distributed to all layers of the tendon (see Figure 6-3).
ations in mind, we first eliminated retroviral vectors. Our above examinations, coupled with desirable fea-
Lentiviral vectors and herpes simplex viral vectors were tures of AAV vectors (nonpathogenicity, low immunity
next excluded, because of concerns of biosafety of len- in human beings, etc.),44-46 and evidence of their utility
tiviral vectors (e.g., potentials of generation of and safety from reported Phase I clinical trials37,47-49 con-
replication-competent lentivirus and oncogenesis) and vinced us that the AAV2 vector is a proper gene transfer
the narrow applications of herpes simplex viral vectors vector. Although AAV vectors, which have small packag-
(i.e., in the nervous system).44 Adenoviral, AAVs, and ing capacity, accommodate up to 4 to 5 kb of DNA
liposome-mediated gene transfer thus became viable insert,46 they are sufficient to package therapeutic cDNAs
candidates. encoding growth factors (usually less than 1 kb each)
To move our decision process along, we implemented to meet our needs.
three sets of studies to examine (1) tissue reactions in To explore how to deliver vectors into the lacerated
tendons caused by the candidate gene transfer methods; tendon, we decided to directly inject the vector to
(2) efficiency of gene delivery to tenocytes using these tendons and tried injections at either one or two sites
methods; and (3) duration and course of transgene on the tendon stump. We found that injection at two
expression in healing tendons by these methods. sites ensures better vector distribution and greater vector
We used both rabbits and chickens to examine reac- delivery. The volume of the injections without spillage
tions in the tendons elicited by three candidate methods. of fluid out of the tendon was also tested. Injection of
Histologically, we observed dramatic tissue reactions in 5 µl liquid to each site on the stump was found appro-
both epitenon and endotenon areas after liposome- priate in rabbit or chicken digital flexor tendons. In
mediated gene transfer. The reactions elicited by adeno- addition, we decided to inject the tendon through the
viral vectors were also pronounced but less severe. lacerated tendon surface, avoiding injuries to the tendon
Tendons treated by AAV serotype 2 (AAV2) vectors dis- gliding surface.
played obvious cellular proliferation and thickening of Information gathered in the above trials established
epitenon, but the reactions were almost completely con- our method of vector delivery to tendons (Figure 6-4).
fined to the epitenon (Figure 6-3). We noted striking Typically, we inject a total of 20 µl of vectors to four sites
similarity between cellular proliferation in the healing (5 µl/site) into two stumps. The needle is inserted from
process of tendons and that caused by the AAV2 vectors the cut surface of the tendon at the depth of about
(see Figure 6-3).26 5 mm.
Efficacy of liposome-mediated transfection and trans-
THE SECOND STEP: TESTING THE EFFECTS OF
duction of adenoviral and AAV2 vectors was next tested.27
GROWTH FACTOR GENE THERAPY IN VITRO
We found that tenocytes are not highly permissive in
cell culture settings; all these vectors were associated We constructed AAV2 vectors harboring the bFGF or
with low efficiency of gene transfer in tenocytes, even VEGF cDNAs, by inserting the therapeutic construct
when test at high titers of vectors. From the later in vivo between the 5′ and 3′ inverted terminal repeat (ITR)
studies, we understand that transduction rates of AAV sequences under the cytomegalovirus (CMV) immediate-
vectors in the cells of tissues are much higher than in early promoter (Figure 6-5), and examined the in vitro
cell culture conditions. AAV2 and adenoviral vectors efficacy of therapies using these vectors. We treated
have similar transduction efficiency, both more efficient the tenocytes with AAV2-bFGF or sham AAV2 vector
Day 7
Cut and repaired tendons AAV2 treated

A B C
Day 14
Cut and repaired tendons AAV2 treated

D E F
Day 7 Day 14
G AAV2 treated H AAV2 treated
Figure 6-3 Tissue reactions and transduction efficiency of the AAV2 vectors. The tissue reactions during the tendon healing
(A, B, D, E) and those caused by AAV2 (C, F) are strikingly similar. The tendons treated with AAV2 vectors exhibit obvious
cellular proliferation and thickening of epitenon, but there are almost no tissue reactions in the endotenon area. Enhanced
green fluorescent protein (EGFP) expression was obvious in endotenon and epitenon areas at days 7 and 14 (G, H) after
injection of AAV2-EGFP into the tendon. *Epitenon area. (A and D, magnification ×100; B and E, ×200; all others, ×400).
(harboring the lacZ gene), with nontreated tenocytes as cells treated with sham vectors or in nontreated con-
the control.50 We assessed transgene expression, expres- trols. We concluded that delivery of exogenous bFGF
sion levels of the bFGF gene, and type I and III collagen gene to tenocytes significantly increases the levels of
genes. Expression of the bFGF gene increased signifi- expression of bFGF and type I and III collagen genes.
cantly after AAV2-bFGF treatment. Expression of type I Similarly, we tested the effectiveness of AAV2-VEGF and
and III collagen genes increased significantly after trans- found enhancement of collagen I production and pro-
fer of the exogenous bFGF gene compared with that in liferation of tenocytes in vitro.
Lacerated tendons
FDS
cm FDP
5
0.
Pulley
Micro-injection
A syringe
C
Figure 6-4 Method of delivery of AAV2-bFGF to the tendon. A, How vectors were injected AAV2 to both stumps of the
tendon cut ends at the depth of 0.5 cm. The vectors were injected to two sites in each stump, at the center of the left and
right tendon bundle of the FDP tendon. B, Structures of flexor tendons and the major pulley in the area between the proximal
and distal interphalangeal joints in chicken toes, which are similar to those of the human tendons around the A2 pulley.
C shows an example of injection of vectors through the lacerated tendon cross-sectional surface into the tendon. D shows
a microinjection needle used for vector injection.
AAV GENOMES AND VECTOR CONSTRUCTION

In the first set of experiments, a total of 104 toes from
52 chickens underwent surgery and were randomized
P5 p19 p40
into three groups, with 38 toes in each of two groups
and 28 toes in one group.5 The FDP tendon was tran-
5′ Rep Cap 3′ sected completely with a sharp surgical blade and was
ITR ITR subjected to one of three treatments: (1) AAV2-bFGF
injection (38 toes) in which a total of 2 × l09 particles
Promoter
of AAV2 containing the bFGF cDNA were injected into
Therapeutic construct
both stumps of the cut tendon ends; (2) AAV2-luciferase
injection (28 toes) in which AAV2-luciferase in the same
number of viral particles was injected into the tendon
Growth factor cDNA stumps; and (3) noninjection (38 toes) in which the
tendons did not receive injection. Immediately after the
Figure 6-5 AAV genomes and vector construction. A above treatments, the tendon was repaired surgically
therapeutic construct was inserted into downstream of a with a modified Kessler method using 4-0 suture. Post-
promoter, which replaces the Rep and Cap components of surgery, the toes were immobilized in semiflexion posi-
the wild-type AAV. tion by adhesive tapes for the first 3 weeks and were
released to allow free motion thereafter.
The FDP tendons from 20 toes of 10 chickens were
THE THIRD STEP: ASSESSMENT OF EFFECTS OF
cut and repair, for test of strength of repaired tendon
GROWTH FACTOR GENE THERAPY IN VIVO
immediately after surgery, and the 10 toes from 5
Over the past 5 years, we conducted four sets of in vivo chickens were not injured and were tested for work of
experiments to evaluate the effectiveness of growth toe flexion, to obtain time-zero strength and work of
factor gene therapy using chickens as a model. flexion data.
We evaluated the outcomes at four time points from 14 120

2 to 12 weeks, with emphasis on variables reflecting p <0.001 p <0.001 p <0.05
12 100
Ultimate strength (N)

healing status and adhesions differently at early and late NS
10 NS NS
healing stages. Postoperative 2 and 4 weeks correspond 80
to the early healing period, and 8 and 12 weeks corre- 8
60
spond to the late healing period. At 2 weeks, tendons 6
were tested for strength and evaluated for healing status 40
4
and adhesions. At 4 weeks, the tendons were harvested 2 20
for strength tests and to score the severity of adhesions.
0 0
At 8 and 12 weeks, when the adhesions and healing had A 2 weeks 4 weeks 8 weeks
matured, we measured the tendon strength, work of toe
flexion, and scored adhesions. AAV2-bFGF treated
We found that the ultimate strength of repaired AAV2-lucifereas
No injection
tendons treated with AAV2-bFGF was significantly
greater than that of tendons treated with the sham-
vector or noninjection at 2, 4, and 8 weeks (Figure 6-6). 5 NS
Scores of adhesions (points)

The AAV2-bFGF treatment at 4 weeks increased the p <0.05
strength to about 140% that of tendons treated with
sham-vector or noninjection. Statistically, the grading of 4 p <0.05 p <0.05
adhesions was the same among all three groups at 8
weeks and the treated tendons had less severe adhesions
at 12 weeks (see Figure 6-6). Work of toe flexion after 3
AAV2-bFGF treatment was not increased compared with
that of noninjection controls at 8 and 12 weeks.
In the second set of experiments, we examined the effects 2
of delivery of different amounts of AAV2-bFGF on B 2 weeks 4 weeks 8 weeks 12 weeks
tendon healing. We examined the strength 4 weeks after
AAV2-bFGF treated
injection of 2 × l07, 1 × l08, 2 × l08, 4 × l08, 1 × l09, and
AAV2-lucifereas
2 × l09 viral particles to each tendon and obtained a No injection
range of vector amount (1 × l09 to 2 × l09 of viral
particles/tendon) that gives the best outcomes in terms
Figure 6-6 A, Ultimate strength of the repaired FDP
of healing strength.
tendon at 2, 4, and 8 weeks postsurgery. The sample
In the third set of experiments, we expanded AAV2- sizes were 10 to 12 tendons at each time point for each
bFGF gene therapy experiments to include comprehen- treatment. At all the three time points, the strength of the
sive biomechanical evaluation of the healing strength tendon treated with AAV2-bFGF was significantly greater
and molecular biological examinations at 10 postsurgi- than that of the no-injection controls. B, Adhesion scores at
cal time points (day 0, weeks 1, 2, 3, 4, 5, 6, 8, 12, and four time points. Sample sizes were 10 tendons at each time
16). The purpose of this set of experiments was to obtain point for each treatment. Adhesions were similar between
a broader picture of the efficacy and mechanism of the treated tendons and no-injection controls at week 8.
AAV2-bFGF treatment. Three groups (AAV2-bFGF treat- The treated tendons had less severe adhesions than the
ment, sham vector control, and noninjection control) no-injection controls at week 12. Adhesions were scored
by criteria in Tang JB, Ishii S, Usui M, et al: Dorsal and
were included, with a total of 134 chickens (268 toes)
circumferential sheath reconstructions for flexor sheath
used. The sample size ranged from 6 to 14 tendons at
defect with concomitant bony injury, J Hand Surg (Am)
each time point for each group. The results of this set 19:61–69, 1994.
of studies are detailed in Figure 6-7. This set of experi-
ments offers further sound evidences of the effectiveness
of AAV2-bFGF: the tendons treated with AAV2-bFGF gene therapy, tenocyte proliferation is increased, teno-
showed an early increase in strength from postsurgical cyte apoptosis decreased, production of extracellular
week 1 through week 4, with percent strength gain of matrix components accelerated, and the rate of degrada-
40% to 70% over the non-injection controls (see Figure tion of extracellular matrix in the tendon decreased.
6-7). The no-gain period in healing strength was effec- These molecular changes offer a mechanistic explana-
tively corrected by AAV2-bFGF gene therapy. Transgene tion for the observed effects of AAV2-bFGF gene therapy.
expression was detectable from week 2 to 6, but the In the fourth set of experiments, we tested the effective-
expression ceased at weeks 8 or 12. The amount of bFGF ness of AAV2 vector harboring VEGF cDNA on improve-
in the treated tendon returned to levels similar to those ments in healing strength. Thirty-six chickens (72 toes)
in the noninjection control at 8 weeks. With AAV2-bFGF were used; transversely cut FDP tendons were injected
16
VEGF gene therapy is effective in correcting the insuffi-
AAV2-bFGF gene therapy ciency of intrinsic healing capacity and offers a thera-
14 peutic possibility for enhancing tendon healing.
12 GENE THERAPY ASSOCIATED
WITH MICRO-RNA REGULATION

10
IN TENDON HEALING
8 Gain in the strength by
AAV2-bFGF gene therapy Adhesion formation is another major problem in
6 tendon healing. With the AAV2-bFGF or AAV2-VEGF
therapies described above, no increase in tendon adhe-
4
sions was recorded compared with sham vector-treated
AAV2-bFGF treated
2 Non-injection
or noninjection controls. However, morphologically
most treated and healed tendons still showed the forma-
0 tion of adhesions; the work of digital flexion did not
0 1 2 3 4 5 return to normal at postoperative 8 or 12 weeks. As an
A (Day) Weeks integral part of investigatory efforts, over the past 3
years, we explored the possibility of RNA interference
16 (RNAi) in reducing adhesion formations of tendon.8
AAV2-VEGF gene therapy Synthetic RNAi is an emerging and rapidly developing
14
field. Gene therapy incorporating siRNA or micro-RNA
12 (miRNA) is a new dimension to the field of gene therapy.
Delivery of siRNA or miRNA to the healing tissues pres-

10
ents as an efficient tool to downregulate expression of
8 Gain in the strength by genes critical to tissue repair.
AAV2-VEGF gene therapy Because transforming growth factor (TGF)-β1 is a
6
master mediator and a major player in tissue fibrosis
4 and scar formation, we aimed at silencing the TGF-β1
AAV2-VEGF treated gene and mitigating the effects of TGF-β1 during tendon
2 Non-injection healing. We synthesized four pre-miRNAs according to
0 sequences of the chicken TGF-β1 gene and constructed
0 1 2 3 4 5 four plasmids containing these pre-miRNA sequences
B (Day) Weeks
and one control containing mock miRNA sequences
(Figure 6-8). Using cultured tenocytes of chicken digital
Figure 6-7 Effects of AAV2-bFGF and AAV2-VEGF gene flexor tendons, we then screened the sequences that
therapy on the tendon healing strength in a chicken tendon effectively downregulate expression of the TGF-β1 gene.
cut and repair model. AAV2-bFGF and AAV2-VEGF gene We transfected cultured tenocytes with these plasmid
therapy substantially augmented tendon healing, helping the vectors and quantified expression of TGF-β1, type I and
tendon “leap over” the lag period in the early stage of the
III collagen, and connective tissue growth factor (CTGF)
tendon healing.
genes using real-time polymerase chain reactions
(Figure 6-9). Subsequently, the plasmid miRNA that
with AAV2-VEGF (2 × l09 viral particles to each tendon). most effectively silenced the TGF-β1 gene in vitro was
The results were evaluated at postsurgical day 0, and in used to test its effectiveness on reducing adhesions in
weeks 1, 2, 3, 4, 5, 6, and 8. We found that the AAV2- vivo. The plasmid miRNA and the control were injected
VEGF treatment is basically as effective as AAV2-VEGF into the injured tendons of 25 chickens. We found that
treatment (see Figure 6-7). in both in vitro and in vivo settings, delivery of engi-
To sum up our in vivo experiments, we found that neered miRNA to the tendon downregulated expression
supplementing lacerated tendons with the bFGF or of the TGF-β1 gene but did not affect expression of the
VEGF cDNAs to produce supernormal amounts of bFGF collagen I gene.
or VEGF (1) substantially increased growth factor activ- In the healing tendon of chickens, we found that
ity within healing tendons, (2) promoted proliferation TGF-β1 gene expression was downregulated 50% to
(but inhibited apoptosis) of the tenocytes and produc- 60% at weeks 1 and 6. At 6 weeks, collagen III gene
tion of extracellular matrix critical to gain in strength, expression was reduced by 55%, and the CTGF gene was
and (3) significantly enhanced the strength of the healed downregulated by 25%. A smoother gliding surface of
tendon. Moreover, production of supernormal amounts the tendon with fewer adhesions was detected 6 weeks
of growth factors had ceased after healing was achieved. after plasmid miRNA treatment compared with plasmid
Taken together, our evidence indicates that bFGF or mock miRNA treatment.
Transcript degradation
Cytoplasm
Target
transcript or
Translational
repression
Exportin 5 (requires only partial
Pasha
complementarity)
Drosha Pre-miRNA
Pri-
miRNA RISC Argonaute
Dicer
Nucleus
A Mature miRNA
Insertion of pre-miRNA
BamH I
ds oligo
Xho I
Bgl II
Dra I
Dra I
Sal I
5′ miR flanking CAGG 3′ miR flanking

attB1 EmGFP region region
attB2
ACGA
TK pA
MV f1
PC or
i
SV
40
Spe
ori
pCDNA 6.2-GW/
ctinomycin
EmGFP-miR
EM7
(5699 bp)
Bla
sti
c
pU
C
id
in
or
i
B SV40 pA
5′ miRNA flanking region 3′ miRNA flanking region
AGGC T T GC T G A AGGC T G T A T GC T G pre-miRNA C AGGA C A C A AGGCC T G T T A C T AGC A C T

T CCGA A CGA C T T CCGA C A T A CG A C ds oligo G T CC T G T GT T CCGGA C A A T GA T CG T GA
Structures of engineered pre-miRNA oligo
5′G + antisense Sense ∆2 nt

TGCT Loop sequences CAGG
C target sequences target sequences
Figure 6-8 A, Biogenesis and biological effects of miRNAs. (Adapted from Mack GS: MicroRNA gets down to business,
Nat Biotechnol 25:631–638, 2007). B and C, Construction of a plasmid harboring in vitro engineered pre-miRNA to silence
expression of TGF-β1 gene of chickens in the tenocytes or in the healing tendon.
We also found downregulation of the type III type I collagen, an essential contributor to tendon
collagen and CTGF genes after plasmid miRNA treat- strength, was not affected, while expression of the
ment, but type I collagen gene expression was not TGF-β1 gene was inhibited. These findings warrant
affected in cultured tenocytes and in the healing further exploration of RNAi gene therapy in preventing
tendons. This treatment meets an essential requirement: adhesions.
140
biomechanically in vivo, though they were successful in
increasing the cellular activities or promoting healing
120 potential in vitro.
We believe that in vivo findings from a series of our
Gene expression (%)
100
experiments provide support for future clinical trials,
80 laying a scientific ground for this treatment. Future
efforts will eventually determine the efficacy of these
60
p <0.001 p <0.001 p <0.001 gene therapy strategies in patients.
40 To expand the future scope of gene therapy for tendon
healing, the following needs to be considered: (1) We
20
tested only AAV2-bFGF and AAV2-VEGF treatments for
0 their ability to improve the healing strength. It is pos-
A TGF-beta Collagen I Collagen III CTGF sible that therapies involving other growth factors, such
as PDGF-BB or IGF-1, could be equally effective. For
140 tissues that generally lack growth factors, sustained sup-
plementation of any (rather than “specific”) growth
120
factors (by gene therapy or other delivery methods such
Gene expression (%)
100 p <0.01 as controlled release) would have a positive impact on

healing strength. Nevertheless, exogenous factors such
80
as TGF-β or CTGF should not be supplied, because they
p <0.001
60 p <0.001 are likely to exacerbate adhesions. (2) The goal of
tendon repair is to restore normal function of the
40 tendon, but its resolution is often hampered by two
20 factors: weak healing strength and adhesion formation,
which may require simultaneous biological manipula-
0 tion. Though we have considered the possibility of “dual
B TGF-beta Collagen I Collagen III CTGF regulation” by increasing the factors favoring strength
Figure 6-9 A, Silencing effects of the miRNA on the gain, while inhibiting factors responsible for adhesions,
TGF-β1 gene expression and downregulation of the collagen this idea of dual regulation remains untested. We specu-
III and CTGF genes in vitro; and B, 6 weeks after delivery of late that such manipulation of tendon healing may be
the miRNA to injured digital flexor tendons. desirable in some clinical situations such as with exten-
sive trauma. However, biological prevention of adhe-
sions may not be necessary for clean-cut tendon injuries,
because strong surgical repairs, augmented by growth
FUTURE PERSPECTIVES
factor gene therapy, if necessary, allow rigorous active
It is hard to speculate when gene therapy for tendon tendon motion, which may effectively limit adhesions.
healing will become a commonly available clinical Gene therapy to inhibit adhesions may become reserved
reality. Nevertheless, past investigations appear to have exclusively for cases of extensive tendon or peritendi-
identified a feasible path to overcome the slow biologi- nous damage in which adhesions are pronounced and
cal healing responses of the tendons reflected by the unavoidable, or hand trauma precludes early tendon
“no-gain” period in strength. This is an important step movement. (3) Regarding gene therapy using miRNAs
in biological augmentation of tendon healing. Previ- or siRNA, our efforts have offered only preliminary evi-
ously, investigators have failed to augment tendon dences. Comprehensive in vivo experiments examining
healing reliably by other methods, and the effectiveness effectiveness are necessary. The significance of these
was either small or could not be reproduced at other treatments will become clear only when further investi-
time points. Most past efforts failed at increasing strength gations have generated more information.
References
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5. Tang JB, Cao Y, Zhu B, et al: Adeno-associated virus-2-medi- 24. Tang JB, Xu Y, Ding F, et al: Expression of genes for collagen
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increases healing strength. An in vivo study, J Bone Joint Surg tendons, J Hand Surg (Am) 29:564–570, 2004.
(Am) 90:1078–1089, 2008. 25. Tang JB, Xu Y, Wang XT: Tendon healing in vitro: activation of
6. Yao J, Korotkova T, Riboh J, et al: Bioactive sutures for tendon NIK, IKKα, IKKβ, and NF-κB genes in signal pathway and
repair: assessment of a method of delivering pluripotential proliferation of tenocytes, Plast Reconstr Surg 113:1703–1711,
embryonic cells, J Hand Surg (Am) 33:1558–1564, 2008. 2004.
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tendon healing through controlled delivery of PDGF-BB, adeno-associated viral, and liposome-plasmid vectors in
J Orthop Res 27:1209–1215, 2009. tendons and comparison with early-stage healing responses
8. Chen CH, Zhou YL, Wu YF, et al: Effectiveness of microRNA of injured flexor tendons, J Hand Surg (Am) 31:1652–1660,
in down-regulation of TGF-β gene expression in digital flexor 2006.
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(Am) 34:1777–1784, 2009. adeno-associated virus-2 effectively transduces intrasynovial
9. Abrahamsson SO, Lundborg G, Lohmander LS: Long-term tenocytes with persistent expression of the transgene, but
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human insulin-like growth factor-I and serum on matrix 28. Chen CH, Cao Y, Wu YF, et al: Tendon healing in vivo: gene
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11. Gelberman RH, Amiel D, Harwood F: Genetic expression for period, J Hand Surg (Am) 35:2–10, 2010.
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Reconstr Surg 100:937–944, 1997. 33. Kubota H, Manske PR, Aoki M, et al: Effect of motion and
14. Chang J, Most D, Thunder R, et al: Molecular studies in flexor tension on injured flexor tendons in chickens, J Hand Surg
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2000. 35. Boyer MI, Gelberman RH, Burns ME, et al: Intrasynovial
16. Boyer MI, Watson JT, Lou J, et al: Quantitative variation in flexor tendon repair. An experimental study comparing low
vascular endothelial growth factor mRNA expression during and high levels of in vivo force during rehabilitation in
early flexor tendon healing: An investigation in a canine canines, J Bone Joint Surg (Am) 83:891–899, 2001.
model, J Orthop Res 19:869–872, 2001. 36. Friedmann T, Roblin R: Gene therapy for human genetic
17. Tsubone T, Moran SL, Amadio PC, et al: Expression of growth disease? Science 175:949–955, 1972.
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Plast Surg 53:393–397, 2004. therapy on visual function in Leber’s congenital amaurosis,
18. Mehta V, Kang Q, Luo J, et al: Characterization of adenovirus- N Engl J Med 358:2231–2239, 2008.
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(Am) 30:136–141, 2005. red-green colour blindness in adult primates, Nature 461
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20. Thomopoulos S, Harwood FL, Silva MJ, et al: Effect of several topoietic stem cell gene therapy with a lentiviral vector in
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447, 2005. 40. Chong AK, Ang AD, Goh JC, et al: Bone marrow-derived
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38:225–234, 2010. 41. Chan BP, Fu S, Qin L, et al: Effects of basic fibroblast growth
22. Sakiyama-Elbert SE, Das R, Gelberman RH, et al: Controlled- factor (bFGF) on early stages of tendon healing: a rat patellar
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(Am) 33:1548–1557, 2008. II flexor tendon repair using growth differentiation factor 5
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activation, J Hand Surg (Am) 28:215–220, 2003. genous basic fibroblast growth factor on intrasynovial flexor
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(AAV), J Med Virol 59:406–411, 1999. GAD gene for Parkinson’s disease: an open label, phase I trial,
46. Daly TM: Overview of adeno-associated viral vectors, Methods Lancet 369(9579):2097–2105, 2007.
Mol Biol 246:157–165, 2004. 50. Wang XT, Liu PY, Xin KQ, et al: Tendon healing in vitro: bFGF
47. Mueller C, Flotte TR: Clinical gene therapy using recombi- gene transfer to tenocytes by adeno-associated viral vectors
nant adeno-associated virus vectors, Gene Ther 15:858–863, promotes expression of collagen genes, J Hand Surg (Am)
2008. 30:1255–1261, 2005.
CHAPTER
7
TENDON TISSUE ENGINEERING
AND BIOACTIVE SUTURE
REPAIR
Brian C. Pridgen, BS, Jeffrey Yao, MD, and
James Chang, MD
OUTLINE plantaris, and toe extensor tendons. Limitations of

autograft harvesting include donor site morbidity and
Tissue engineering is a field that aims to apply our additional anesthesia and operative time. In cases of
expanding basic knowledge of tissue biology to the mutilating injuries to the hand (Figure 7-1), the demand
design of engineered tissue substitutes. Despite for graft material may outstrip the autograft supply in a
advances in tendon repair, many patients still experi- patient, leaving these patients without a good solution
ence poor outcomes that can lead to lifelong disability. for restoring hand function.
Tendon tissue engineering and bioactive sutures are Although synthetic graft materials such as Dacron
well suited to address this clinical need. In injuries to grafts and Silastic rods have been used for tendon recon-
the hand that require interposition tendon grafts, the struction, outcomes are generally poor, and the life
need for autograft material may outstrip the supply in span of these grafts tends to be short. Failure is typically
a given patient, or the available autograft material may due to mechanical wear or rupture of the tendon–graft
lead to suboptimal outcomes for the patient. A tissue- interface. These synthetic materials are designed to
engineered tendon would be readily available as an replace tendon tissue, rather than to regenerate it. Thus,
off-the-shelf product designed to optimize the healing the resulting repair does not heal with tendon tissue
process and to recapitulate normal function. Design properly and does not support the ingrowth of cells
of such a tendon requires a detailed understanding of to promote biodegradation and remodeling of the
the tendon healing process as well as normal tendon implant.
function and biology, including its structure and com-
TISSUE ENGINEERING
position, cells and their role in tendon function, and
biomechanical properties of tendons. This under- One of the earliest articles broadly defining tissue engi-
standing can then be applied to the four primary com- neering was a 1993 Science article by Langer and Vacanti.1
ponents of a tissue-engineered tendon: cells, scaffolds, In this article, they defined the nascent field of tissue
growth factors, and mechanical manipulation. Injuries engineering as “an interdisciplinary field that applies
requiring suture repair, whether or not an interposi- the principles of engineering and the life sciences toward
tion graft is necessary, often have poor outcomes the development of biological substitutes that restore,
despite advances in suture techniques and materials. maintain, or improve tissue function.” They described
Current research into bioactive sutures loaded with three general strategies of tissue engineering: (1) cells or
growth factors or cells offers a new strategy for strength- cell substitutes, (2) tissue-inducing substances such as
ening and improving suture repairs of tendons. growth factors and delivery vehicles, and (3) cell-seeded
scaffolds. These principles have been applied to clinical
Despite recent advances in flexor tendon repair surgery, needs in hand surgery, resulting in commercially avail-
many patients still experience poor outcomes following able products including engineered skin substitutes2
repair. This is often due to severe adhesion formation, and allogeneic nerve grafts.3 However, a tissue-engineered
which may require tenolysis procedures to improve tendon is not yet available.
motion. Additional causes of poor outcomes include
TENDON BIOLOGY
tendon rupture or failure at the repair site, due to either
suture pull-through, suture breakage, knot slippage, or At their simplest, tendons can be thought of as thick
gapping at the repair site. collagen ropes that transmit forces from muscles to act
When graft material is required, repairs are currently across joints to move and stabilize them. Development
limited to autografts such as the palmaris longus, of a tissue-engineered tendon requires a much deeper
71
zone 2, better outcomes are achieved when reconstruc-

tion is performed with intrasynovial autografts rather
than extrasynovial autografts.
Brockis and others made early observations about the
vascular supply to flexor tendons.7 They observed that
tendons receive their blood supply through the muscu-
lotendinous junction, the paratenon surrounding the
tendon in the extrasynovial region, the vincula within
the intrasynovial region, and the osteotendinous inser-
tion. In addition to vascular nutrition, the intrasynovial
Figure 7-1 Mutilating injury to the forearm and hand with portion of the tendon receives nutrition by diffusion
significant soft tissue loss, including tendon damage. This through the synovial fluid.8,9
patient required extensive reconstruction and would have
benefited from a tissue-engineered tendon. Cells
Tenocytes, the primary cell type in tendons, are spindle-
shaped fibroblast-like cells oriented along the long axis
understanding. The mechanical properties of tendons of tendons that are responsible for the production and
crucial to their proper functioning rely not only on maintenance of the extracellular matrix of the tendon.
the structure and organization of its major collagen As they mature, their metabolic activity and energy
constituents but also on the other extracellular matrix demand decrease. This enables tendons to carry loads
components. At steady state, tendons are relatively and maintain tension for long periods of time without
hypocellular and have low metabolic demands. During becoming ischemic and necrotic. However, during
times of injury and healing, cells and their nutritional injury and repair, this slow metabolic rate leads to pro-
pathways play a critical role, and their activity is a major longed healing.
determinant of tendon healing.
Tendon Healing
Structure and Anatomy Tendons heal slowly because of their hypocellularity,
Collagen is the basic structural unit of tendons.4,5 It is hypovascularity, and low metabolic rates.10 This pro-
organized into a hierarchical structure of progressively longed healing process requires immobilization to
larger and more organized subunits to form the crimped reduce the risk of tendon rupture or gap formation. The
or sinusoidal pattern visible by light microscopy. duration of this immobilization must be balanced
While collagen is the major constituent of tendons, against the risk of adhesion formation. Modulating this
proteoglycans are critical to the biological and mechani- healing process to create a strong tendon repair with
cal functioning of tendons.6 Proteoglycans promote minimal adhesion formation requires an understanding
hydration through hydrophilic subunits and mediate of the three stages of tendon healing: inflammatory,
interactions between structural units of the tendon, proliferative, and remodeling.4,10
which are important determinants of the viscoelastic The inflammatory stage occurs within the first 24
properties of tendons. Another important function of hours and is characterized by recruitment of inflamma-
proteoglycans is their role in promoting cell signaling tory cells. The proliferative stage begins as tenocytes are
to mediate growth, proliferation, and migration. recruited to the site of injury and begin to produce
Synovial sheaths around tendons are found in areas extracellular matrix components, including collagen
subjected to mechanical stress in which efficient gliding type III. After several weeks, the remodeling stage begins.
is mediated by synovial lubrication. Examples of tendons The randomly organized extracellular matrix produced
of the hand with intrasynovial portions include the during the proliferative stage is organized into parallel
flexor digitorum superficialis and flexor digitorum pro- fibrils, while the collagen type III production decreases
fundus tendons. These tendons have an intrasynovial and collagen type I production increases. As healing is
region in their more distal portions within the hand and completed, tenocyte number and metabolism then
an extrasynovial region in their more proximal portions. begin to decrease.
In addition to assisting with gliding in areas of high
mechanical stress, the synovial sheath also provides Extrinsic Versus Intrinsic Healing
nutrition by diffusion through synovial fluid. Extrasyno- It was originally thought that tendons must heal by an
vial tendons are covered by the paratenon, a loose extrinsic process in which ingrowth of new cells occurred
connective tissue that carries the blood supply. This dis- through vascularized adhesions to surrounding tissue.11
tinction is important because although overall outcomes It was later demonstrated that intrasynovial tendons
are generally unsatisfactory with injuries to intrasyno- could heal by a process mediated by cells intrinsic to
vial tendons and graft reconstruction, particularly in the tendon.12,13 This suggested that adhesion formation
Chapter 7: Tendon Tissue Engineering and Bioactive Suture Repair 73
might not be necessary for tendon healing if cells within tenocyte-seeded scaffolds resembled native tendons in
the damaged tendon are available to mediate repair. histologic structure, collagen arrangement, and breaking
strength.14 However, tenocytes may not be a practical
TENDON TISSUE ENGINEERING
source of cells because autologous tendon harvest
Tissue engineering a tendon requires an understanding required for their isolation results in donor site morbid-
of the basic science of tendon healing and tendon func- ity. They also expand very slowly in culture, which may
tion. This knowledge can then be applied to designing make them further impractical due to a lengthy in vitro
and choosing the components of a tissue-engineered expansion time following cell isolation and before
tendon, which can include cells, a scaffold, growth seeding of the tendon construct.
factors, and mechanical manipulation (Figure 7-2), Human dermal fibroblasts are another terminally dif-
some or all of which can be used to create the final ferentiated cell type that closely resembles tenocytes and
tissue-engineered product. have been widely considered as a candidate cell line for
tendon tissue engineering. Like tenocytes, dermal fibro-
Cells blasts are derived from the mesoderm, have similar
As the machinery responsible for tissue repair and main- morphology, and have similar extracellular matrix pro-
tenance, cells are a necessary component of a tissue- duction capacity. Harvest of autologous dermal fibro-
engineered construct in order to achieve functional blasts through a simple skin biopsy would cause
restoration of the tendon. Despite this clear goal of a minimal morbidity or expense, which is a notable
tissue-engineered construct, the steps necessary to advantage over tenocytes, and they are easily and rapidly
achieve this goal remain uncertain. Questions research- expanded in culture. In a study comparing human teno-
ers continue to face include determining the appropri- cytes and human dermal fibroblasts, each cell type was
ate cell type and cell source and determining the site of isolated and grown separately on a polyglycolic acid
cell seeding. scaffold.15 The authors found no difference in a number
of outcome measurements comparing tenocyte-seeded
Cell Type and Cell Source and dermal fibroblast–seeded tendon constructs, includ-
Selection of the cell type and cell source for seeding of ing gross structure, histology, collagen deposition, col-
the tendon construct is an important decision that must lagen fibril diameter, and construct strength. These
consider (1) the ease of harvest of the chosen cell type results suggest that dermal fibroblasts may be a suitable
without inflicting collateral morbidity at the donor site, substitute for tenocytes, which will also avoid the prob-
(2) the ability to culture and expand the cells in vitro, lems with using autologous tenocytes.
and (3) whether the chosen cells will achieve functional Mesenchymal stem cells (MSCs) are a multipotent
restoration of the tendon. Cell types that have been cell line present in adult bone marrow and adipose
considered include tenocytes, dermal fibroblasts, and tissue that may be cultured as undifferentiated cells
mesenchymal stem cells. or driven to differentiate into mesenchymal lineages
Tenocytes are the predominant cell type of native including tenocytes, osteoblasts, chondrocytes, and adi-
tendon. Thus, they should be capable of restoring func- pocytes.16 Although harvest of MSCs from bone marrow
tion of a tissue-engineered tendon construct. In a study is invasive, provides low yields, and requires time con-
using unwoven polyglycolic acid scaffolds seeded with suming and expensive in vitro expansion in culture, it
hen tenocytes, Cao and colleagues demonstrated that does not carry the donor site morbidity of tenocyte
harvest. Several groups have demonstrated improved
tendon strength, remodeling, and tissue formation
when seeded with bone marrow–derived MSCs.17-19
Cells Scaffold
Cell type Biologic scaffolds Adipose-derived MSCs, on the other hand, are easily
Cell source Synthetic scaffolds obtainable in sufficient quantities with minimal mor-
Site of cell seeding Acellularized scaffolds bidity, and they have been shown to have a similar dif-
Autogenous vs.
allogeneic cells ferentiating potential to bone marrow–derived MSCs.20
One of the concerns with the use of MSCs is the risk for
Growth factors Mechanical manipulation undesirable differentiation down nontenogenic lines.
IGF-I Continuous strain Several authors have noted ectopic bone formation with
TGF-β Cyclic strain
VEGF Intermittent strain MSCs used for tendon tissue engineering,18,21 although
PDGF another group modulated MSC differentiation by over-
bFGF expressing Smad8 to promote tenogenic differentia-
Figure 7-2 Components of a tissue-engineered tendon tion.22 Further research will be necessary to better
and some of the considerations necessary for each of these understand MSC differentiation and replication. This
components. A final tissue-engineered tendon product may may include identifying possible subpopulations of
contain some or all of these components. MSCs with predispositions to differentiate down a
particular lineage and to better characterize tenocyte although in vitro manipulation carries some risk of
markers to verify proper differentiation. infectious contamination.
The greatest concern with the use of allogeneic cells
Site of Seeding (In Vivo versus In Vitro) is the risk of immune rejection due to incompatibility
Much research has focused on seeding scaffolds with with the recipient. However, recent work has shown that
cells in vitro prior to implantation. This offers a possible the use of allogeneic MSCs avoids an immune response
advantage of providing a cell population intrinsic to the in recipients. Possible explanations for this include low
tissue-engineered construct that may initiate the healing expression of MHC-II and disruption of leukocyte
process. This may mediate an intrinsically mediated function.25
healing process that may result in fewer adhesions, The use of allogeneic cells presents a number of
while promoting more rapid healing at the repair site, advantages over autogeneic cells. First, an existing supply
remodeling, and engraftment. Many of the previously of allogeneic cells would eliminate the need for a time-
mentioned studies have successfully demonstrated cell intensive and costly harvest and in vitro expansion of
attachment to the surface of tendon scaffolds. However, autogeneic cells. Having this existing supply would
there has been limited success with establishing cell allow clinicians to more rapidly seed a scaffold and to
populations deep to the surface of tendon scaffolds. provide definitive repair without a staged process of cell
Some groups have attributed this to the tight weave of harvest, in vitro cell expansion, and implantation.
the scaffold matrix, which inhibits cells from migrating Second, there may be some regulatory advantages to
deeper into the tendon.23 Another possible explanation using allogeneic cells. By having a large bank of cultured
could be poor nutritional supply deeper into the tendon cells, cell samples could be removed for safety testing
in the absence of the native intratendinous vascular without significantly reducing the cell count and neces-
supply or nutrition by diffusion of synovial fluid. This sitating further in vitro expansion, as would be neces-
may be of particular concern for newly seeded cells that sary for safety testing of autogeneic cells. Last, MSCs
are metabolically more active than native tenocytes, have been shown to decrease in number, life span, and
thus inhibiting them from migrating deeper from the proliferative capacity with increasing donor age.26 This
surface. Despite the difficulty with seeding deep to the age-related decline of MSCs may make autogeneic MSCs
surface, it has been shown that host cells infiltrate and an impractical option for seeding of a scaffold in older
replace seeded cell populations in a time-dependent patients. An available source of allogeneic MSCs from
manner.24 Further work will be needed to understand younger donors would avoid this problem.
the importance of establishing cell populations deep to
the surface of the tendon and how to promote seeding Scaffolds
deeper into the core of the tendon. Cultured cells alone are incapable of replacing the func-
Another option would be to implant an acellular tion of a tendon. They require the three-dimensional
scaffold and to rely on the patient’s body to cellularize scaffolding of the extracellular matrix in tendons. In
the graft. To allow more rapid healing at the repair addition to providing an attachment site for cells, the
site, remodeling, and engraftment, some groups have tendon extracellular matrix provides the mechanical
attempted to accelerate this process of in vivo seeding properties to the tendon and has attached signaling
by using guided regeneration. This includes the use of molecules important for cell growth, proliferation, and
growth factors or using an acellularized tissue scaffold migration. The role of a scaffold in tissue engineering is
that contains important biomolecules. Advantages to to provide a three-dimensional biocompatible and bio-
this approach include avoiding in vitro cell expansion degradable construct to support growth, proliferation,
and seeding, which would be expensive and time con- and migration of cells and to allow remodeling by
suming, carry infectious risks to patients, and involve cells without the production of toxic or inflammatory
regulatory hurdles. Challenges to this approach include degradation products. The scaffold should provide
requirement of a detailed understanding of the biology mechanical strength sufficient to permit postoperative
of tendon healing and the temporal distribution of key mobilization therapy without rupture of the tendon
growth factors. Additionally, as the seeding process graft. Scaffolds have been produced from natural bio-
would be dependent on extrinsic cells, this may mediate logic materials, synthetic materials, or acellularized
adhesion formation. cadaver tissue.
Autogenous versus Allogeneic Cell Seeding Biologic Scaffolds

Much of the research in tendon tissue engineering has Because collagen is the primary component of tendons,
focused on using autogenous cells for seeding of the it has been widely investigated as a possible scaffold for
scaffold. This approach avoids problems with immuno- tendon tissue engineering. As the natural major con-
logic incompatibility and rejection of the grafted cells. stituent of tendons, collagen is highly biocompatible
It also reduces concerns of infection transmission, with safe degradation products, and it supports cell
attachment and proliferation better than synthetic metabolites, including glycolic acid and lactic acid,
materials.27 Collagen scaffolds may be made either as a these metabolites are acidic and may give rise to sys-
gel or as a sponge. Collagen gels alone do not possess temic or local reactions.33 Such a reaction may promote
inherent mechanical strength to act as a suitable scaf- an inflammatory response that may delay healing by
fold; they must be used with a supporting material, such killing cells, disrupting the newly forming neotendon,
as suture.18 Collagen sponges possess superior mechani- and promoting adhesion formation. Another hurdle to
cal strength but have inferior cell attachment pro the implantation of synthetic scaffolds is their poor
perties.28 Some groups have combined the superior mechanical strength. They are typically far weaker than
cell-seeding characteristics of collagen gels with the native tendon, and it takes several weeks of in vitro or
superior mechanical characteristics of collagen sponges in vivo culture with cells before these constructs begin
in a joint gel–sponge construct.29 While these scaffolds to approach the strength of native tendon.14,19 If in vitro
have the advantages of being easily manufacturable with maturation of the scaffold is performed, this will be
natural nonimmunogenic materials, they lack GAG sig- expensive, put the tissue-engineered construct at risk of
naling molecules and do not have the mechanical infection, and require the patient to wait for an extended
strength of native tendon. period of time for the repair if autogeneic cells are used.
If in vivo maturation of the scaffold is performed, this
Synthetic Scaffolds will put the patient at risk for adhesion formation and
The most commonly used biodegradable synthetic scaf- joint contracture with prolonged immobilization to
folds for tendon tissue engineering are polyesters, prevent rupture of the weak graft.
including polylactic acid (PLA), polyglycolic acid (PGA),
and their copolymer polylactic-co-glycolic acid (PLGA). Acellularized Scaffolds
The ability to manufacture them synthetically permits One of the disadvantages of biologic and synthetic scaf-
researchers to manipulate the material properties of folds is that they are biologically inert; they lack the
the scaffold to achieve the appropriate balance of signaling molecules necessary to promote cell migra-
degradability and scaffold mechanical strength and to tion, cell proliferation, and extracellular matrix produc-
create a surface environment that encourages cell attach- tion. Although molecules may be incorporated into
ment, migration, and proliferation. A study by Lu and these structures, tendon biology is not yet well under-
coworkers compared the suitability of PLA, PGA, and stood enough to entirely recapitulate the local
PLGA as a scaffold for ACL reconstruction.30 They found environment.
that although PGA initially was the strongest of the Native tendon, on the other hand, contains many of
three materials, it rapidly degraded with in vitro cell these signaling molecules in the form of proteoglycans.
culture, which would put such a graft at risk of rupture Native tendon also possesses the mechanical strength
if used in vivo. When seeded with ACL fibroblasts, the necessary to withstand normal loading forces without
PLA scaffold supported the greatest number of cells the need for lengthy in vitro or in vivo neotendon
with normal morphology. In a different study by formation, unlike many of the biological or synthetic
Ouyang and colleagues, they observed that PLGA scaffolds. However, native tissue containing these bio-
scaffolds supported the greatest attachment and pro logical and mechanical advantages cannot be grafted
liferation of bone marrow–derived MSCs.31 Groups from one individual to another because of the existing
continue to use a variety of scaffolds with no agreement immunogenic cellular material. Instead, the tissue must
yet in the literature, which could attributable to a variety be acellularized to remove the immunogenic compo-
of factors, including differing manufacturing specifica- nents without compromising the signaling molecules,
tions of the polymer scaffolds, cell types used, culture mechanical strength, and biocompatibility.
conditions, or mechanical testing parameters. Other A number of groups have produced a scaffold from
observations that have been made using synthetic scaf- fresh tendons treated with detergents to remove immu-
folds include the use of a fibronectin coating to over- nogenic cellular material (Figure 7-3).34,35 They demon-
come the surface hydrophobicity of the scaffolds to strated that these acellularized tendons retained the
promote cell attachment30; the use of knitted scaffolds, biochemical signaling molecules and mechanical prop-
rather than braided scaffolds, to promote improved cell erties important for proper biological and mechanical
attachment and ingrowth19; and electrospinning of functioning of the tendon. They went on to show that
nanofibers to promote cell attachment, proliferation, these scaffolds are capable of supporting the attachment
and migration.32 and growth of allogeneic cells, suggesting that these
Despite the advantages of having a manufacturable acellularized tendon scaffolds may be suitable for clini-
and easily modified synthetic scaffold and the many cal use in tendon tissue engineering. Other tissue that
recent advances made in this field, there are a number has been considered for producing an acellularized scaf-
of disadvantages that remain. Although polyester scaffold for tendon tissue engineering include acellular
folds are degraded by hydrolysis into naturally occurring dermal matrix36 and human umbilical vein.37
B
Figure 7-3 Acellularization of a full-length human tendon.
A, Untreated control tendon showing nuclear staining with
a fluorescent nucleic acid stain. B, Acellularized tendon
showing removal of nuclear material.
Growth Factors Figure 7-4 A bioreactor designed to accommodate a

full-length human flexor tendon. The system can be
The temporal distribution of growth factors during the
connected to a motor and programmable control system
healing process is still being investigated, but it is known
that permits continuous, cyclic, and/or intermittent strain to
that they play an important role in mediating the tendon be applied.
repair process. Well-studied growth factors involved in
tendon healing include insulin-like growth factor-I
(IGF-I), transforming growth factor-β (TGF-β), vascular alignment and that this collagen was composed pre-
endothelial growth factor (VEGF), platelet-derived dominantly of collagen type I typically found in tendon
growth factor (PDGF), and basic fibroblast growth factor rather than collagen type III typically found in skin,
(bFGF).4,38 These growth factors have roles in inflamma- suggesting a phenotype switch of the dermal fibroblasts
tion, cell migration and proliferation, collagen produc- to a tenogenic cell type. They also noted the improved
tion, angiogenesis, and remodeling of the tendon. strength of their tissue engineered constructs following
Methods of growth factor delivery include seeding of mechanical loading. A study by another group demon-
genetically engineered cells, loading with vectors har- strated that intermittent cyclic strain, rather than con-
boring the genes of interest, or direct delivery of growth tinuous strain, promoted greater cell proliferation, type
factors. Although much progress has been made, further I collagen production, and maintenance of tenocyte
research will be required. A better understanding of morphology.40 They then went on to demonstrate that
the temporal changes and role of growth factors in the acellular tendon scaffolds re-seeded with cells and then
different stages of healing will be necessary. Further subjected to intermittent cyclic strain are stronger than
research into delivery methods will also be necessary to re-seeded tendons that were not subjected to strain. An
determine a method that is safe, efficacious, and cost example of a tendon bioreactor is shown in Figure 7-4.
effective.
BIOACTIVE SUTURE
Mechanical Manipulation Once a tissue-engineered tendon is developed, it must
Mechanical strain is known to be an important con- be interposed into the defect and then sutured into
tributor to tenocyte function, maintenance of a teno- place. Following repair, patients should initiate early
genic phenotype, and collagen production.39 One group postoperative mobilization therapy to reduce adhesion
noted in a series of studies the role of mechanical formation. However, the benefits of early mobilization
loading on PGA scaffolds seeded with human dermal must be weighed against the risk for gap formation,
fibroblasts.15 They found that mechanical loading which can lead to delayed healing and reduced tensile
promoted maturation of collagen fibers with parallel strength at the repair site. Recent advances in suturing
A B C
Figure 7-5 Seeding of mouse embryo pluripotential cells onto FiberWire suture. A, Control suture with no coating and few
adherent cells. B, Suture with poly(L-lysine) coating mediating cell adhesion. C, DAPI staining of cells adherent to the suture.
techniques and suture material have improved the survive the trauma of passage through acellularized
strength of tendon repairs, but the risk of gap formation tendons, proliferate, and remain metabolically active.
with early mobilization has not been eliminated. Addi- These cells repopulate the acellular zones shown to sur-
tionally, the trauma from suture repair has been impli- round suture material in repaired tendons, and may
cated in creating acellular zones and inflammation that thereby accelerate healing. Animal studies to evaluate
delay tendon healing.41 the use of bioactive sutures are currently ongoing.
Several groups have investigated the use of bioactive These techniques will be beneficial both for direct
suture to augment tendon repairs. The two primary repair of tendon ends or for placement of a tissue-
strategies under investigation are to modulate cells engineered interposition graft. By promoting early
present at the repair site through growth factors incor- healing and cell proliferation at the repair site through
porated into the suture or to attach cells directly onto the use of bioactive sutures, early tensile strength may
the suture with the intention of seeding them to the be increased and overall healing time decreased. This
repair site. may permit earlier initiation of safe postoperative
Multiple groups have investigated the use of suture mobilization with minimal risk of gapping or tendon
as a drug delivery device. An in vitro study using epi rupture.
dermal growth factor seeded onto Mersilene suture
CONCLUSION
demonstrated increased cell proliferation along the
coated suture.42In another study, bFGF was loaded onto Despite many of the recent advances in flexor tendon
a nylon monofilament suture used to repair rabbit repair, many patients still experience poor outcomes.
tendon injury.43 The bioactive suture increased strength Adhesion formation leads to reduced mobility. Large
of the repair and promoted cell proliferation at the defects require autograft harvesting, which carries mor-
repair site. A third group used growth differentiation bidity and may be insufficient in extensive mutilating
factor-5 to coat sutures and achieved similar results to injuries. Traditional suture repair requires delayed post-
the previous groups, demonstrating increased strength operative mobilization due to the risk of gap formation.
of the tendon repair and enhanced cell proliferation.44 Continuing research in tendon biology has increased
Another group has attempted to address directly the our understanding of tendon structure, function, and
problem of the acellular zones at the site of suture repair healing. The application of this basic science research
by incorporating pluripotential cells into the suture.45 through the use of tissue-engineering principles has led
These pluripotential cells have been shown to be deliv- to the development of many technologies that promise
ered to a tendon repair–reconstruction site (Figure 7-5) to one day improve the repair and reconstruction of
as well as along the entire path of the suture. The cells flexor tendon injuries.
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CHAPTER
8
INDICATIONS FOR PRIMARY
FLEXOR TENDON REPAIR
Jin Bo Tang, MD
OUTLINE Kleinert and his colleagues on primary flexor tendon

repairs followed by early mobilization established that
Injuries to the flexor tendons occur in the digits, palm, the lacerated digital flexor tendon can be treated by
wrist, or distal and mid-forearm. Repairs of flexor direct end-to-end repairs when wound conditions are
tendons in the digital sheath area are technically favorable.1-3
demanding. When wound conditions are favorable,
ANATOMICAL DIVISIONS
primary tendon repair is preferable in terms of ease.
However, it is important that primary repairs be per- By virtue of their anatomical features, the flexor tendons
formed by experienced surgeons. Alternatively, a well- in the hand and forearm are divided into five zones,
accepted strategy is to postpone the repair for a few which delineates the fundamental nomenclature for
days, or even 1 to 2 weeks, to the delayed primary flexor tendon anatomy and surgical repairs.1,3,6 In the
stage, for an experienced surgeon to become available. 1990s, the most complex areas—the flexor tendons
Repairs during either the primary or delayed primary within the digital sheath—were subdivided by Moiemen
stage produce comparable clinical outcomes. and Elliot7 and by Tang.8 The zoning is described in
Primary and delayed primary flexor tendon repairs Box 8-1, and its relation to the locations of pulleys is
are indicated in clean-cut tendon injuries with limited shown in Figures 8-1 and 8-2.
damage to the peritendinous tissues or a wound that
ETIOLOGIES AND EVALUATION
can be converted to a clean-cut wound. Neurovascular
OF TENDON INJURIES
injury is not a contraindication to primary repairs.
Loss of soft tissue coverage over the tendon or the Tendons can be injured through open wounds, caused
presence of fractures is a borderline contraindication. by sharp cuts or machine injuries, as closed ruptures
Local defects in skin and subcutaneous tissues can be after fractures, through other bony problems, or even
covered by flap transfer. A simple fracture limited to spontaneously, without history of injury or clear etiol-
the phalangeal or metacarpal shaft can be securely ogy. Severe forms of tendon injury can present as part
fixed with screws or mini-plates and the tendons can of compound injuries due to major trauma to the
be repaired. extremities. Surgically repaired tendons may disrupt
Serious crush injuries, severe wound contami during functional exercise.
nation, extensive loss of soft tissues, or extensive Tendon injuries often present as open injuries and
destruction of pulleys and tendon structures are con- are associated with a variety of open wounds. Open
traindications to primary tendon repairs. trauma with deep, narrow traumatic laceration should
raise suspicion of concomitant tendon injuries. Such a
Injuries in the flexor tendons can occur in the digits, diagnosis can be missed if surgeons do not carefully
palm, wrist, or distal and mid-forearm. Tendon repairs evaluate active motion of the potentially involved digits.
in the digital sheath area are most technically demand- When a tendon is partially cut, the fingers may still func-
ing and controversial. The advent of primary flexor tion well in many cases, easily causing such cuts to be
tendon repairs within the synovial sheath region should neglected. Some larger partial cuts of the tendon may
be credited to pioneers of nearly half a century ago, be detected through triggering during finger flexion.
including Verdan1 and Kleinert and colleagues.2,3 Prior Large open traumas deep enough to reach the bony
to that time, over most of the previous half century, structures are usually accompanied by tendon injuries,
primary tendon repair was not advocated and surgeons which are not difficult to diagnose. Open trauma to the
were accustomed to removing the tendons entirely and palm or wrist areas is frequently accompanied by tendon
grafting in new tendon.4,5 The reports of Verdan and of injuries. Trauma to the wrist area may injure only a part
81
82 Section 2: Primary Flexor Tendon Surgery
Box 8-1 Nomenclature for Flexor Tendon

Anatomy in the Hand and Forearm
1
Zones of Finger Flexor Tendons (Verdan)
1 From the insertion of the FDS tendon the terminal
insertion of the FDP tendon
2 From the proximal reflection of the digital synovial
sheath to the FDS insertion 2
3 From the transverse carpal ligament to the digital
synovial sheath
4 Area covered by the transverse carpal ligament
5 Proximal to the transverse carpal liagment 1
Zones of Thumb FPL Tendon 2 3

1 Distal to the IP joint
2 From the IP joint to the A1 pulley 3
3 The area of the thenar eminence
4
Zone 1 in Fingers (Moiemen and Elliot)

1A The very distal FDP tendon (usually <1 cm)
1B From zone 1A to distal margin of the A4 pulley
1C The FDP tendon within the A4 pulley 5
Zone 2 in Fingers (Tang)

2A The area of the FDS tendon insertion
2B From the proximal margin of the FDS insertion to
Figure 8-1 Zoning of the digital flexor tendons.
the distal margin of the A2 pulley
2C The area covered by the A2 pulley
2D From the proximal margin of the A2 pulley to the
proximal reflection of digital sheath
Transverse metacarpal ligament
of the wrist flexors, without interfering in normal finger

Vertical septa
aponeurosis
and wrist flexion. However, injuries to the majority of

Palmar
the wrist flexors cause weakness of wrist flexion and/or A1 A2 C1 A3 C2 A4 C3 A5

render active finger flexion impossible.
The levels of division of the tendons often do not lie
immediately deep to the finger skin lacerations. The
location of the distal tendon ends depends on the posi-
tion of the fingers at the time of injury. If the finger
is lacerated in flexion, the distal end of the tendon is
2D 2C 2B 2A 1C 1B 1A
drawn distally as the finger is extended. If the finger is
lacerated in extension, the distal tendon end is usually Zone 2 Zone 1
found at the site of the laceration. The proximal tendon
Figure 8-2 Pulleys and subdivisions of the digital flexor
end often retracts to into the palm because of the pull
tendons (zones 1 and 2).
of the muscles. When the laceration is in the distal
half of the fingers, the vincula to the tendons may
prevent the proximal tendon from retracting. Therefore,
the proximal end of the lacerated flexor digitorum patients are asked to actively flex the fingers. Inability to
superficialis (FDS) or flexor digitorum profundus (FDP) actively flex the finger proximal interphalangeal (PIP)
tendons sometimes retracts over only a short distance or distal interphalangeal (DIP) joints using the specific
and is still found within the digital sheath. The proximal tests shown in Figures 8-4 and 8-5, when passive motion
end of the lacerated flexor pollicis longus (FPL) tendon is complete, indicates that the FDP or FDS tendon (or
usually retracts to the thenar area, or even more proxi- both) is completely severed.
mally, due to the vigorous pull of the muscle. In making decisions about treatment, surgeons
During examination, any changes in resting position should consider the condition of the hand thoroughly.
of the fingers should be closely observed (Figure 8-3). Tendon injuries often present as a part of compound
In assessment of function of the FDP and FDS tendons, injuries with open wounds. Nerve and vascular injuries
Chapter 8: Indications for Primary Flexor Tendon Repair 83
are the most commonly associated injuries and soft

tissue defects may also be present. Injury to a single
artery in the digit does not need repair, but it is essential
to repair the lacerated digital nerve even when the con-
tralateral one is intact.
Wound contamination can be a serious problem. All
wounds should be thoroughly washed and débrided. If
the wounds have clear signs of contamination, thor-
ough washing of the wounds, débridement, and intra-
venous infusion of antibiotics are necessary. The tendons
should be repaired during the delayed primary stage,
after inflammation has been controlled. For such
patients, intravenous administration of antibiotics is
indicated and status of tetanus immunization should
Figure 8-3 Change of the resting position of the digits be evaluated. If tendon injuries are accompanied by a
indicates complete laceration (or disruption) of the digital fracture, these can be treated on the same day or sepa-
flexor tendon. The picture showing a case of complete cut of
rately on different days. The fracture can be treated first
the FDP tendon 2 weeks after primary skin closure without
by internal fixation, and the tendons can be repaired
tendon repairs.
after 1 week, or even later.
Closed rupture of the tendons presents as the inabil-
ity to actively flex the digits without an open wound.
Forced extension during active flexion of the finger can
cause avulsion injury of the FDP tendon at its insertion
to the distal phalanx, which is called “Jersey” finger.
Tendon rupture from chronic attrition may occur in
rheumatoid diseases, Kienböck disease, scaphoid non-
union, hamate fracture, or distal radius fracture. Tendon
rupture may also occur spontaneously without clear eti-
ology. Closed rupture of the pulleys usually presents in
special populations engaged in forceful flexion of the
fingers, such as rock climbers. Clinically, patients can
actively flex the fingers but present signs of tendon bow-
stringing of the involved fingers.
Radiographic examination should be routine for
Figure 8-4 Active flexion of the DIP joint indicating patients with large wounds and suspected of having
integrity of the FDP tendon. Loss of active flexion of the DIP compound injuries. Ultrasound or computed tomogra-
joint indicates FDP tendon injury. phy should be used for patients suspected of having a
closed tendon injury or closed pulley disruption.
TIMING OF TENDON REPAIR
Primary tendon repair is end-to-end repair performed
immediately after wound cleaning and débridement,
usually within several to 24 hours after trauma. Delayed
primary repair is defined as end-to-end repair performed
days to weeks after tendon injuries (usually within 3, or
even 4, weeks after tendon lacerations), after immediate
closure of the wounds without tendon repairs. When-
ever possible, acutely lacerated flexor tendons in the
hand and forearm should be treated primarily or during
the delayed primary stage. The ideal situation is that a
patient with digital flexor tendon lacerations is brought
into the clinic soon after injury, an experienced surgeon
Figure 8-5 Normal function of the FDS tendon in the is readily available, and surgery begins within a few
middle finger is shown. Loss of active flexion of the PIP joint hours (Figure 8-6). In particular, a tendon injured in
while the flexion of the other fingers is blocked indicates loss critical areas (such as zone 2) should not be repaired by
of FDS function, hence complete severance of the tendon. an inexperienced surgeon. In such cases, tendon repair
Primary repair Delayed primary repair Secondary repair

Do: Do: Do:
Within a few hours or one A few days or within 2 to 3 3 to 6 months later
day after injury weeks after injury ideally Tendon grafting
Experienced surgeons are After edema subsided and Staged reconstruction
available infection controlled Pulley reconstruction
Not do: Not do: Not do:

Experienced surgeons are Over 4 weeks after injury Passive joint motion
not available generally not ample
Skin conditions
not good
• Primary and delayed repairs have comparable outcomes. Risk of infection exists
• Avoid primary repairs by inexperienced surgeons.
• Primary wound closure followed by tendon repair in later
days by experienced surgeons is a standard practice.
Lengthy loss of tendon substance, extensive pulley

Go
When: destruction, serious wound contamination, or
unstable fractures or joint destruction. to
Figure 8-6 Flow-chat of the decision-making process for primary or delayed primary tendon repairs in zone 2 flexor tendon
repair.
should be delayed until an experienced surgeon is avail- wound, with limited damage to peritendinous tissues.
able (see Figure 8-6). Inadvertent damage to the tendon Simultaneous injuries to the nerves and arteries are
structures by inexperienced operators may introduce a common and are not a contraindication for primary
second “injury” to the tendon system, which may render repairs.
the tendons difficult to repair at subsequent operations, “Clean-cut” wounds, the simplest clinical situation
even in the hands of an experienced surgeon. So far, no associated with digital tendon lacerations, are a prime
clinical data have shown that delayed primary surgery indication for primary flexor tendon repair.6,10 A “clean-
within a few days to 1, or 2, weeks after injury, per- cut” wound is one in which the structures are injured
formed by an experienced surgeon, are inferior to through a clean and tidy cut, usually a single transverse
primary surgery in terms of outcomes. In deciding or oblique laceration in the digits, palm, or distal
between primary and delayed primary repairs, I advise forearm, often produced by a knife or a piece of glass.9
to always place the expertise of the operators before the The cut should also be “clean” in terms of contamina-
exact timing of the repairs. tion and infection. Anatomically, the tendon(s) is “only”
No clinical investigations have actually validated the severed, and without tissue defect. The cut tissues may
best time for primary or delayed primary repair. My even align well (Figure 8-7). This is the best indication
preferred period of deliberate delay is 4 to 7 days, when for primary repair, with the greatest likelihood of rela-
the risk of infection can be properly addressed and tively uncomplicated repair, rehabilitation and satisfac-
edema has reduced substantially.9,10 Delay of the repair tory outcome. Such wounds are often accompanied by
beyond 3 to 4 weeks may cause myostatic shortening of divisions of the digital neurovascular structures.
the muscle–tendon unit; for these late cases, lengthen- Crush injuries to a very limited segment of the fingers,
ing the tendon within the muscles in the forearm can palm, or wrist produce untidy skin and subcutaneous
ease the tension.11 injuries and tendon wounds (Figures 8-8 and 8-9).
Rupture of the repaired flexor tendons after surgery Such wounds are also good candidates for primary
can be re-repaired if the rupture occurs within a few repairs, because the soft tissue wounds and tendons can
weeks up to a month after surgery; secondary tendon be converted to those associated with a clean-cut wound
grafts may be the only choice for ruptured cases in the through débridement of nonviable tissues and direct
presence of obvious retraction of the tendon end(s), wound closure. However, these injuries have a greater
extensive scarring when both tendons ruptures or exten- potential for contamination. Primary tendon surgery is
sive scarring around the intact FDS tendon when the possible, although more difficult than with a truly clean-
FDP tendon alone ruptures.12, 13 cut wound. Phalangeal fractures are rarely associated
with a clean-cut flexor tendon laceration but can be part
INDICATIONS
of a crush injury. A simple and stable fracture in the
Indications for primary or delayed primary end-to-end phalangeal shaft can be securely fixed internally, thus
tendon repairs are clean-cut tendon injuries or tendon presenting no contraindication to primary tendon
injuries in a wound that can be converted to a clean-cut repair.
Figure 8-7 Clean-cut digital flexor tendon laceration and primary repair. The tendon was tidily severed without loss of
tendon substance. Primary tendon and nerve repairs are indicated. (Courtesy of Department of Hand Surgery, Nantong
University.)
Severity of tendon injuries ranges from isolated

partial to complete divisions of either the FDP or FDS
tendon, to complete severance of both tendons, to com-
plicated tendon injuries in multiple fingers involving
soft tissue or bone injuries. Although isolated partial
FDS tendon injuries usually do not need surgical repair,
complete FDP tendon laceration in the distal half of the
fingers do. A partial FDP tendon cut through over 80%
of its diameter is also an indication for surgical repair
and is treated similarly to a complete tendon cut.
Tendon lacerations through 50% to 80% of the tendon
diameter require surgical repair to lessen the chance of
tendon triggering during finger motion and to increase
strength. A partial cut of less than 50% of the tendon
Figure 8-8 Injuries in the distal palm area, resulting in diameter may not need surgical suture, or the cut sites
untidy wounds, lacerations of flexor tendons to multiple can simply be trimmed to smooth the tendon surface.
fingers, and injuries to neurovascular bundles. Primary Complete lacerations of both flexor tendons in one, or
tendon and nerve repairs are indicated. multiple, digits are typical indications for primary repair,
and tendon injuries accompanied by other tissue
damage constitute some of the borderline indications
discussed later.
BORDERLINE INDICATIONS
Borderline indications to primary or delayed primary
repairs have been less thoroughly addressed. Loss of soft
tissue coverage over the tendon or the presence of frac-
tures is a borderline indication. Five clinical situations
represent borderline indications to tendon repair.
1. Localized soft tissue injuries: crush, or compression,

injuries on the palmar aspect of the fingers some-
times lead to localized soft tissue defects. The
underlying flexor tendons may present with a
short traumatic defect, or such a defect may arise
after débridement of nonviable, ragged tendon
tissue. This situation includes no contraindica-
Figure 8-9 Injuries to the distal forearm and wrist area, tions to primary repair if the soft tissue defect is
producing lacerations of multiple wrist and digital flexor less than one-third the length of the fingers and
tendons and the median nerve. Primary tendon and nerve the tendon loss is less than 1.5 to 2 cm. In my
repairs are indicated. experience, the FDP tolerates shortening by up to
1.5 to 2 cm. The soft tissue can be repaired with tendon, even if the tendon has already been
a local, or free, flap transfer and the tendon is trimmed by a similar amount at the initial surgery.
repaired by direct end-to-end suture. Flap transfer In my experience, the FDP tolerates shortening by
provides fresh and vascularized tissue coverage, up to 1.5 to 2 cm. The ruptured FDS tendon
roughly similar to the original subcutaneous should be removed. Re-repair of both tendons is
tissue. However, a tendon with a defect length impractical, and shortening of the FDS, particu-
close to 2 cm is hard to draw together. Direct larly within zone 2, is mechanically disadvanta-
end-to-end suture of the tendon should be accom- geous. The digital sheath system is usually less
panied by a procedure to reduce the tension on elastic, narrow, and inclined to collapse after
the tendon when the surgeon is less experienced primary repair rupture. Rupture of a repair within
with dealing with tendons with a defect. In such one month after the initial repair is always worth
cases, intramuscular tendon lengthening through an attempt at re-repair. However, by one month
a forearm incision may release the tension.11 after primary repair, re-repair is rarely indicated, as
Lengthening of the tendons at the wrist level may ruptured tendons are likely to be surrounded by
be also needed for this degree of tendon loss. adhesions and their healing potential is limited,
When the tendon is repaired directly, care should particularly if repaired under increased tension.
be taken to prevent repair rupture when starting 4. Delayed repairs: All estimates of the “best timing”
early active tendon motion. Early active motion for primary flexor tendon repair suggested so far
and its progress to full active digital flexion should have been empirical. I do not have a rigid “best”
be delayed. time frame in mind, as previous suggestions
2. Injuries including a simple and stable fracture: A regarding the timing of primary repair are not con-
simple, stable fracture in the phalanx or metacar- sistent and may not be imperative. My clinical
pal is not a contraindication to primary tendon impression is that treatment outcomes after delay
surgery. Fractures in the shafts of more than one for such a short period are almost identical to
metacarpal bone may sometimes accompany a cut those associated with primary repair promptly
digital flexor tendon. These injuries do not pre- after the trauma. Upon re-opening of the wound,
clude primary tendon surgery, providing the frac- the cut tendon ends still appear fresh and no col-
tures are simple, limited to the shaft and do not lapse or fibrosis of the sheath is seen. The tendons
involve the joints. Internal fixations in the palm can be treated as if they were freshly cut. However,
with mini-plates, screws, or K-wires usually ensure when the surgery is postponed further beyond that
a stable reduction, but early postoperative exercise period, the tendon ends may be rounded, with
may have to be less aggressive. What are seen more varying degrees of adhesions present, and the elas-
frequently, however, are tendon injuries associated ticity of the sheath is likely to be reduced, making
with fractures involving joints in more than one repair more difficult. Although a delay of more
phalanx, with crush, or abrasion, of the overlying than 1 month would rule out direct end-to-end
soft tissues. These skeletal injuries are contraindi- repair surgery, the report of McFarlane and col-
cations to primary tendon repair, because fractures leagues showed that direct end-to-end repair after
involving joints tend to be unstable, the soft tissue a delay for 1 to several months can been possible
wounds are always contaminated and early post- without undue tension.14 For these late cases, the
operative tendon mobilization is either difficult or tendon may be lengthened within the muscles in
not feasible. However, some surgeons still perform the forearm to ease the tension on the proximal
tendon repair and mobilize the hand after surgery tendon end.11 Of note is one situation in which
under these conditions. repair delayed more than 1 month is still feasible
3. Rupture of tendon repairs: Ruptures of primarily (i.e., a wound around the PIP joint level in which
repaired flexor tendons have been noted in the FDP tendon has been cut but the long vincula
most case series incorporating early active finger connecting to the proximal cut tendon has not
mobilization. I approach the ruptured tendon been severed). In this instance, retraction of the
repair as I would a primary tendon repair. At least FDP tendon is limited. When the wound is opened,
half of the segment, if not the entire segment, the retracted proximal end is found locally within
encompassed by the original sutures should be the sheath and the tendon can be repaired with
trimmed off, because the ends are softened and relative ease.
ragged, which decreases the holding power of the 5. Massive soft tissue damage: Generally, this is a con-
subsequent re-repair. The length of tendon seg- traindication to primary flexor tendon surgery,
ments that I trim off is about 0.8 to 1.0 cm (0.5 cm and I discourage primary repairs under this
or less on either end). This amount of shortening circumstance. However, such situations can be
is of no biomechanical consequence to the FDP broken down further into: (1) extensive soft tissue
damage without apparent loss of tendon sub- infection, and should be handled by surgeons
stance and (2) soft tissue damage with loss of a with considerable experience in tendon repairs.
significant length of tendon. The former injury Such repairs should not become routine.
may still leave room for primary tendon repair,
providing the surgeon is prepared to carry out sec-
ABSOLUTE CONTRAINDICATIONS
ondary tenolysis later. This borderline indication
is controversial and has not been well defined. Absolute contraindications to flexor tendon repair are
Although the decision is difficult, we must balance severe contamination, signs of infection, bony injuries
the merits of primary repair and early mobiliza- involving joint components and long defects of
tion, followed by tenolysis if necessary, against the flexor tendons, including extensive destruction of
those of secondary tendon grafting. It may be pulleys. Serious crush injuries, extensive loss of soft
acceptable, to repair these injured tendons primar- tissues, or fractures involving multiple bones, particu-
ily and prepare the patient for the possibility of larly at different levels or which cannot be stabilized
tenolysis. Nevertheless, these cases should be adequately by internal fixation, are also contraindicative
managed carefully in order to prevent wound to primary tendon repairs.
References
1. Verdan CE: Primary repair of flexor tendons, J Bone Joint Surg 8. Tang JB: Flexor tendon repair in zone 2C, J Hand Surg (Br)
(Am) 42:647–657, 1960. 19:72–75, 1994.
2. Kleinert HE, Kutz JE, Ashbell TS, et al: Primary repair of lacer- 9. Tang JB: Clinical outcomes associated with flexor tendon
ated flexor tendons in “No Man’s Land”, [abstract] J Bone Joint repair, Hand Clin 21:199–210, 2005.
Surg (Am) 49:577, 1967. 10. Tang JB: Indications, methods, postoperative motion and
3. Kleinert HE, Schepel S, Gill T: Flexor tendon injuries, Surg outcome evaluation of primary flexor tendon repairs in Zone
Clin North Am 61:267–286, 1981. 2, J Hand Surg (Eur) 32:118–129, 2007.
4. Bunnell S: Repair of tendons in the fingers and description 11. Le Viet D: Flexor tendon lengthening by tenotomy at the
of two new instruments, Surg Gynecol Obstet 26:103–110, musculotendinous junction, Ann Plast Surg 17:239–246,
1918. 1986.
5. Bunnell S: Repair of tendons in the fingers, Surg Gynecol Obstet 12. Dowd MB, Figus A, Harris SB, et al: The results of immediate
35:88–97, 1922. re-repair of zone 1 and 2 primary flexor tendon repairs which
6. Kleinert HE, Verdan C: Report of the Committee on Tendon rupture, J Hand Surg (Br) 31:507–513, 2006.
Injuries (International Federation of Societies for Surgery 13. McFarlane RM, Lamon R, Jarvis G: Flexor tendon injuries
of the Hand), J Hand Surg (Am) (5 Pt 2):794–798, within the finger. A study of the results of tendon suture and
1983. tendon graft, J Trauma 8:987–1003, 1968.
7. Moiemen NS, Elliot D: Primary flexor tendon repair in zone 14. Elliot D, Barbieri CH, Evans RB, et al: IFSSH Flexor Tendon
1, J Hand Surg (Br) 25:78–84, 2000. Committee Report 2007, J Hand Surg (Eur) 32:346–356, 2007.
CHAPTER
9
TREATMENT OF THE FLEXOR
TENDON SHEATH AND PULLEYS
Jin Bo Tang, MD
OUTLINE particular—has received great attention in efforts to

optimize the outcomes of flexor tendon surgery.
The flexor sheath system consists of a continuous
ANATOMY
synovial sheath and segmental pulleys. The pulleys are
arranged in either cruciform or annular patterns over- The digital flexor sheath is a closed synovial system
lying the membranous synovial sheath. The synovial extending from the distal part of the digits to the meta-
sheath provides the tendons with a smooth gliding carpophalangeal (MCP) joint levels of the digits. The
bed and the pulleys strengthen the sheath and main- sheath consists of membranous portions of continuous
tain the proper mechanics of tendon motion. The synovial sheath (called simply the “sheath”), and con-
digital sheath system is closed and compact, making densed retinacular components (the “pulleys”). A layer
it structurally comparable to a compartment of the of thin, smooth, and continuous membrane covers the
extremities. The traumatized and edematous tendon inner surface of the entire sheath and pulleys. Pulleys
can be easily compressed by the tightly closed sheath, are segmentally located and overlie the membranous
resulting in poor tendon healing, adhesion formation, lining. The pulleys include annular pulleys (condensed,
and loss of integrity of the sheath. rigid, and heavier annular bands), cruciate pulleys
The guiding principle in treating the sheath is not (filmy cruciform bands), and the transverse palmar apo-
to narrow the injured, or opened, sheath and not to neurosis pulley (Figure 9-1).1
compress the repaired tendons. Closure of the injured, In each of the four fingers, there are five annular
or opened, synovial sheath is not necessary, unless pulleys (A1, A2, A3, A4, and A5), three cruciate pulleys
such openings are long. Venting of a part of the A2 (C1, C2, and C3), and one palmar aponeurosis (PA)
pulley and the A4 pulley, under the condition of the pulley.1-3 The A1, A3, and A5 pulleys originate from the
other annular pulleys and the remainder of the syno- palmar plates of the MCP and proximal and distal inter-
vial sheath being intact, improves outcomes and does phalangeal (PIP and DIP) joints, respectively. The A2
not produce a clinically significant functional distur- and A4 pulleys originate from the middle portion of the
bance. The length of such active release of the sheath– proximal and middle phalanges, respectively. The broad-
pulley complex should not exceed 2 cm. est is the A2 pulley, which covers the proximal two-
Pulley-release procedures should not be carried out thirds of the proximal phalanx and encompasses the
without thorough mastery of pulley anatomy and rec- bifurcation of the flexor digitorum superficialis (FDS)
ognition of the borders of these pulleys during dissec- tendon. The A4 pulley is located at the middle of the
tion. Releasing multiple pulleys (cruciate and annular) middle phalanx. The A2 and A4 pulleys are structurally
or leaving a lengthy defect, or opening, in the synovial the most critically located and, functionally, the most
sheath and pulley system is harmful and impairs important.
digital function. Losses of significant length of the The length of the A2 pulley is about 1.5 to 1.7 cm
sheath or multiple pulleys should be reconstructed. and the length of the A4 pulley is about 0.5 to 0.7 cm
in the middle finger of an average adult. The diameter
The synovial sheath and segmental pulleys are a of the flexor sheath is at its narrowest at the level of the
prominent feature of the flexor tendon system in the A4 pulley and in the middle and distal parts of the A2
hand. Because injury to the sheath occurs in all flexor pulley. The A2 and A4 pulleys appear as white con-
tendon lacerations in the digits and we cannot approach densed bands; they are easily recognizable, because
the tendons without violating the sheath surgically, con- both are remarkably denser and more rigid than their
siderable investigations have been devoted to this topic adjacent flexor sheath. The A1 pulley, with a length of
over decades.1-33 The significance of proper treatment of about 1.0 cm, is located proximal to the A2 pulley; in
the sheath—the rigid and condensed annular pulleys in some instances, both A1 and A2 pulleys merge to form
88
Chapter 9: Treatment of the Flexor Tendon Sheath and Pulleys 89
In the finger, the A2 pulley is the strongest in respect

PA A1 A2 C1 A3 C2 A4 pulleys of preventing anterior displacement of the tendons and
is at the most critical location. The A2 and A4 pulleys
are most important in maintaining the biomechanics
of the tendon gliding, although the other sheath com-
ponents do contribute to the maintenance of tendon
mechanics. Absence of a series of pulleys will affect
A tendon mechanics. Manske and Lesker2 investigated the
roles of the A2, A1, and PA pulleys and found that
absence of any two, or all three, pulleys resulted in
A4 tendon bowstringing. Tang and Xie20 investigated the
A1 C2 roles of the A3, C1, and C2 pulleys and found that these
A3
A2 C1 pulleys help to restrain tendon bowstringing.
In the thumb, the proximally located A1 pulley and
the oblique pulley are the most important functionally.
The distally located A2 pulley of the thumb is thin and
B is relatively unimportant. Doyle and Blythe3 found sig-
nificant decrease in motion of the distal joint of the
Digital pulley system
thumb when both the A1 and the oblique pulleys were
removed, but loss of either alone did not noticeably
affect the motion of this joint.
PA A1
A2 HISTORICAL REVIEW
C1 A3 C2 A4 C3 A5
A review of the conceptual changes regarding roles and
treatments of the sheath, pulleys in particular, are pro-
vided by Elliot, together with his commentaries in the
C Chapter 10. Here, Box 9-1 summarizes the work of other
Figure 9-1 The anatomy of the flexor pulleys and synovial groups that influenced our studies, the time sequence of
sheath of the fingers (A), with the finger flexed (B), and the our investigations, and evolving philosophies, leading
concertina effect on the sheath during finger flexion (C). to current treatment guidelines.4-29
INVESTIGATIONS
a compound pulley complex. The A3 pulley is located Over two decades, I have organized and conducted a
palmar to the PIP joint, is short (0.3 cm) and difficult series of investigations to explore the basic science and
to distinguish from the synovial sheath. to develop clinical treatments relevant to the flexor
In the thumb, there are three pulleys (A1, oblique, sheath and pulleys. My investigations proceeded after
and A2) with no cruciate pulleys. The A1 pulley (0.7 to starting with a study of the methods of sheath recon-
0.9 cm in length) is located palmar to the MCP joint. struction in 1988 under the instruction of an exemplary
The oblique pulley (0.9 to 1.1 cm) spans the middle hand surgeon, Professor Seichii Ishii.
and distal parts of the proximal phalanx. The A2 pulley My interest was developed in the studies of the
(0.8 to 1.0 cm) is close to the insertion of the flexor methods of sheath treatment and their effects on tendon
pollicis longus (FPL) tendon. gliding, followed by an anatomical study of the flexor
pulleys. Over the past decade, I have been joined by a
FUNCTION
group of capable colleagues in studying the effects of
The synovial sheath offers a smooth gliding bed and pulleys and pulley incisions on tendon biomechanics
provides synovial nutrition to the tendons. Mechani- and tendon biology.
cally, the pulleys serve to strengthen the sheath and hold
the flexor tendons close to phalanges and their joints. Investigation of Sheath Treatment—Excision,
The annular pulleys act as a fulcrum, optimizing the Repair and Reconstruction
mechanical efficiency of digital flexion. The more com- In the 1980s, there was an upsurge in awareness of the
pressible cruciate pulleys allow for digital flexion with importance of synovial nutrition of the tendon and in
condensation of the fibro-osseous sheath at the inner attempts to restore the integrity of the injured synovial
part of flexed fingers (called the “concertina effect”) (see sheath. My first study was on sheath excision, closure,
Figure 9-1). Both forms of pulley prevent anterior dis- and enlargement plasty using a graft. However, the find-
placement (i.e., bowstringing) of the tendon during ings did not support particular benefit from direct
finger flexion. closure of the opened sheath, but, instead, indicated
Box 9-1 Some Major Steps Toward Current Treatments of Sheath and Pulleys Over the Past 25 Years
1985: Lister, in a review, advocated sheath closure and described the method to create sheath flaps to assess the tendon
and accommodate surgical repairs.4 This review had a great impact on later clinical practice of sheath closure.
1985: Strauch and colleagues compared the results of sheath closure with vein grafts with sheath excision in chickens.
They found improved digital motion after restoration of sheath integrity.5
1986: Peterson and Manske compared the mechanical and histologic outcomes of sheath repair and excision in a chicken
model. They concluded that closure of the flexor sheath does not improve tendon gliding.6,7
1987: Saldana and colleagues compared surgical closure (42 fingers) and opening (48 fingers) of the sheath after tendon
repairs in zone 2 in a comparative perspective study. There was no statistical difference between the results of the patients
with the two treatments.8
1988: Manske, in a review, stated, “It should be kept in mind that a water-tight closure of the tendon sheath may in fact
narrow the diameter of the fibro-osseous canal and reduce its volume.”9
1990: Tang, Ishii, and Usui compared the mechanical and histological results of sheath repair, excision, and enlargement
sheath plasty by autogenous grafts using chickens. Tendon gliding was not improved after sheath closure, but was
improved after enlargement plasty. They considered that the fibro-osseous digital sheath is comparable to the fibro-
osseous muscle compartments in the extremities, and proposed a “digital sheath syndrome” to explain pathophysiology
in the tendon after tight sheath closure.10
1990: Gelberman and colleagues compared sheath reconstruction and excision in canines treated by early motion reha-
bilitation, and substantiated that sheath repair—either by suture or graft—does not improve the biomechanical, biochemi-
cal or morphologic features of the tendons.11
1990: Savage measured tendon excursion, profundus tendon flexion force, and tendon bowstringing using five cadaveric
hands after varying combined excisions of the annular pulleys. He stated, “In an otherwise intact digital fibrous flexor
sheath, A2 and A4 pulleys were no more important mechanically than the other pulleys.”12
1994: Tang and colleagues reported that closure of the sheath did not improved tendon gliding in chickens at multiple
time-points of delayed primary repair.13
1995: Tang studied the anatomy of the A2 pulley specifically, using cadaveric hands, by measuring the tendon excursion
after midline incisions through part of the A2 pulley, and the vertical and horizontal diameters of distal, middle, and proxi-
mal parts of this pulley. He proposed the partial release of the pulley and stated, “To improve tendon healing and gliding,
procedures for A2 pulley release, including incision of the critical portion to free tendon motion or enlargement of the A2
pulley, can be performed.”14
1996: Tang, Shi, and Zhang examined the effects of sheath narrowing and enlargement on tendon excursions, healing,
and adhesions using chickens. They demonstrated that the diameter of the surgically repaired sheath exerts great influ-
ences on tendon function.15
1998: Kwi, Ben, and Elliot reported the clinical results of zone 2 flexor tendon repairs in 185 fingers in 166 patients together
with lateral release of the A2 and A4 pulleys. They showed practicability of active partial release of these pulleys. They
stated, “It was necessary to vent the A4 pulley between 10 and 100% of its length in 71 (56%) of the fingers and to vent
the distal edge of the A2 pulley by 4 to 10 mm in 10 (8%) of the fingers.”16
1999: Tang and colleagues reported 1-year follow-up of the finger motion after simple partial release through the one-half
to two-thirds portion along the midline of the A2 pulley or with enlargement pulley plasty in 16 fingers. No tendon bow-
stringing was noted. They advocated “partial release of the A2 pulley up to 1/2 or 2/3 lengths of the A2 pulley under the
condition that other pulleys are intact.”17
1998, 1999: Tomaino, Mitsionis, and colleagues performed cadaveric studies to substantiate that partial release of the
A2 and complete release of the A4 pulley do not significantly alter tendon mechanics.18,19
2001: Tang and Xie, in a cadaveric study, showed that loss of an A3 pulley does not affect tendon biomechanics, but cruci-
ate pulleys and synovial sheath restrain tendon bowstringing. They advise not creating lengthy sheath defects, given the
integrity of major annular pulleys.20
2002: Elliot, in a review, highlighted the feasibility of pulley-venting. He stated: “In reality, … as the A2 pulley is of sufficient
length that one can excise any one-third of it to allow repair and free movement of the repair and still have a pulley which
is one or more centimetres in length, and thus, functional.” Regarding the sheath, he stated: “It is now our practice after
zone 2 repairs to simply lay the sheath back over the tendons without suturing, after adequate venting of the A2 and A4
pulleys to allow free running of the repairs.21
2002: Amadio, Zhao, Paillard, and colleagues investigated gliding resistance of the FDP tendon after resection of one
slip of the FDS tendon and Kapandji pulley plasty, and found that both pulley plasty and resection of one slip of the FDS
reduce gliding resistance.22
2003, 2007: Tang, Xie, Xu, and colleagues investigated tendon repairs within and proximal to a major pulley using chick-
ens. Worse results of surgeries were noted in the pulley area.24 They compared the results of simple pulley incision, Kapandji
pulley plasty, and excision of one slip of the FDS and found no improvement of tendon gliding after Kapandji pulley plasty.25
2004: Tanaka, Amadio, An, and colleagues investigated gliding resistance of the tendon and pulley strength after the A2
pulley was excised successively by 25%, 50%, and 75%. Their data support the clinical practice of partial pulley excision,
up to a limit of 50%.26
2007: Tang, in a review, highlighted the critical roles of proper and sufficient release of critical annular pulleys in achieving
predicable functional recovery. He outlined precisely the lengths and areas to be release in different locations of injuries.
He considered that proper release of the pulley may be even more effective in reducing repair ruptures than use of a strong
repair.27
2009: Cao and Tang compared the strength of the repaired tendon with the A2 pulley intact or vented at varying digital
flexion. They recorded that the strength decreased significantly when the pulley was intact.29 Rupture of the healing
tendons was significantly more frequent when the pulley was intact.28
that enlargement of the sheath accommodates tendon

DIGITAL SHEATH: A MINIATURE COMPARTMENT
gliding more effectively than direct closure of the sheath
after tendon repair. Tight closure of the sheath/pulleys
In this study, we used 90 long toes of 45 white
Leghorn chickens to compare the effect of enlargement
sheath plasty—interposing a patch of grafted sheath Compress the edematous tendons
from the extensor retinaculum area into a longitudinal
opening of the sheath, without excising the digital
sheath—with two treatments: sheath excision or direct
Digital sheath syndrome
sheath closure after longitudinal incision.10 Tendons in FDS • Poor tendon healing (ruptures)
zone 2 were completely cut and surgically repaired FDP • Adhesion formations
either primarily or at the delayed primary stage (3 days Sheath narrowing • Destruction of closed synovial sheath
after tendon division).
We found that 6 weeks later, in toes with primary Avoid compression to repaired tendons!
Tendons are edematous after surgery.
repair, sheath enlargement produced greater tendon
excursion than sheath excision or closure, but no differ- Figure 9-2 Consequences after tight closure of the sheath
ence was found between the latter two treatments. In the or pulleys.
toes with delayed primary repair, the tendons with
sheath enlargement had the greatest gliding, and those
with the sheath closed directly had the worst gliding. The explain the pathophysiological changes in the tendons
sheath that had been closed during delayed primary was proposed to describe the triad phenomena fre-
repair have dissolved among the extended adhesions. quently associated with tight closure of the sheath,
Conclusions: We concluded that enlargement sheath namely: (1) loss of integrity of the directly closed sheath;
plasty by a graft improves tendon gliding. Direct closure (2) increased peritendinous adhesions; and (3) worsened
of the sheath does not improve tendon gliding, and may tendon healing. These considerations are further sup-
in fact impair tendon gliding at the delayed primary ported by a subsequent study to deliberately narrow the
stage.10 We considered the digital sheath comparable sheath and compare this with direct closure of the
to the fibro-osseous compartments of the extremities incised sheath, partially excised the sheath or sheath
(Figure 9-2). A concept of “digital sheath syndrome” to enlargement by an interposition graft.15
Clinical application: Between 1989 and 1991, we Among 21 fingers with such grafts, 7 fingers were rated
treated 21 fingers in 17 patients presenting with zone 2 excellent (33.3%), 11 good (52.4%), and 3 fair (14.3%).
tendon injuries and a graft was taken from the sheath No tendon rupture occurred.
covering the extensors in the wrist or with a part of the
dorsal retinaculum to reconstruct and enlarge the trau- Investigation of the Anatomy of the A2 Pulley
matically defected sheath (Box 9-2).31 The size of the and Clinical Partial A2 Pulley Release
graft was made greater than the size of the real defect. In 1993, I reviewed the results of flexor tendon repairs
in different subdivisions of the zone 2, and noted that
the worse outcomes were most frequently associated
Box 9-2 Some Major Clinical Reports of Case
Series of Sheath or Pulley Plasty Procedures with zone 2C (A2 pulley area) injuries. This finding
prompted me to specifically observe the A2 pulley
1993: Tang, Ishii, and Zhang reported 21 fingers in 17 anatomy and the mechanics of FDS and FDP tendon
patients with enlargement sheath reconstruction using motion under the A2 pulley.
autografts during delayed primary tendon repair in zone I dissected 40 fingers of 10 cadaveric hands. The
2. No repair ruptures were noted in this case series.31 transverse and vertical diameters of the A2 pulley were
measured at its distal border, middle, and proximal
2005: Bakhach and colleagues reported a new
procedure—flexor pulley Omega plasty, which consists
border.14 The excursions of the FDP tendons and
of releasing the lateral attachment of the pulley to maximal finger flexion were measured after incision
increase the internal volume (the flexor tendon gliding through volar midline of the proximal half, and then,
space) in the A2 and A4 pulley localities. They consid- the whole length of the A2 pulley.
ered that “this procedure respects the anatomical con- Anatomically, the distal and middle parts of the A2
tinuity of the pulley and its mechanical properties.”31 pulley are the narrowest. Movement of the FDP tendon
is restrained by both the A2 pulley and the FDS tendon
2009, 2010: Bunata and colleagues presented his (Figures 9-3 and 9-4). Mechanically, given the integrity
experimental data in cadavers32 and, subsequently, nine of the other annular pulleys, incision of half of the A2
fingers of primary pulley enlargement plasty using auto- pulley resulted in only minimal (0.7%) loss of total
grafts.33 No repair ruptures were found.
flexion of motion; complete division of the A2 pulley
A2
IID
IIB
IIC
A2
FDS bifurcation Double sheath for FDP
Figure 9-3 The anatomy of flexor tendon zone 2C, i.e., the A2 pulley area. The gliding of the FDP tendon is restricted by
both the rigid and narrow A2 pulley and the bifurcating FDS tendon which surrounds the anterior, lateral, and dorsal aspects
of the FDP tendon. The presence of such a “double sheath” restricting motion of the FDP tendon is a unique anatomical
feature in this locality, which contributes to difficulties of surgery and recovery of tendon function after surgical repair.
CHANGES IN SHEATH DIAMETER: A2 PULLEY
Distal A2 Middle A2 Proximal A2 Proximal to A2
S FDS FDS FDS

FDP FD
FDS S FDP
FD FDP FDP
Most narrow Most narrow Relatively large Relatively large

Very restrictive Very restrictive Less restrictive Less restrictive
Figure 9-4 The anatomy of the A2 pulley: changes of sheath diameter in the locality covered by and proximal to the A2 pulley.
resulted in a larger (2.3%) loss of flexion. Incision of part produces significantly worse tendon gliding and
of the A2 pulley did not lead to tendon bowstringing.14 increased work of digital flexion. Incision of the sheath
Conclusions: The distal and middle parts of the A2 produces identical results, regardless of whether the
pulley are particularly restrictive to tendon gliding. sheath is closed by a graft; (4) tendon gliding resistance
Partial A2 pulley release affects digital motion insignifi- decreases substantially after release of the pulley in the
cantly and does not cause tendon bowstringing.14 Based postoperative period; (5) tendon repair strength
on the findings, I proposed procedures for partial release increases significantly when the pulley is released com-
of the A2 pulley to release compression of the repaired pared with the pulley intact; and (6) presence of an
tendon under the pulley. intact A2 pulley contributes more substantially to
Clinical application: From 1994, I started to partially increase in the resistance to active tendon movement
incise the A2 pulley along its volar midline when repair- than edematous subcutaneous tissue.
ing the tendons in this area; the length of the release Clinical application: My colleagues and I have contin-
was either the distal or proximal half to two-thirds. ued the practice of partial A2 pulley release thus far. I
Before partial release of the A2 pulley, the other annular further defined the length and location of the sheath
pulleys were confirmed to be intact and uninjured. In pulley which can be released without causing clinical
carrying out these A2 releases, a part of the A2 pulley problems of tendon bowstringing.27 In this period, we
was always retained. In 1998, we examined the outcome reviewed more than 40 cases of release of part of the A2
of 16 fingers with FDP tendon repairs and partial release pulley or the A4 pulley. We did not detect tendon bow-
of the A2 pulley.15 No functionally disturbing tendon stringing sufficient to cause clinically perceivable func-
bowstringing was noted after this procedure. Although, tional disturbances after partial and limited pulley
from a rigorous viewpoint, the tendon would displace release procedures, given the integrity of the other
after even minor releases of the pulley after incision pulleys. Proper release of these pulleys, together with
through its midline, such changes are insignificant clini- strong surgical repairs, even without very strictly super-
cally and are well within the compensatory reserves of vised postsurgical motion in our recent case series, led
the tendon system for normal function. to good or excellent recovery of finger flexion when the
tendon wounds were clean or could be converted to
Investigations of the Effects of Integrity of clean wounds.
the A2 Pulley in Chicken Models and Partial
A2 and A4 Pulley Releases in Clinical Cases TREATMENT GUIDELINES
Between 2000 and 2011, my colleagues and I studied (1) The guideline for treating the sheath is not to narrow the
different results of tendon repairs after tendon injuries sheath and not to compress the repaired tendons. Surgically,
within, or proximal to, the A2 pulley; (2) the biome- priority should be given to avoiding narrowing of the
chanics and adhesions of tendons after repair of a single tendon gliding space, rather than complete restoration
slip of bifurcated FDS tendon, incision of the A2 pulley, of sheath integrity. Complete closure of the sheath is
Kapandji pulley plasty, and direct pulley closure; (3) insignificant to tendon function and, thus, is not a
tendon gliding and the work of digital flexion after necessity during primary tendon repair. During delayed
flexor tendon repair together with sheath enlargement primary repair, sheath closure is usually not possible
by a graft, sheath incision, or sheath closure with delib- due to sheath contracture. However, a lengthy defect in
erate narrowing; (4) tendon gliding resistances in the sheath would impair tendon mechanics and, thus,
tendon repairs with the pulley released and intact; (5) should be avoided.
tendon repair strengths with the pulley released and
intact; and (6) relative contribution of an intact A2 INDICATIONS AND OPERATIVE METHODS
pulley and edematous subcutaneous tissue to resistance
to active tendon movement. All studies were carried out Direct Closure
in the chicken toe model and involved more than 260 Direct closure of the sheath, usually performed with
chickens. The study methods were detailed in previous interrupted 5-0 suture, may be indicated at primary
reports.23-25,28,29 repair in a clean-cut wound without sheath defect. I
Conclusions: (1) tendon repairs located under the A2 personally do not close the sheath if it appears likely
pulley have significantly worse gliding excursion and to be difficult, but do avoid leaving a lengthy sheath
more adhesion formation than those proximal to the opening or defect (greater than 2 cm). Possible benefits
pulley; (2) release of the A2 pulley or resection of one of direct closure of the sheath may be avoiding catching
slip of the FDS tendon produces greater tendon excur- of the repaired tendons on the cut edges of the sheath
sions, smaller work of digital flexion and less adhesion and avoiding invasion adhesions to the tendon repair
formation than closure of the pulley. Kapandji pulley site. However, closure of the sheath is not necessary to
plasty does not improve tendon gliding more than a nutrition and healing of the tendon. Clinically, there is
simple pulley incision; (3) narrowing of the sheath no clear evidence of improvement of tendon gliding
after sheath closure. In delayed primary repair, sheath procedure, the surgery is simpler, and outcomes are
contracture usually makes direct closure impossible. similar, in my experience.
Excision Venting of the Major Pulleys

Sheath excision has been a practice of hand surgeons for (such as the A2 and A4)
decades and comes from the era when outside adhesions Venting a part of the A2 pulley or the entire A4 pulley
were considered necessary to tendon healing. However, has been advocated by a number of surgeons to improve
it is equally appropriate, or even more appropriate, to gliding of the repaired tendons.14,16,21,34-36 Those reports
leave it unrepaired. I leave the sheath unrepaired in most have shown that such venting does not lead to tendon
cases at primary repair but excise a part of an already bowstringing, given the integrity of other parts of the
thickened, or contracted, sheath at delayed repair. sheath, including the other annular pulleys.14,16,21,27,34-36
Venting of the most constrictive part of the pulley
Sheath Reconstruction by Grafts substantially decreases gliding resistance and avoids
Sheath defects can be reconstructed by grafting a sheath catching of a bulky repair on the pulley edge. Of par
with extensor retinaculum.30,33 The graft, with the syno- ticular note, several recent reports showed no repair
vial aspect facing the tendons, is sutured with 5-0 inter- rupture in the cases that underwent venting of the major
rupted sutures to the in situ sheath. In performing such pulleys.27,34-36
grafting, I emphasize that the graft size should be greater In my experience, given the integrity of the other
than the size of the defect, to avoid potential compro- annular pulleys, the A2 pulley can be vented through
mise to the repaired tendons. Sheath enlargement plasty two-thirds of its length, either distally or proximally.
by a graft may decrease resistance to the tendon and act The A4 pulley can be vented entirely (Figures 9-5
as a barrier to adhesion invasion. If the laceration through 9-8). The degree of the venting should be such
extends over the entire length of the A2 pulley, such a as to ensure that the passive digital motion during
graft of extensor retinaculum may both improve gliding surgery allows the tendon repaire site to glide freely
and decrease tendon bowstringing. distal to or under the vented pulley. Whether the vented
In the early 1990s, I reconstructed digital sheath part of the pulley needs to be excised or trimmed is still
defects by harvesting an autograft.30 During the last 10 questionable. Because the A2 pulley is thick and rigid,
years, I have not reconstructed sheath defects using graft if the release by an incision is judged to be insufficient,
as I have changed to partially releasing the A2 pulley it may be appropriate to remove a part of the incised
together with part of the adjacent synovial sheath, portion of the pulley, or a part of the pulley is trimmed
without recourse to grafts. Without this reconstructive to form an oblique or oval opening.
A5 C3 A4 C2 A3 C1 A2 A1
Tendon laceration Sheath-pulley release
Figure 9-5 Proposed sites and lengths of sheath-pulley releases in primary or delayed primary flexor tendon repair in the
fingers, which allow access to the tendons and release constriction to tendon gliding, but do not produce loss of tendon
function due to tendon bowstringing.
A B
Figure 9-6 A case of venting of the entire A4 pulley when tendon passage under this pulley is difficult (A and B).
Pulley
Pulley
B
Figure 9-7 A case of venting of the A2 pulley through the
midline. The distal 60% of the A2 pulley was vented.
The function and treatment of the condensed sheath Shortened

parts, i.e., the pulleys, are complex and may even be part of
confounding. Most information on this subject has been the pulley
derived from investigations over the past two decades.36,37
C
Here, I summarize the current understanding of the
function and treatment of pulleys (1) Most pulleys (includ- Figure 9-8 Three methods of releasing pulleys: A, midline
ing at least a part of the A2 pulley) should be preserved to incision; B, lateral incision; C, shortening (partial resection).
maintain normal digital function: most of the annular
pulleys, including at least part of the A2 pulley, should
be preserved during tendon repair. Individual minor
annular pulleys (A1, A3, PA, or A5) are not essential
functionally and, thus, may be incised to allow access to obstacles to repaired tendon passage or are judged to
the tendons. The A2 and A4 pulleys are the most impor- restrict tendon gliding during surgery.
tant functionally, but maintenance of the majority of the
CONSIDERATIONS
other pulleys still is necessary for normal tendon func-
tion. (2) A part of the A2 pulley or the entire A4 pulley can In the late 1980s, at the start of investigations of the
be incised without clinically significant loss of digital func- sheath, I was initially puzzled by a variety of suggestions
tion: given that the other annular pulleys and adjacent of sheath treatment by different surgeons. Over the past
sheath are intact, the integrity of part of the A2 or the two decades, I came to believe that the sheath and
entire A4 pulley is not as important as previously pulleys can be treated by a more simple and straightfor-
believed;4 incision of part of the A2 or the entire A4 ward principle. Although valid and theoretically sup-
pulley does not result in remarkable functional distur- ported, complicated repairs, or reconstructions, of the
bance. Therefore, part (but not all) of the A2 pulley or synovial sheath are not a necessary part of the surgery.
part, or all, of the A4 pulley is expendable when the Over the years, my practice has evolved from reconstruc-
other pulleys and most of the sheath are uninjured. (3) tion of the lost synovial sheath, to leaving the injured
Lengthy defects or incisions in the sheath should be avoided: sheath unrepaired, and to intentional venting of the
lengthy sheath defects lead to tendon bowstringing. The critical part of a pulley that is too narrow. After I reviewed
allowable length of defects, or incisions, is less than my cases of pulley release and pondered the importance
approximately 1.5 to 2 cm, depending on size of the of venting a part of the pulley to lessen resistance to
fingers. In exposing the lacerated tendon, we should tendon motion, and compared it to a strong surgical
avoid incising a lengthy part of the sheath. Though not repair, another part of my past work, I came to realize
commonly seen, the lengthy traumatic opening in the and became gradually convinced that a properly per-
sheath should be closed partially to reduce the length formed pulley release is important and may even be a
of sheath opening, and the large defect should be recon- vital step in improving the function of the tendons. This
structed. (4) Cruciate pulleys become important when procedure will probably be proved to be a key to com-
annular pulleys are lost: cruciate pulleys do not play a key plete avoidance of repair rupture, eventually becoming
role in restraining tendon bowstringing in normal a critical step in reaching the elusive goal of predictable
fingers, but they do restrain the tendons when adjacent outcome of flexor tendon repair.
annular pulleys are destroyed. If the annular pulleys are It is very likely that outcomes of some of past cases,
intact, it is not necessary to repair the cruciate pulleys. treated by experienced and inexperienced surgeons
On the other hand, if the annular pulleys are not intact, alike, have been affected by the way in which the pulleys
care should be taken to preserve the cruciate pulleys and were treated, yielding a general impression of “unpre-
synovial sheath. (5) Two pulleys should be preserved in the dictability” of flexor tendon repairs. When patients were
thumb: in the thumb, at least two pulleys should be pretreated by inadvertent venting of the pulleys or the par-
served for better FPL function. Venting of either the A1 tially lacerated pulleys were left unrepaired (which was
pulley or the oblique pulley in the presence of one of not unusual in cases treated by inexperienced physi-
the two pulleys and an intact A2 pulley is clinically cians), they may have achieved good results inexplica-
acceptable. (6) Two or three strong annular pulleys should bly. Conversely, when surgeons strictly followed the
be preserved in secondary tendon surgery: during secondary instruction to maintain the entire A2 pulley, repairing
tendon grafting or tenolysis, at least two, or three, strong both FDS and FDP tendons specifically, the cases had
annular pulleys at critical locations should be preserved unpredictably poor outcomes, even when the surgeons
or reconstructed. Preservation of the A2 and A4 pulleys were experienced. This remains a bold interpretation in
is essential in secondary surgery. respect of the “unpredictability” of the outcome of past
My own practice has evolved. I no longer repair an cases, but I believe this is, at least, partly true.
opening in the sheath except in some of very clean My final comment is that pulley-release surgery
wounds and at primary tendon repair. In delayed repair, should be attempted only with precise mastery of pulley
the sheath frequently has contracture, thickening, or is anatomy and recognition of the borders of these pulleys
embedded in immature adhesions. It was rarely possible during dissection. Releasing of multiple pulleys (cruci-
to close the sheath directly. In fact, I have not encoun- ate and annular) or leaving a lengthy defect or opening
tered a case in which the sheath could be approximated in the synovial sheath and pulleys is harmful and
easily without tension. I no longer continue my practice impairs digital function. Such losses of a significant
of sheath plasty by interposing a graft and consider that length of the synovial sheath with multiple pulleys
this procedure may not yield better results than the should be reconstructed. My observation of operations
much easier procedure of simple cutting, or venting, the in a number of units in different countries has made
pulley. It is my current preference to simply incise a me aware that a significant number of surgeons have
part of the sheath-pulleys without performing any not precisely mastered the anatomy of these pulleys.
reconstructive procedures, when the pulleys constitute I strongly advise that surgeons working in this field
review relevant anatomical descriptions in textbooks insufficiently released and the procedures made ineffec-
or journals to obtain a clear and detailed knowledge of tive, (2) the entire A2 pulley could be released, cutting
the pulleys before performing these releases. Without a series of annular pulleys, or (3) a lengthy segment of
good mastery of the anatomy and clear recognition of injured sheath is left unattended, resulting in significant
the major pulleys during surgery, (1) pulleys could be loss of finger function.
References
1. Doyle JR: Anatomy of the finger flexor tendon sheath and 20. Tang JB, Xie RG: Effect of A3 pulley and adjacent sheath
pulley system, J Hand Surg (Am) 13:473–484, 1988. integrity on tendon excursion and bowstringing, J Hand Surg
2. Manske PR, Lesker PA: Palmar aponeurosis pulley, J Hand (Am) 26:855–861, 2001.
Surg (Am) 8:259–263, 1983. 21. Elliot D: Primary flexor tendon repair: Operative repair,
3. Doyle JR, Blythe WF: Anatomy of the flexor tendon sheath pulley management and rehabilitation, J Hand Surg (Br)
and pulleys of the thumb, J Hand Surg (Am) 2:149–151, 27:507–513, 2002.
1977. 22. Paillard PJ, Amadio PC, Zhao C, et al: Pulley plasty versus
4. Lister G: Indications and techniques for repair of the flexor resection of one slip of the flexor digitorum superficialis after
tendon sheath, Hand Clin 1:85–95, 1985. repair of both flexor tendons in zone II: A biomechanical
5. Strauch B, de Moura W, Ferder M, et al: The fate of tendon study, J Bone Joint Surg (Am) 84:2039–2045, 2002.
healing after restoration of the integrity of the tendon sheath 23. Tang JB, Wang YH, Gu YT, et al: Effect of pulley integrity
with autogenous vein grafts, J Hand Surg (Am) 10:790–795, on excursion and work of flexion in healing flexor tendons,
1985. J Hand Surg (Am) 26:347–353, 2001.
6. Peterson WW, Manske PR, Bollinger BA, et al: Effect of pulley 24. Xu Y, Tang JB: Effects of superficialis tendon repairs on lacer-
excision on flexor tendon biomechanics, J Orthop Res 4:96– ated profundus tendons within or proximal to the A2 pulley:
101, 1986. An in vivo study in chickens, J Hand Surg (Am) 28:994–1001,
7. Peterson WW, Manske PR, Kain CC, et al: Effect of flexor 2003.
sheath integrity on tendon gliding: A biomechanical and his- 25. Tang JB, Xie RG, Cao Y, et al: A2 pulley incision or one slip
tologic study, J Orthop Res 4:458–465, 1986. of the superficialis improves flexor tendon repairs, Clin Orthop
8. Saldana MJ, Ho PK, Lichtman DM, et al: Flexor tendon repair Relat Res 456:121–127, 2007.
and rehabilitation in zone II open sheath technique versus 26. Tanaka T, Amadio PC, Zhao C, et al: The effect of partial A2
closed sheath technique, J Hand Surg (Am) 12:1110–1114, pulley excision on gliding resistance and pulley strength in
1987. vitro, J Hand Surg (Am) 29:877–883, 2004.
9. Manske PR: Flexor tendon healing, J Hand Surg (Br) 13:237– 27. Tang JB: Indications, methods, postoperative motion and
245, 1988. outcome evaluation of primary flexor tendon repairs in Zone
10. Tang JB, Ishii S, Usui M: Surgical management of the tendon 2, J Hand Surg (Eur) 32:118–129, 2007.
sheath at different repair stages. Biomechanical and morpho- 28. Tang JB, Cao Y, Wu YF, et al: Effect of A2 pulley release on
logical evaluations of direct sheath closure, partial sheath repaired tendon gliding resistance and rupture in a chicken
excision, and interposing sheath grafting, Chin Med J (Engl) model, J Hand Surg (Am) 34:1080–1087, 2009.
103:295–303, 1990. 29. Cao Y, Tang JB: Strength of tendon repair decreases in the
11. Gelberman RH, Woo SL, Amiel D, et al: Influences of flexor presence of an intact A2 pulley: Biomechanical study in a
sheath continuity and early motion on tendon healing in chicken model, J Hand Surg (Am) 34:1763–1770, 2009.
dogs, J Hand Surg (Am) 15:69–77, 1990. 30. Tang JB, Zhang QG, Ishii S: Autogenous free sheath grafts in
12. Savage R: The mechanical effect of partial resection of the reconstruction of injured digital flexor tendon sheath at the
digital fibrous flexor sheath, J Hand Surg (Br) 15:435–442, delayed primary stage, J Hand Surg (Br) 18:31–32, 1993.
1990. 31. Bakhach J, Sentucq-Rigal J, Mouton P, et al: The Omega
13. Tang JB, Ishii S, Usui M, et al: Flexor sheath closure during “Omega” pulley plasty. A new technique to increase the diam-
delayed primary tendon repair, J Hand Surg (Am) 19:636– eter of the annular flexor digital pulleys, Ann Chir Plast Esthet
640, 1994. 50:705–714, 2005.
14. Tang JB: The double sheath system and tendon gliding in 32. Bunata RE, Kosmopoulos V, Simmons S, et al: Primary
zone 2C, J Hand Surg (Br) 20:281–285, 1995. Tendon sheath enlargement and reconstruction in zone 2: An
15. Tang JB, Shi D, Zhang QG: Biomechanical and histologic in vitro biomechanical study on tendon gliding resistance,
evaluation of tendon sheath management, J Hand Surg (Am) J Hand Surg (Am) 34:1436–1443, 2009.
21:900–908, 1996. 33. Bunata RE: Primary pulley enlargement in zone 2 by incision
16. Kwai Ben I, Elliot D: “Venting” or partial lateral release of the and repair with an extensor retinaculum graft, J Hand Surg
A2 and A4 pulleys after repair of zone 2 flexor tendon inju- (Am) 35:785–790, 2010.
ries, J Hand Surg (Br) 23:649–654, 1998. 34. Al-Qattan MM, Al-Turaiki TM: Flexor tendon repair in zone
17. Tang JB, Shi D, Shen SQ, et al: An investigation of morphol- 2 using a six-strand “figure of eight” suture, J Hand Surg (Eur)
ogy and function of flexor tendons in zone IIc in the hand 34:322–328, 2009.
and treatment of flexor tendons, Chin J Surg (in Chinese) 35. Giesen T, Sirotakova M, Copsey AJ, et al: Flexor pollicis
37:639, 1999. longus primary repair: Further experience with the Tang tech-
18. Mitsionis G, Bastidas JA, Grewal R, et al: Feasibility of partial nique and controlled active mobilisation, J Hand Surg (Eur)
A2 and A4 pulley excision: Effect on finger flexor tendon 34:758–761, 2009.
biomechanics, J Hand Surg (Am) 24:310–314, 1999. 36. Tang JB: Clinical outcomes associated with flexor tendon
19. Tomaino M, Mitsionis G, Basitidas J, et al: The effect of partial repair, Hand Clin 21:199-210, 2005.
excision of the A2 and A4 pulleys on the biomechanics of 37. Amadio P, An KN, Ejeskar A, et al: IFSSH Flexor Tendon Com-
finger flexion, J Hand Surg (Br) 23:50–52, 1998. mittee report, J Hand Surg (Br) 30:100–116, 2005.
CHAPTER
10
VENTING OF THE MAJOR
PULLEYS
OUTLINE Following identification of a synovial means of nutri-

tion and repair of injured flexor tendons, complete
Review of the history of the management of the flexor repair of the flexor tendon sheath was advocated both
tendon sheath over the last half century is necessary to reestablish the synovial environment of the tendon
to understanding why venting the pulleys has met and to diminish formation of adhesions, no longer
with such resistance among hand surgeons. The believed to be necessary for tendon healing and recog-
author’s clinical research illustrating why venting of nized to be a hindrance to movement.1,4-8 The method-
the A2 and A4 pulleys is necessary in clinical practice ology of complete closure of the sheath following
is then described. This is followed by review of other primary tendon repair was elaborated by Lister.9 The
subsequent research supporting the practice of venting zeal to completely close the flexor sheath waned in the
these pulleys as a necessary surgical activity to ensure 1980s and 1990s from a lack of supportive evidence that
safe rehabilitation of primary repairs of the digital this is either necessary or beneficial.10-16
flexor tendons. Various authors at this time pointed out again that
repaired, and thereby thickened, flexor tendons might
To repair flexor tendon injuries in zones 1 and 2, it is not move freely in the closed tendon sheath, because of
inevitable that the tendon sheath be opened for access. the increased diameter of the repaired tendon and/or
Over the past 40 years, treatment of the sheath on narrowing of the sheath by the process of closing it.1,16-22
completion of the tendon repair(s) appears to have The problems identified after complete closure of the
been determined partly on theoretical grounds and sheath were (1) complete immobility of the repair and
partly by interpretation of the tendon healing research (2) (more likely) snagging of the repair on the edges of
at the time. adjacent pulleys during tendon movement. Such an
impediment to full mobility might be expected to cause
HISTORY
either a loss of range of motion of the digit or a rupture
After primary repair, the subsequent discrepancy of the repair during early postoperative mobilization,
between the external diameter of flexor tendons and the depending on the vigor with which the hand was reha-
internal diameter of the tendon sheath was first dis- bilitated. It was suggested that it might be necessary to
cussed by Mason in 1940.1 He pointed out the impor- partially release or “vent” the sheath laterally to achieve
tance of excision of the sheath adjacent to the primary a free-running repair.1,17,21 Strickland (1986) described
repair and over a sufficient length to allow free gliding and illustrated the technique of lateral “venting” pulleys
of the repair. In 1958, Verdan2 again highlighted this but thought that this was only necessary when a particu-
point, stating that “the sheath is excised over a distance lar bulky repair came to lie adjacent to a pulley, which
of about two to three centimeters, the amount of the restricted its full excursion.21 In most instances, he con-
sheath to be resected was determined by estimating the sidered that complete sheath closure without this
physiological gliding amplitude at this level.” Ketchum,3 maneuver was possible. Schneider (1985) wrote that
in 1977, also mentioned the need to excise a portion of “excising a portion of the sheath in badly damaged cases
the sheath. Although these authors were writing when may be required to allow free mobility of the tendon
it was assumed that adhesion formation between the juncture” and also admitted having been forced to
tendons and the subcutaneous fat was necessary to remove the A4 pulley on rare occasions with delayed
achieve repair of the sutured tendon, a secondary need repairs.23 There has been no work done since Strickland
for adequate sheath excision to allow free movement of (1986) to identify any useful difference between split-
the repair is clear. ting the pulleys laterally and in the midline.
98
Chapter 10: Venting of the Major Pulleys 99
Throughout all of these reports, there was a palpable in flexion in zones 2A and 2B are those in which the
reluctance to condone such venting of pulleys as, in repairs of the flexor digitorum profundus (FDP) tendon
practice, this would usually entail partial division of the are likely to impinge on the proximal edge of the A4
A2 or the A4 pulleys, the complete integrity of which pulley on finger extension. In fingers injured in exten-
was believed to be of great importance in maintaining sion, the tendon injury lies immediately beneath the
the mechanical efficiency of the flexor system.13,24-27 laceration of the sheath. These repairs are liable to
Toward the end of this period, and coinciding with the impinge on the distal edge of the A2 pulley on flexion
waning of the enthusiasm for complete closure of the of the finger. After completion of each repair, the finger
flexor sheath, Savage (1990) questioned the absolute was moved passively through a full range of motion and
need to preserve the A2 and A4 pulleys completely.20 the repair observed for catching on the proximal edge
Tomaino and his colleagues subsequently lent support of the A4 or distal edge of the A2 pulley. When catching
to Savage’s work.28,29 occurred, the appropriate pulley was vented along one
edge for as much of its length as was necessary to allow
AUTHOR’S CLINICAL RESEARCH
a full and unimpeded range of motion of the repair. The
There was also a degree of imprecision in these reports degree to which the A4 pulley had been vented was
as to which pulleys should be vented and by how much expressed as a percentage of the total length of the
and how often such releases were necessary. With this pulley. Venting of the distal edge of the A2 pulley was
background, we designed a prospective study to examine measured and expressed in millimeters as expressing
those zone 2 injuries in which this problem arises most this as a percentage of the whole of the A2 pulley would
commonly, namely those occurring between the proxi- have involved unnecessary opening of the base of the
mal end of zone 1 and the distal edge of the A2 pulley, finger and palm of the hand to measure the full length
designated zones 2A and 2B by Tang (1994)30 in his of the A2 pulley. After venting of the pulleys, and achiev-
proposed subdivision of the original zone 2 described ing free movement through the full range of motion of
by Verdan and Michon (1961)31 and modified to its the finger, the sheath was laid over the flexor tendons,
present form by Kleinert and Weiland (1979).32 Over a hemostasis was achieved, and the skin of the finger was
period of 29 months, 126 consecutive fingers with zone closed. The fingers were then mobilized using the variant
2A and 2B flexor tendon injuries were repaired as part of the controlled (early) active motion regimen we rou-
of the routine emergency workload of our unit by senior tinely use and have described previously.34
trainee plastic and orthopedic surgeons, who had been Of the 126 consecutive zone 2A and 2B injuries with
briefed to vent the A2 or A4 pulley as necessary to at least one tendon completely divided, 85 (67%) were
achieve sound tendon repairs and to allow the repaired cut in flexion and 40 (32%) were cut in extension. The
tendons to move passively through their full excursion position of the injury was not specified clearly in one
before closing the finger.33 Whenever possible, tendon finger (1%). In eight cases (6%), the record of the find-
repair was carried out through the wound of the tendon ings at surgery was unclear. A variable degree of venting
sheath with only sufficient further opening of the sheath of the pulleys was necessary. In general, the length of
as necessary to allow tendon suture. In zones 2A and the pulleys is proportional to the length of the digit.35
2B, this usually requires release of part of the A3 pulley, The average length of the A2 pulley is between 18 and
either distal, proximal, or both distal and proximal to 20 mm.26,36 In this study, the A2 pulley was vented dis-
the initial wound. As the A3 pulley and the adjacent C tally for between 4 and 10 mm, which represents 20%
pulleys were not then considered essential to the pres- to 50% of its average length. The degree of venting of
ervation of full flexor mechanical function, particular the A4 pulley ranged from 10% to 100% of its length
efforts to preserve this part of the tendon sheath were with a mean of 52%. In 14 cases, the A4 pulley had to
not made and its fate was not recorded. When tendons be completely divided. In all of these cases, the site of
were injured close to, or under the A4 pulley, extension division of the FDP tendon was in zone 2A close to, or
of the tendon sheath wound to allow placement of the under, the A4 pulley. In all 14 cases, the surgeon par-
intratendinous core suture often required some degree tially vented the A4 pulley and the assistant flexed the
of venting of the A4 pulley. A tendon injury adjacent to distal interphalangeal (DIP) joint while holding the
the distal edge of the A2 pulley does not usually require proximal interphalangeal (PIP) joint straight to deliver
venting of the distal A2 pulley for repair as the tendons the distal stump from under the remainder of the A4
can be drawn out distal to the pulley to undertake the pulley and allow insertion of the core suture. In some
repair(s). In those fingers that were cut in partial flexion, cases, complete division of the pulley was necessary to
the tendon injury was identified more distally when the insert the core suture into the distal end of the tendon.
finger was in the extended position necessary for surgi- In some, it was only necessary to partially vent the
cal repair and was reached either by extending the pulley for access but the repaired tendon then impinged
primary opening or, more commonly, through a sepa- on the distal remnant of the pulley on full finger exten-
rate window of the sheath more distally. Fingers injured sion and it was necessary to complete the division of
A B
Figure 10-1 A, Division of both flexor tendons in zone
2B of the left ring and little fingers. B, The sheath has
been penetrated at the A3 pulley level. C, The FDP tendon
has been divided distal to the A4 pulley when the finger is
extended.
the pulley to allow full mobility. In many instances, FDS tendon to the middle phalanx, this helps explain
repair of the FDP tendon at this level can be achieved the need for different degrees of venting of this pulley
while leaving a small distal part of the pulley, with the and how the FDP division could occasionally be distal
repair then moving through a full range of motion to the A4 pulley. Although the original definition of the
without impinging on this remnant. It is questionable boundary between zone 1 and zone 2 was the distal
whether pulley remnants of less than 10% to 20% of the edge of the FDS insertion into the middle phalanx,31
original length will continue to function adequately as there would be benefit in redefining it as the proximal
a pulley and do not snap during early mobilization. In edge of the A4 pulley. This would both simplify discus-
one case in this study, and in one subsequent case, the sion of zone 1 and zone 2 injuries and bring this part
FDP division was beyond the A4 pulley when the finger of the classification into line with the definitions of the
was fully extended (Figure 10-1), requiring pulley more proximal boundaries in the classification, which
venting from distal to proximal to allow full passive are all defined in terms of the pulleys.
mobilization of the repair. In summary, given the brief that two requisites—
It was noted during the study that the length of the good flexor repairs and a full range of motion passively
flexor digitorum superficialis (FDP) insertion was vari- of all three finger joints after completion of the repairs—
able and that the relationship of the insertion of the FDS were necessary, our senior fellows (all experienced in
tendon and the A4 pulley was inconstant. In examina- this surgery and the surgeons most likely to carry out
tion of the latter relationship, we found that the FDS this type of surgery in most specialist hand units) found
insertion lay immediately beneath the A4 pulley in 22 it necessary in clinical practice to vent the A2 or the A4
cases (73%), whereas the FDS insertion was entirely pulley in 81 fingers (64%), either to perform the flexor
proximal to the A4 pulley in eight fingers (27%). Given tendon repair(s) or to allow the repairs to run freely
that Tang’s zone 2A is defined as the insertion of the without snagging, or for both indications. This study of
Figure 10-2 A, Clinical picture of distal

bowstringing of the flexor tendons of the
finger following secondary flexor tendon
surgery in which the C1, A3, and C2 pulleys
were excised for access and the A4 pulley
A4
subsequently snapped during tenolysis of
the distal FDP tendon. B, Diagrammatic
A3 illustration of the removal of the C1, A3, C2,
and A4 pulleys.
A2
A B
routine flexor tendon repairs in zone 2 would suggest skeleton could have given rise to changes in power of
that both the frequency and the degree of venting of flexion, not measured in our other studies.
the A2 and A4 pulleys necessary in clinical practice are
DISTAL BOWSTRINGING
greater than the earlier literature would suggest. The
inviolability of the A2 pulley was further undermined Visible distal bowstringing, which is a rare problem,
by laboratory studies in chickens by Tang and his col- only occurs when there is a complete absence of the
leagues, which provided evidence of improved gliding sheath beyond the A2 pulley (Figure 10-2). This is
excursions and reduced resistance to motion of repaired mostly an iatrogenic problem resulting from secondary
tendons after partial incision of the A2 pulley.37 Venting flexor tendon surgery that should not occur in primary
of the A4 pulley, particularly in its entirety, is, arguably, flexor tendon surgery if we retain all, or most, of the
the more important debate, as the A2 pulley is so long sheath. In secondary flexor surgery, our entry into the
that it is unlikely that removal of any one-third of it will tendon sheath to visualize the tendons is usually
cause bowstringing. Whether one vents the A4 pulley as between the distal edge of the A2 pulley and the proxi-
much as needed to allow full and free passive move- mal edge of the A4 pulley, and this often leads to exci-
ment of the repair or leaves the distal part of the A4 sion of much, or all, of the A3 and the adjoining C
pulley intact and accepts a loss of full extension of the pulleys. Later in the dissection, we find the A4 is often
DIP joint is a moot point, and one’s practice in this not only small and very flimsy, but also tightly bound
respect will depend on how much credence one gives to to the underlying profundus tendon. During the subse-
the research showing no absolute need for the A2 and quent tenolysis, it is too easy to snap the A4, leaving no
the A4 pulleys to always be completely intact. In this pulley system beyond the distal edge of the A2 pulley.
study, we had hoped to confirm whether the practice of Visible distal bowstringing then occurs. We now rou-
dividing the A4 pulley entirely is harmful to long-term tinely start all secondary surgery by keeping some of the
flexor tendon function. This was thwarted by 5 of the scarred sheath around the PIP intact as an A3 pulley, in
14 patients with complete A4 venting choosing to ter- case we snap the A4 pulley later in the dissection. While
minate their follow-up before meaningful measure- this paragraph digresses into secondary flexor tendon
ments could be taken. surgery, it makes the point that we should aim to pre-
This study is incomplete in that it did not examine serve as much as possible of the sheath between the A2
the function of the fingers after full recovery to deter- and A4 pulleys when exploring flexor tendon injuries
mine whether this policy of pulley venting leads to any distal to the A2 pulley when the finger has been cut in
loss of range or power of flexion. From other studies flexion, whether in a primary or secondary surgical
carried out in our unit during the same period and with setting. These observations are supported by the results
the same policy of pulley venting occurring as the from a human cadaveric study by Tang and Xie.38
routine of the unit, it is unlikely that range of motion Although this study found the actual A3 pulley itself to
was significantly affected. However, alteration of the be of little importance compared with the surrounding
mechanical relationship between the tendons and the sheath and C pulleys, it did suggest that the sheath
the relevant pulleys to accommodate the larger

tendon(s).40,41 Most clinicians who have tried to enlarge
pulleys at some period in their career are probably sus-
picious of the ability of the small sutures one has to use
in such repairs to withstand the forces involved in early
active motion, making it seem likely that it is the
remainder of the intact flexor sheath that is actually
functioning to restrain the tendon(s) against the skele-
ton of the finger. This being so, is the pulley reconstruc-
tion actually necessary?
THE SIGNIFICANCE OF PULLEY VENTING
Perhaps more realistic to clinical practice has been the
policy of Tang and his colleagues in China,42 which
Figure 10-3 The right little finger after primary repair of takes the writings from this unit33,43 on this subject a
both flexor tendons in zone 2B by a middle-grade trainee
quantum step farther. This team not only describes
with a two-strand Kessler core suture and a Silfverskiöld
circumferential suture. Full DIP joint extension could only be
exactly what part of the tendon sheath should be, and
achieved by venting two-thirds of the A4 pulley. can be safely, vented for tendon repairs at different levels
of injury in the finger, including complete division of
the A4 pulley whenever necessary, but also raises the
adjacent to the A3 pulley plays an important role in need for such venting to that of a necessity if we are to
preventing tendon bowstringing at the PIP joint. overcome the unpredictability of outcome of primary
So, the question remains unanswered as to whether flexor tendon repair in zones 1 and 2. In 2007, in a
the clinical practice of venting pulleys has any deleteri- review of primary flexor tendon surgery, Tang made the
ous effect on long-term flexor function. Conversely, the statement, “It is, thus, obvious to me that even a multi-
long-term effect of retaining the A4 pulley in its entirety strand tendon repair should be accompanied by proper
in respect of loss of DIP extension is unknown but, pos- and sufficient release of the critical part or the entire
sibly, more immediately obvious. The larger core and pulley in the vicinity of the repair, to eliminate the
circumferential sutures we are now using would seem danger of overloading the tendon as a result of tendon
likely to lead to greater need for venting pulleys, both for gliding against the pulley rim or constriction by the nar-
access and then to allow the repairs to move, as the new rowest pulley parts.”42 In analyzing the critical points of
sutures create added bulk at the repair site (Figure 10-3). primary flexor tendon surgery, Tang considered appro-
Discussion of the acceptability of venting pulleys has priate release of the pulleys as probably most important,
continued into this century. The argument for preser followed by the use of strong repairs to increase the
vation of all pulleys has been supported indirectly by margin of safety. He considered closure of the synovial
two reports following the philosophy of Messina and sheath of least importance and repair of the strong
Messina39 of accepting the change in diameter of the annular pulleys over, or proximal to, edematous tendon
repaired tendon as inevitable and attempting to enlarge repairs to be positively harmful.
References
1. Mason ML: Primary and secondary tendon suture. A discus- 8. Matthews P, Richards H: Factors in the adherence of flexor
sion of significance in tendon surgery, Surg Gynecol Obstet tendon after repair, J Bone Joint Surg (Br) 58:230–236, 1976.
70:392–404, 1940. 9. Lister GD: Incision and closure of the flexor sheath during
2. Verdan CE: La reparation immediate des tendons fleuchis- primary tendon repair, Hand 15:123–135, 1983.
seurs dans le canal digital, Acta Orthop Belg 24 (suppl III):15– 10. Chow JA, Thomes LJ, Dovelle S, et al: A combined regimen
23, 1958. of controlled motion following flexor tendon repair in “no
3. Ketchum LD: Primary tendon healing: A review, J Hand Surg man’s land,” Plast Reconstr Surg 79:447–455, 1987.
2:428–435, 1977. 11. Gelberman RH, Woo SLY, Amiel D, et al: Influences of flexor
4. Amadio PC, Hunter JM, Jaeger SH, et al: The effect of vincular sheath continuity and early motion on tendon healing in
injury on the results of flexor tendon surgery in zone 2, dogs, J Hand Surg (Am) 15:69–77, 1990.
J Hand Surg (Am) 10:626–632, 1985. 12. Lister GD, Tonkin M: The results of primary flexor tendon
5. Eiken O, Hagberg L, Lundborg G: Evolving biologic concepts repair, J Hand Surg (Am) 11:767, 1986.
as applied to tendon surgery, Clin Plast Surg 8:1–12, 1981. 13. Peterson WW, Manske PR, Kain CC, et al: Effect of flexor
6. Lister GD, Kleinert HE, Kutz JE, et al: Primary flexor tendon tendon sheath integrity on tendon gliding: A biomechanical
repair followed by immediate controlled mobilization, and histological study, J Orthop Res 4:458–465, 1986.
J Hand Surg 2:441–451, 1977. 14. Peterson WW, Manske PR, Lesker PA: The effect of flexor
7. Lister GD: Indications and techniques for repair of the flexor sheath integrity on nutrient uptake by primate flexor tendons,
tendon sheath, Hand Clin 1:85–95, 1985. J Hand Surg (Am) 11:413–416, 1986.
15. Saldana MJ, Ho PK, Lichtman DM, et al: Flexor tendon repair 30. Tang JB: Flexor tendon repair in zone 2C, J Hand Surg (Br)
and rehabilitation in zone II: Open sheath technique versus 19:72–75, 1994.
closed sheath technique, J Hand Surg (Am) 12:1110–1114, 31. Verdan CE, Michon J: Le traitement des plaies des tendons
1987. flechisseurs des doigts, Rev Chir Orthop et Repar l’App Mot
16. Tang JB, Ishii S, Usui M, et al: Flexor sheath closure during 47:290–296, 1961.
delayed primary tendon repair, J Hand Surg (Am) 19:636– 32. Kleinert HE, Weiland AJ: Primary repair of flexor tendon
640, 1994. lacerations in zone II. In Tendon Surgery of the Hand, Verdan
17. Duran RJ, Houser RG: Controlled passive motion following C, editor, Edinburgh/London/New York, 1979, Churchill
flexor tendon repair in zones 2 and 3. In AAOS Symposium Livingstone, pp 71–75.
on Tendon Surgery in the Hand, St Louis, 1975, Mosby, pp 33. Kwai-Ben I, Elliot D: “Venting” or partial lateral release of the
105–114. A2 and A4 pulleys after repair of zone 2 flexor tendon inju-
18. Manske PR: Flexor tendon healing, J Hand Surg (Br) 13:237– ries, J Hand Surg (Br) 23:649- 654, 1998.
245, 1988. 34. Elliot D, Moiemen NS, Flemming AF, et al: The rupture
19. Peterson WW, Manske PR, Dunlap J, et al: Effect of various rate of acute flexor tendon repairs mobilised by the con-
methods of restoring flexor sheath integrity on the formation trolled active motion regimen, J Hand Surg (Br) 19:607–612,
of adhesions after tendon injury, J Hand Surg (Am) 15:48–56, 1994.
1990. 35. Idler RS: Anatomy and biomechanics of the digital flexor
20. Savage R: The mechanical effect of partial resection of the tendons, Hand Clin 1:3–11, 1985.
digital fibrous flexor sheath, J Hand Surg (Br) 15:435–442, 36. Zancolli EA, Cozzi EP: Atlas of Surgical Anatomy of the Hand,
1990. New York, 1992, Churchill Livingstone, pp 327–345.
21. Strickland JW: Flexor tendon injuries. Part 2: Flexor tendon 37. Tang JB, Wang YH, Gu YT, et al: Effect of pulley integrity on
repair, Orthop Rev 15:701–721, 1986. excursions and work of flexion in healing flexor tendons,
22. Tang JB, Shi D, Zhang QG: Biomechanical and histological J Hand Surg (Am) 26:347–353, 2001.
evaluation of tendon sheath management, J Hand Surg (Am) 38. Tang JB, Xie RG: Effect of A3 pulley and adjacent sheath
21:900–908, 1996. integrity on tendon excursion and bowstringing, J Hand Surg
23. Schneider LH: Flexor Tendon Injuries, Boston, 1985, Little, (Am) 26:855–861, 2001.
Brown, pp 47–75. 39. Messina A, Messina JC: The direct midlateral approach with
24. Barton NJ: Experimental study of optimal location of flexor lateral enlargement of the pulley system for repair of flexor
tendon pulleys, Plast Reconstr Surg 43:125–129, 1969. tendons in fingers, J Hand Surg (Br) 21:463–468, 1996.
25. Doyle JR: Palmar and digital flexor tendon pulleys, Clin 40. Bunata RE: Primary pulley enlargement in zone 2 by incision
Orthop Relat Res 383:84–96, 2001. and repair with an extensor retinaculum graft, J Hand Surg
26. Doyle JR , Blythe W: The finger flexor tendon sheath and (Am) 35:785–790, 2010.
pulleys; anatomy and reconstruction. In AAOS Symposium on 41. Dona E, Walsh WR: Flexor tendon pulley V-Y plasty: An alter-
Tendon Surgery in the Hand, St Louis, 1975, Mosby, pp 81–88. native to pulley venting or resection, J Hand Surg (Br) 31:133–
27. Rispler D, Greenwald D, Shumway S, et al: Efficiency of the 137, 2006.
flexor tendon pulley system in human cadaver hands, J Hand 42. Tang JB: Indications, methods, postoperative motion and
Surg (Am) 21:444–450, 1996. outcome evaluation of primary flexor tendon repairs in Zone
28. Mitsionis G, Fischer KJ, Bastidas JA, et al: Feasibility of partial 2, J Hand Surg (Eur) 32:118–129, 2007.
A2 and A4 pulley excision: Residual pulley strength, J Hand 43. Elliot D: Primary flexor tendon repair: Operative repair,
Surg (Br) 25:90–94, 2000. pulley management and rehabilitation, J Hand Surg (Br)
29. Tomaino M, Mitsionis G, Basitidas J, et al: The effect of partial 27:507–513, 2002.
excision of the A2 and A4 pulleys on the biomechanics of
finger flexion, J Hand Surg (Br) 23:50–52, 1998.
CHAPTER
11
THE OMEGA “Ω” FLEXOR
PULLEY PLASTY
Joseph Bakhach, MD
OUTLINE gliding have led several surgeons to abandon this

approach.3-8
In this chapter, we present our methods for the Omega The repair of injured digital flexor tendons, either
plasty used to treat A4 and A2 digital flexor pulleys in primarily or secondarily, is accompanied by an increase
primary or delayed primary tendon repair. This proce- in the diameter of the tendon where sutures are placed,
dure expands the inner diameter of the annular pulleys increasing resistance to movement.9 To avoid this risk,
of the flexor sheath, but anatomically it does not several authors10-12 prefer to deal with the fibrous sheath
disturb the integrity of the pulleys. During surgery one structure and propose a partial or a complete resection
lateral attachment of the annular pulley is entirely of the A2 or A4 annular pulleys.
released from the corresponding anterior phalangeal Enlarging the digital fibrous sheath by “venting” the
bony surface. Our clinical series includes 34 Omega pulley is attractive theoretically.12 However, even if it
pulley plasties performed in 34 fingers of 27 patients. does improve the local mechanical conditions around
In 15 patients, 19 pulley plasties were performed with the tendon repair site, incision into the pulley structures
primary repair of flexor tendon rupture, while in the may decrease digital flexion to a certain degree. Ana-
remaining 12 patients, 15 Omega pulley plasties were tomic work has showed that the most remarkable loss
done concomitantly with delayed primary tendon of function is caused by resection of the annular pulleys
repair. Among the 34 fingers, 7 fingers subsequently A2 and A4.13 We thus began to imagine technical inno-
needed tenolysis 3 months after initial surgery. After vations that would resolve this conflict more specifically
7-month mean follow-up, excellent results were seen without affecting the integrity of the annular pulleys.
in 29 fingers (85%), and good in 5 fingers (15%) The Omega (“Ω”) pulley plasty we describe consists
according to Strickland criteria. The advantage of this of releasing one lateral pulley attachment from its cor-
subperiosteal surgical release is that it increases pulley responding lateral phalangeal bony surface. The most
diameter and inner volume, which accommodates relevant fact is that this technique preserves the ana-
better tendon gliding. tomical integrity of the pulley and its continuity with
the periosteum and the floor of the digital fibrous
The surgical management of traumatic flexor tendon sheath. If one attachment is released, the annular pulley
injuries, especially in zone 2 (sometimes called “no moves palmarly and rotates transversally, enhancing
man’s land”), has always been a controversial subject. its internal space. This procedure may provide better
These injuries in zone 2 are accompanied by injuries to gliding conditions for repaired flexor tendons. We
the digital fibrous sheath. The later the injury is attended named this technique for pulley plasty Omega, or “Ω,”
to, the more fibrosis and collapse of the digital sheath reflecting the anatomical shape of the annular pulleys
are likely. The methods for repairing the functional cross-sectionally.
flexor unit (i.e., the finger flexor tendons and their fibro-
osseous sheath) are still evolving, testifying to the ana- METHODS AND OUTCOMES
tomical as well as the functional complexity of this
structure. Anatomy of the Fibrous Digital
The conservative camp proposed the concomitant Sheath Tunnel
repair of the digital fibrous tube with the primary suture Though the anatomy of the digital fibrous sheath is
of the flexor tendon injuries to restore the sheath integ- familiar, we review some points that are important for
rity and avoid the formation of adhesions.1,2 However, explaining the Omega (“Ω”) pulley plasty. The pulleys
the failure of the fibrous sheath to heal and, more dra- segmentally distributed along the synovial sheath differ
matically, the risk of creating a constriction to tendon by their sites of insertion and their plasticity.14 The
104
Chapter 11: The Omega “Ω” Flexor Pulley Plasty 105
annular pulleys A1, A3, and A5 (also called articular

pulleys), are attached to the palmar joint plates of the
metacarpophalangeal (MP), the proximal interphalan-
geal (PIP), and the distal interphalangeal (DIP) joints,
respectively. The lengths of these pulleys change during
digital motion, with an approximate 50% retraction
after full digital flexion,13,15 whereas the A2 and A4
pulleys (bone pulleys) insert on the lateral phalangeal
crests in continuity with the lateral periosteum and with
the floor of the digital fibrous sheath tunnel. The A2
pulley is situated in the middle and proximal part of the
proximal phalanx, and the A4 pulley in the middle third
of the middle phalanx. The lengths of the A2 and A4
pulleys change somewhat (less than 25%) during digital
flexion.
All the relevant biomechanical studies to date agree, Figure 11-1 A patient with FDP tendon injury in zone 2B
giving functional priority in finger flexion to the A2 and with the finger in an intermediate flexed position. The DIP
A4 pulleys.13,16 It is on these two pulleys that the pulley joint was passively flexed to bring the distal stump out of
plasty is performed during tendon repair in zone 2,17 the A4 pulley into the operative field.
more precisely in zones 2B and 2C.18
Operative Techniques
Pulley plasty during tendon surgery in zone 2 may be
necessary under two circumstances: (1) primary tendon The ulnar digital neurovascular bundle is retracted
repair that generates an immediate impingement on or and the entire ulnar phalangeal bone attachment of the
impediment to the digital fibrous sheath tunnel and (2) A4 pulley is exposed. The ulnar periosteum is sharply
delayed management of injured tendons with a col- incised along the body of the middle phalanx and freed
lapsed and retracted digital fibrous sheath over the progressively from dorsal to palmar. The ulnar pulley
injured area. attachment is then reached and freed from the ulnar
phalangeal crest until it has been totally liberated
Omega Plasty of the A4 Pulley (Figure 11-2).
For a description of the operative technique, we con- Despite the total release of the pulley insertion, the
sider a case of primary repair of an injured flexor digi- integrity of the fibrous sheath is fully preserved, with
torum profundus (FDP) tendon in zone 2B with the complete continuity between the pulley and the ante-
finger in an intermediate flexed position. The wound is rior periosteum of the phalanx, which forms the floor
cleaned. The digital fibrous sheath is exposed through of the digital fibrous tunnel. This release produces a
classic oblique incisions on both sides of the cutaneous lengthening of the pulley circumference and conse-
wound. The collateral neurovascular pedicles are dis- quently an enhancement of its internal diameter. This
sected and protected. The second cruciform (C2) pulley induces the rotational movement of the tendon gliding
is opened, and the stumps of the tendon are located. tunnel, which is the basic rationale of the Omega pulley
If the finger is in an extended position, the distal plasty.
tendon stump is retracted and hidden completely under Then we verify sliding of the tendon passively, par-
the A4 pulley. It is necessary to flex the DIP joint to ticularly the suture area of the tendon through the proxi-
expose the tendon and to place the two stumps in the mal ring of the enlarged A4 pulley, by extending gently
operative field (Figure 11-1). the DIP joint (Figure 11-3). In case of any remaining
The tendon suture is completed with the Kleinert resistance, it is necessary to carry out a complementary
technique using Prolene 4-0 suture material with an release of the periosteum flap until perfect concord
epitendinous continuous running suture using Prolene between the pulley volume and the tendon is achieved.
6-0. The suture technique itself is not important, and Finally, the expanded pulley is left free and no sutures
different methods can be used. After the reestablish- are placed to fix the pulleys to other structures. The
ment of tendon continuity, finger extension brings the digital neurovascular bundle is placed back, and the C2
sutured part of the tendon under the proximal edge of pulley is left to heal spontaneously.
the A4 pulley, where a conflict process obstructs the In case of delayed primary management of an injured
tendon from sliding beneath the pulley. An A4 expan- tendon, the retracted and collapsed annular pulley is
sion pulley plasty becomes necessary to free the tendon expanded using the same plasty technique. Two tendi-
motion. nous stumps are integrated within the expanded pulley.
B
A
D
C
Figure 11-2 A, B, The annular pulley is firmly fixed by two lateral attachments to the anterior crests of the phalanx.
C, D, Releasing one lateral attachment allows a rotational upward movement, increasing the internal diameter of the pulley.
B, D, Demonstrations in a cadaveric finger. Arrows indicate the side of release at the pulley attachment to the phalanx.
A B
Figure 11-3 After the Omega plasty, passive extension of the DIP joint brings the suture area into the proximal edge of the
expanded A4 pulley, confirming free gliding of the tendon. A, Finger semiflexed. B, Finger extended.
Omega Plasty of the A2 Pulley which is obviously the origin of the resistance phenom-
The same operative technique is applied to the A2 enon during tendon sliding, has prompted a number of
pulley, with some adjustments due to the length of the authors to propose sheath excision in order to enlarge
A2 pulley, which can be three to four times the length the digital fibrous sheath.21,22 On one side, there is the
of the A4 pulley. In our cases, when an A2 pulley plasty conservative stream, which preaches the sealing of the
was necessary, the conflict was located at the distal ring digital fibrous sheath, opposed by those who advise its
of the A2 pulley. In all such cases, the Omega plasty resection. Between those two extreme attitudes, there is
started on one side at the distal end of the pulley and a mixed position.23 It consists in freeing the pulleys as
extended proximally. In our cases, the Omega plasties necessary, thus making it possible to widen the digital
in the A2 pulley were partial and never exceeded 50% fibrous tube and to permit tendon sliding movement
of the pulley length. without resecting the pulleys.
On each side of the expanded pulley, the synovial The work of Kwai Ben and Elliot12 is interesting. They
sheaths injured during the initial trauma are opened pointed out the frequent discrepancies between the
surgically to expose and repair the tendons, then left to repaired flexor tendon volume and the diameter of its
heal spontaneously. We prefer not to repair these syno- digital fibrous tube. In a series of 126 fingers with
vial flaps in order to avoid any constricting scar. tendon injuries in zone 2A and 2B,12 71 fingers (56%)
required venting of the A4 pulley. In 10 fingers (8%) a
Postoperative Care partial lateral section of the A2 pulley was performed,
After surgery, we protected the pulley with an external extending 20% to 50% of its length.
ring skin bandage on the middle phalanx for an A4 This technique of venting the pulley, either partial or
pulley, or on the proximal phalanx for an A2 pulley, and total, practiced to permit the surgical tendon suture or
adopted either the Kleinert or Duran protocol of post- to facilitate normal sliding of the tendon, has been
operative digital motion. accepted by the scientific community. Nevertheless, it
remains unsatisfactory from a biodynamic point of
Outcomes view, because it eliminates a fundamental structure of
Between 2005 and 2007, we carried out 34 Omega the tendon physiology.
pulley plasties (34 fingers) in 27 patients; 20 men and There are numerous clinical situations in which a
7 women, with an average age of 34 years.18 There were conflict arises between the digital fibrous tunnel and its
11 index, 9 middle, 7 ring, and 7 little fingers. In 15 contents. As far as the tendon rupture is concerned, the
patients, 19 Omega pulley plasties were performed position of the finger (extension or flexion) at the time
immediately after injury together with primary flexor of the trauma should be determined. A rupture of the
tendon repairs. In the other 12 patients, 15 Omega FDP tendon in zone 2B or 2C with the finger extended
pulley plasties were carried out secondarily in the will generate a conflict between the tendon and the
delayed primary stage concomitantly with management distal ring of the A2 pulley. However, the rupture of the
of the neglected injured flexor tendons. Among the total FDP tendon in zone 2B with the finger in a flexed posi-
34 plasties, 26 Omega pulley plasties involved the A4 tion will bring the distal tendon stump under the A4
pulleys and 8 involved the A2 pulleys. In 5 fingers, it pulley and will make it difficult to reach for surgical
was necessary to make a proximal incision on the distal repair. The Omega plasty is done on the A4 pulley in
palmar crease in order to find the retracted FDP tendon. order to ensure the adaptation of the pulley volume to
In 2 fingers the flexor digitorum superficialis (FDS) that of the repaired tendon, avoiding any resistance and
tendon was also injured, and in one finger there was a offering normal tendon sliding (Figure 11-4).
neck fracture of the proximal phalanx. In cases of neglected tendon injuries, the trauma to
It was necessary to perform tenolysis in 4 cases (7 the digital fibrous sheath and the retraction of the
fingers) at the third month postoperatively because of tendon stump lead to fibrous sheath retraction and
the persistence of a deficit in the active flexion of the pulley collapse along the gap between tendon ends
DIP joint despite the adapted physiotherapy. (Figure 11-5). This may require an Omega plasty of
The average period of follow-up was 7 months (range, the constricted pulley. It must be noted that about
4 to 9 months) after tendon repairs and pulley plasty. half of our cases concern secondary repair of the rup-
According to the Strickland classification, “excellent” tured tendon. This reveals, even today, ignorance of
results of active motion were achieved in 29 fingers, tendon pathology on the part of non-specialized hand
whereas the other 5 fingers achieved “good” results.19 surgeons.
After its release, the anatomical architecture of the
DISCUSSION
digital fibrous sheath (particularly the anatomy of the
The volume discrepancy between the repaired flexor A2 and A4 pulleys, with their bony attachments) allows
tendon in zone 2 and its digital fibrous sheath has long pulley enlargement and the creation of better condi-
been a concern among surgeons.20 This discrepancy, tions for tendon sliding. The unilateral release of the
A B
Figure 11-4 Rupture of the FDP tendon in zone 2B with
the left index finger in a flexed position. A, B, An Omega
plasty is performed on the total length of the medial A4
pulley attachment, allowing normal gliding of the repaired
tendon through the expanded pulley during surgery.
C, Complete recovery to normal flexion of the index finger
after surgery.
pulley attachment does not impair its biomechanical decrease of 9% simulated active range of digital motion
properties; we preserve the continuity of the pulley with after total section of the A2 pulley, and Savage28 assures
the phalangeal periosteum on one side and the second us that the A2 or A4 pulley can be removed, provided
pulley-to-bone attachment on the other. After surgery, the remaining digital fibrous sheath remains intact.
tissue healing will restore the continuity of the detached According to these previous reports, we believe the
pulley with the phalangeal crest. We have confirmed the Omega pulley plasty creates no risk of pulley rupture
restoration of normal solidity of this new attachment in and does not generate significant disturbance in tendon
the cases that required secondary tenolysis. Indeed, the biomechanics.
pulleys seemed to have regained their anatomical con- We maintain that preserving the anatomical integrity
tinuity and normal solidity, which was tested in the of the pulley and one of its two attachments is sufficient
presence of tendon motion during surgery of tenolysis. to maintain biomechanical properties. Intraoperative
Past investigations indicate that during digital flexion, observations of the expanded A2 and A4 pulleys show
the pulleys are subject to stress from the flexor that the newly healed bone insertion is sufficiently solid
tendons.13,24 Nevertheless, the threshold of tendon to maintain the deep flexor tendon on its axis during
rupture is far from being reached; that would require 7 digital flexion.
times as much stress as occurs during digital grasp.25 The technique of pulley expansion that we describe
Moreover, Mitsionis et al26 showed that the section of here completely preserves pulley integrity. It respects the
half of the A2 or A4 pulley does not alter any bio internal surface of the pulley and does not increase the
mechanical properties, while Tang27 has recorded a risk of tendon adhesions. After this procedure, it is not
necessary to specifically modify protocols for postopera-

tive rehabilitation that we use.29,30 The only necessary
precaution is to protect the pulley plasty with an exter-
nal ring skin bandage.
Our experience indicates that the extent of pulley
release must be carefully considered. We accomplished
the release gradually with intraoperative assessment of
* ample sliding of the tendon repair site inside the
expanded pulley. In our series, all Omega plasties on the
A2 pulley required a partial release not exceeding 50%
of the pulley’s attachment length, while the Omega
plasties of the A4 pulley required a complete release in
60% of our cases. In the remaining 40%, the release did
not extend more than the two thirds the length of the
A A4 pulley.
Approximately 20% of operated fingers required
tenolysis by postoperative month 3 because of a persis-
tent loss of active flexion of the DIP joint. Presumably,
the loss of DIP joint motion was associated with the use
of Kleinert protocols. Rehabilitation began the day after
tendon release, and recovery of complete digital flexion
was obtained, on average, by the third month after the
tenolysis. These tendon adhesions varied depending on
the extent of the initial finger trauma and were gener-
ated by the healing processes around the repaired
tendon. In no cases could these adhesions be correlated
to the Omega pulley plasty itself.
SUMMARY
The Omega plasty of the fibro-osseous annular pulleys
(A2 or A4) is a simple and reliable procedure. The
B release of the pulley from one side of its bony attach-
ment increases the spatial volume within the pulley and
Figure 11-5 Delayed primary repair of a FDP tendon accommodates greater motion of the repaired tendon.
injury in a left ring finger. A, Collapse of the A4 pulley This procedure may create favorable conditions for
(indicated by an asterisk) over a tendon gap. The end of the recovery of tendon gliding and active digital flexion.
proximal tendon is indicated by an arrow. B, Recovery of
Tendon injuries are frequently accompanied by conflicts
the finger motion after pulley plasty performed on its one
and resistance to tendon gliding produced by the
attachment to the phalanx to increase pulley volume and
tendon gliding. annular pulleys. We are confident of the safety and
utility of this new technique, which may be considered
in primary, delayed, or secondary repairs of the flexor
tendons in zone 2.
References
1. Lister GD: Incision and closure of the flexor tendon sheath 6. Saldana MJ, Ho PK, Lichtman DM, et al: Flexor tendon repair
during primary tendon repair, Hand 15:123–135, 1983. and rehabilitation in zone II: open sheath technique versus
2. Lister GD, Tonkin M: The results of primary flexor tendon closed sheath technique, J Hand Surg (Am) 12:1110–1114,
repair with closure of the tendon sheath, J Hand Surg (Am) 1987.
11:767, 1986. 7. Tang JB, Ishii S, Usui M, et al: Flexor sheath closure during
3. Amadio P, Hunter JM, Jaeger SH, et al: The effect of vincular delayed primary tendon repair, J Hand Surg (Am) 19:636–
injury on the results of flexor tendon surgery in zone 2, 640, 1994.
J Hand Surg (Am) 10:626–632, 1985. 8. Tang JB, Shi D, Zhang QG: Biomechanical and histologic
4. Lister GD: Indications and techniques for repair of the flexor evaluation of tendon sheath management, J Hand Surg (Am)
tendon sheath, Hand Clin 1:85–95, 1983. 21:900–908, 1996.
5. Eiken O, Hagberg L, Lundborg G: Evolving biologic concepts 9. Manske PR: Flexor tendon healing, J Hand Surg (Br) 13:237–
as applied to tendon surgery, Clin Plast Surg 8:1–12, 1981. 245, 1988.
10. Peterson WW, Manske PR, Dunlap J, et al: Effect of various 20. Mason ML: Primary and secondary tendon suture. A discus-
methods of restoring sheath integrity on the formation of sion of the significance of technique in tendon surgery, Surg
adhesions after tendon injury, J Hand Surg (Am) 15:48–56, Gynecol Obstet 70:392–404, 1940.
1990. 21. Ketchum LD: Primary tendon healing: a review, J Hand Surg
11. Tomaino M, Mitsionis G, Basitidas J, et al: The effect of partial 2:428–435, 1977.
excision of the A2 and A4 pulleys on the biomechanics of 22. Verdan CE: La réparation immédiate des tendons fléchisseurs
finger flexion, J Hand Surg (Br) 23:50–52, 1998. dans le canal digital, Acta Orthop Belg Suppl III 15–23, 1958.
12. Kwai BI, Elliot D: “Venting” or partial lateral release of the A2 23. Strickland JW: Flexor tendon injuries. Part 2. Flexor tendon
and A4 pulleys after repair of zone 2 flexor tendon injuries, repair, Orthop Rev 15:701–721, 1986.
J Hand Surg (Br) 23:649–654, 1998. 24. Manske PR, Lesker PA: Strength of human pulley, Hand
13. Lin GT, Amadio PC, An KN, et al: Functionnal anatomy of 9:147–152, 1977.
the human digital flexor pulley system, J Hand Surg (Am) 25. Schuind F, Garcia-Elias M, Cooney WP, et al: Flexor tendon
14:949–956, 1989. forces: in vivo measurements, J Hand Surg (Am) 17:291–298,
14. Moutet F: Les poulies de l’appareil fléchisseur: anatomie, 1992.
pathologies, traitement, Annales de Chir Main 22:1–12, 2003. 26. Mitsionis G, Fischer KJ, Bastidas JA, et al: Feasibility of partial
15. Lin GT, Cooney WP, Amadio PC: Mechanical properties of A2 and A4 pulley excision: residual pulley strength, J Hand
human pulleys, J Hand Surg (Br) 15:429–434, 1990. Surg (Br) 25:90–94, 2000.
16. Cleveland M: Restoration of the digital portion of a flexor 27. Tang JB: The double sheath system and tendon gliding in
tendon and sheath in the hand, J Bone Joint Surg 15:762–765, zone 2C, J Hand Surg (Br) 20:281–285, 1995.
1933. 28. Savage R: The mechanical effect of partial resection of the
17. Verdan CE, Michon J: Le traitement des plaies des tendons digital fibreous flexor sheath, J Hand Surg (Br) 15:435–442,
fléchisseurs des doigts, Rev Chir Orthop et Répar 47:290–296, 1990.
1961. 29. Kleinert HE, Kutz JE, Cohen MJ: Primary repair of zone 2
18. Tang JB: Flexor tendon repair in zone 2C, J Hand Surg (Br) flexor tendon lacerations. In AAOS Symposium on Tendons
19:72–75, 1994. Surgery in the Hand. St Louis, 1975, CV Mosby, p 91–104.
19. Bakhach J, Mouton P, Panconi B, et al: The Omega pulley 30. Duran RJ, Houser RG: Controlled passive motion following
plasty. A new technique to increase the diameter of the flexor tendon repair in zones two and three. In AAOS Sympo-
annular flexor digital pulleys, Ann Chir Plast 50:705–714, sium on Tendons Surgery in the Hand. St Louis, 1975, CV
2005. Mosby, p 105–114.
CHAPTER
12
TENDON SHEATH AND PULLEY
ENLARGEMENT
Robert E. Bunata, MD
OUTLINE a slight enlargement using a fascial graft as Lister recom-

mended for a deficient sheath. This seemed to solve the
This chapter presents the results of clinical experience problem of providing a nonrestrictive gliding environ-
and laboratory studies related to the idea of enlarging ment for the repair while adequately restoring impor-
and then repairing a major pulley and closing the tant sheath support. The result of that surgery was
sheath at the time of primary flexor tendon repairs. surprisingly good. Since then this technique has been
This procedure is intended to give room for the more applied to either the A2 or A4 pulleys in a total of 12
bulky tendon repairs to slide while providing an intact fingers in 9 patients, which represent the more difficult
sheath and pulley system that guides the repair and patients treated over a 20-year period.7
prevents bowstringing. The clinical data on a series of Since those developments early in the history of
patients and a description of the surgical technique are primary repairs of flexor tendons, attention and research
presented, and the laboratory studies provide biome- have made tendon repairs stronger to prevent rupture if
chanical findings regarding tendon gliding, triggering, subjected to increased resistance. Stronger repairs are
and bowstringing after this procedure. This chapter often more bulky and can make gliding even more dif-
deals with an alternate solution to the problem of ficult and catching more likely. Even the strongest repair
getting a bulky flexor tendon repair to glide freely might rupture if an exposed edge of pulley that com-
without triggering while maintaining the adequate pletely blocks motion is encountered.8 Venting has
sheath support that is required for efficient finger become an accepted method of sheath management,
flexion. This solution is at odds with the axiom of being a way to preserve enough of the essential pulleys
keeping as much as possible of the major A2 and A4 while improving tendon gliding. Venting allows free
pulleys intact, and instead cuts an obstructing pulley, gliding to occur only within the vented area, and the
subsequently repairing it with a slight enlargement. repair must often reenter a tight, restrictive sheath,
exposing the repair to catching on an edge of sheath or
The history of dealing with this problem started with to traversing an area of resisted gliding.
the earliest attempts at primary flexor tendon repair and Other methods that have been suggested to solve the
continues to the present time. When Kleinert and col- same problem include removal of one slip of flexor
leagues published their successful primary tendon digitorum superficialis (FDS), pulley enlargement by
repairs in zone 2 combined with early motion in 1973, V-Y plasty, and pulley release from the underlying
he initially resected a window of tendon sheath.1 Ten phalanx.7,9-18 Tang and colleagues have shown complete
years later, Lister and coworkers advocated closure of the pulley incision with or without graft repair in chickens
tendon sheath following a limited, pulley preserving reduces work of flexion even after the effects of time and
tendon exposure.2 In 1983, they advocated complete healing are included.12,19,20 Tang8,11 and Elliot10 have even
closure of the sheath so that catching of the repair on recommended completely cutting the A4 pulley as stan-
an edge of sheath would be avoided, and in 1985 Lister dard clinical practice despite the continuing belief that
described replacing a deficient sheath with a fascial graft at least some of the A2 and A4 pulleys are essential to
to accomplish closure.3,4 However, others realized that preventing bowstringing and preserving the efficiency of
tight sheath closure might restrict the free gliding of the finger flexion.
sutured tendons.5,6 Because of the encouraging results in the clinical
This author first used the procedure of pulley enlarge- patients, during the past 5 years laboratory investiga-
ment in 1985 for a patient whose bulky tendon repair tions have been conducted to explore how this tech-
would not glide into or through the A4 pulley. Contrary nique affects gliding within the enlarged sheath,
to the dictum of A2 and A4 pulley preservation, the triggering, and bowstringing. These are summarized
entire A4 pulley was cut. Because of concern that bow- below along with the surgical technique and the clinical
stringing could result, the A4 pulley was repaired with outcomes.
111
SURGICAL TECHNIQUE retinaculum. A transverse ellipse of extensor retinacu-

lum 5 mm wide × 30 mm long is removed. Any septal
Operative Techniques remnants are excised and any defects repaired to present
The flexor tendon sheath is exposed and examined with a smooth, synovial lined graft. The 5-mm gap in the
the finger in full extension. Tendon and sheath injuries donor site retinaculum is closed side-to-side with
are evaluated and the anticipated excursion of the absorbable, interrupted sutures, and the wrist skin inci-
repaired tendon is identified. If the flexor digitorum sion with subcuticular absorbable suture. The elliptical
profundus (FDP) lies within the A4 pulley or if both graft is trimmed to fit to the retinacular sheath and
tendons might have to pass under the A2 pulley, sheath pulley defect of the finger and sutured in place, synovial
and pulley enlargement might be needed, and the side toward the tendon repairs, with a running horizon-
sheath, including any part of a pulley, is opened far tal mattress, alternately locked, 6-0 nylon suture under
enough to provide adequate exposure for easy tendon enough tension to support but not restrict the gliding
repair. The sheath injury is extended distally until, with of the tendons. This usually requires a 2 mm enlarge-
the help of distal interphalangeal joint flexion, a core ment and the graft requires about 20 suture passes per
suture can be placed in the FDP stump. The sheath/ side for closure. Additional injuries or lacerations in the
pulley incision is placed lateral to the volar midline, tendon sheath are closed with everting, interrupted 6-0
leaving enough sheath tissue to secure a suture and sutures.
adjusting the incision to fit the conditions of the original
injury. The distal FDS is always longer than the FDP and Clinical Outcomes
readily visible with this exposure. The proximal tendons Seven of the nine patient were followed to an adequate
are retrieved. If needed, the proximal sheath/pulley is follow-up ranging from 3 months to 11 years.7 All seven
incised far enough to allow room so that an easy tendon patients (nine digits) were treated as primary flexor
repair can be performed. Both tendons are repaired. tendon repairs in zone 2 preferably with the surgery
In the series, all tendons or tendon slips were repaired delayed 2 or 3 days to be confident that the wound was
with a two-strand modified Kessler repair using 3-0 not contaminated. All were managed postoperatively
suture. The suture was performed starting in the distal with Kleinert’s original rehabilitation protocol, which
tendon segment with a 1-cm longitudinal insertion and was begun immediately following surgery in the recov-
a locking loop followed by the transverse pass and a ery room. The final total active interphalangeal joint
grasping loop leading back to the tendon end. The iden- motion of the nine digits averaged 127.5° of a possible
tical pattern was used in the proximal tendon segment. maximum of 175° (Table 12-1). The final range of
This allowed easy tensioning until the ends abutted motion ranged from 65° to 175°. The scores according
without bunching and there was no gapping when to the Strickland-Glogovac system were three excellent,
placed under manual tension. The triple-throw sur- two good, two fair, and two poor.21 There were no
geon’s knot was buried inside the repair. All repairs were tendon ruptures despite the use of a two-strand core
reinforced and smoothed with a circumferential repair. Two fingers in one patient required a tenolysis,
running, alternately locked, 6-0 nylon suture, making and one finger in another patient had a secondary skin
10 to 12 passes around each tendon and 6 to 8 passes scar lengthening. These secondary operations improved
around each tendon slip. The 6-0 suture was tied with finger motion. Only three of the nine digits attained full
one triple-throw square knot on the external lateral PIP joint extension, with the average lack of extension
tendon surface. A stronger repair can be substituted if (flexion contracture) for the nine fingers being 21°.
preferred. While the Kleinert rehabilitation protocol has been
Once the tendons are sutured, the excursion of the associated with developing flexion contractures, they
repairs is checked by passively extending the finger and may be the result of bowstringing if the grafts stretched
by pulling on the tendons through a palm incision to with time and/or use.7 One finger, the right ring finger
flex the finger. If any intact sheath or pulley tissue of patient 3, had visible and palpable bowstringing
restricts the full excursion of the repair pulley, enlarge- when seen at follow-up post tenolysis. Another finger,
ment may be indicated and the sheath/pulley incisions the right little finger of patient 4, had clinical evidence
are extended even if this means completely incising an of bowstringing at follow-up.
entire major pulley. If an entire A2 or A4 pulley is cut, The two patients with bowstringing merit comment.
the entire sheath is repaired and closed with an extensor The sheath repair of right little finger of patient 4 may
retinaculum graft in an attempt to reestablish the incised have been too loose because even a limited enlargement
major pulley in order to limit bowstringing and guide of the small fifth digit sheath can be disproportionately
the tendons into the sheath without snagging. large. The right ring finger of patient 3 had no evidence
The graft is obtained through a transverse skin inci- of bowstringing at 6 months, immediately before a
sion on the dorsum of the wrist extending from the tenolysis to improve flexion was performed. When seen
second to the sixth compartments of the distal extensor 18 years later, this finger had midline skin callous
Chapter 12: Tendon Sheath and Pulley Enlargement 113
Table 12-1 Patient Information About Injuries, Operations, and Follow-Up

Age(y)/ Digit(s) Tendon(s) Pulleys PIP Joint DIP Joint
Patients Gender Injured Repaired Incised Follow-Up Motion Motion TAM Grade
1 54/M L middle FDP/FDS Mid-A2, A3, A4 11 yr 30/105 0/85 160 Excellent
2 18/M R little FDP/FDS Mid-A2, A3, A4 2 yr 45/90 0/90 135 Good
3 21/M R ring FDP A3, A4 6 mo 0/90 20/34 105 Fair*
R little FDP A3, A4 30/90 25/40 75 Poor
4 17/M R ring FDP/FDS Mid-A2, A3, A4 5.5 yr 15/100 15/50 120 Fair
R little FDP/FDS Mid-A2, A3, A4 50/90 20/45 65 Poor**
5 20/M R middle FDP/FDS A2, A3 3 mo 0/100 0/65 165 Excellent
6 45/F L ring FDP/FDS A2, A3 1.5 yr 20/95 0/70 145 Good
7 15/M R index FDP/FDS Mid-A1, A2, A3 3 yr 0/115 0/60 175 Excellent
M, Male; F, Female; R, Right; L, Left. Graded by Strickland-Glogovac method.21
*Finger without clinical observable tendon bowstringing 6 months after tendon repair before tenolysis, but had clinically observable
bowstringing when examined 18 years after tenolysis.
**Finger with clinically observable bowstringing after primary surgery.
formation directly over underlying flexor tendons which Study of the effect of venting and pulley enlargement
were distinctly prominent during gripping. The PIP joint on the incidence of triggering in the force recordings
had complete extension and 95° flexion; the DIP joint (see Figure 12-1B) revealed that after the bulk of the
motion was 30/65°. Possible explanations for this may tendon was increased by tendon repair, triggering
be: (1) there was bowstringing present at 6 months that occurred in some fingers. Venting alone had a variable
was not detected, (2) the sheath function was damaged effect on the incidence of this triggering, but closing the
during the tenolysis, or (3) the graft stretched from sheath with enlargement provided smoother gliding of
heavy use over the following 18 years. the repair and reduced the incidence of triggering.3,29,30
Regarding bowstringing, in a preliminary, unpub-
BIOMECHANICAL STUDIES
lished study of nine cadaver fingers, total range of
Uchiyama and colleagues’ method of testing resistance motion (TROM) in the uninjured state was compared
of an isolated segment of the tendon/tendon sheath to the motion after cutting the A4 pulley plus additional
provides the opportunity of observing and testing the sheath for the distance equal to the FDP excursion, and
effects of sheath enlargement and repair on gliding resis- then to the motion after that sheath was repaired with
tance and triggering.22 Using a tensioning force (F1) a 2-mm-wide fascial graft. Cutting the sheath reduced
through a load cell attached to the distal FDP and an the finger TROM to 93.8% of normal. Repairing the
activating force (F2) through a proximal load cell, force sheath and pulleys enlarged by 2 mm brought the loss
recordings as seen in Figure 12-1A, are obtained. The of TROM to 99.3% of the uninjured state. This suggests
difference in force between the load cells is the gliding that a 2-mm enlargement may preserve acceptable finger
resistance (the friction between the tendon and the flexion efficiency. We have not tested how well the
sheath). pulley repair holds up under stress and with time. With
Gliding resistance measurements in our laboratory more tension on the tendons or with time, the pulley
for the normal, uninjured A1 through A3 segment has repair may stretch. This technique of the pulley repair
averaged about 0.4 N (see red line in Figure 12-1A). requires further study to evaluate the need or benefit of
After the FDP is cut and repaired with a two-strand 3-0 strengthening or reinforcement.
core suture and running, locked 6-0 epitenon suture,
DISCUSSION
gliding resistance increases to 1.25 to 1.5 N, or by 200%
to 250% (see blue line in Figure 12-1A). These values Considering the three goals of sheath and pulley man-
are similar to what others have found for various tendon agement during primary zone 2 flexor tendon surgery
suture techniques.18,23-28 Experiments done in our labo- of providing a good gliding environment, avoiding trig-
ratory revealed that either venting (50% or 66%) or a gering, and minimizing bowstringing, this experience
2-mm sheath enlargement and repair reduces the resis- with sheath enlargement and repair may offer insight
tance to approximately 1.0 N, or by 22% to 31% from into future research and clinical practice, especially with
the tendon repair resistance level (see green line in regards to the benefits of a closed sheath. The surgeon
Figure 12-1A). has the option and obligation to reconsider decisions
8 8
F2 tendon repair
7 7
A B
6 F2 sheath 6
enlarged
F2
Uninjured
Force (N)
Force (N)
5 5
F1 F1
C
4 4
3 3
2 2
25 30 35 40 45 50 22 27 32 37
A Time(s) B Time(s)
Figure 12-1 Force recordings generated using Uchiyama et al testing technique. F1 is tensioning force; F2 is activating
force. A, Resistance recordings during tendon gliding in a simulated digital flexion cycle. Red, force recorded without tendon
injuries; blue, force tracing after the FDP tendon has been cut and repaired; green, force tracing after the sheath has been
enlarged. B, An example of the force recordings when triggering occurs. Orange, gliding resistance (F2). An increase (A) in
gliding resistance followed by a sudden drop (B), associated with a disturbance in F1 (purple, C), called an echo, indicate
triggering.
throughout an operation. During primary repair, pulley established procedure. The procedure carries the risks of
and sheath enlargement may be a useful choice to increasing the sheath injury, cutting a major pulley,
provide repaired tendon with adequate tendon gliding obtaining a distant graft, and inserting a graft of uncer-
amplitude. tain strength to repair the cut pulley, but for those
Use of the technique of sheath enlargement should patients in which a strong repair plus venting do not
be carefully considered. More basic and clinical investi- permit adequate tendon excursion, complete pulley
gation is needed before it can be considered an enlargement may become an option.
References
1. Kleinert HE, Kutz JE, Atasoy E, et al: Primary repair 3. Lister GD: Incision and closure of the flexor sheath during
of flexor tendons, Orthop Clin North Am 4:865–876, primary tendon repair, Hand 15:123–135, 1983.
1973. 4. Lister GD: Indications and techniques for repair of the flexor
2. Lister GD, Kleinert HE, Kutz JE, et al: Primary flexor tendon tendon sheath, Hand Clin 1:85–95, 1985.
repair followed by immediate controlled mobilization, 5. Manske PR: Flexor tendon healing, J Hand Surg (Br) 13:237–
J Hand Surg (Am) 2:441–451, 1977. 245, 1988.
Chapter 12: Tendon Sheath and Pulley Enlargement 115
6. Strickland JW: Flexor tendon surgery. Part 1: Primary flexor 19. Tang JB, Wang YH, Gu YT, et al: Effect of pulley integrity on
tendon repair, J Hand Surg (Br) 14:261–272, 1989. excursions and work of flexion in healing flexor tendons,
7. Bunata RE: Primary pulley enlargement in zone 2 by incision J Hand Surg (Am) 26:347–353, 2001.
and repair with an extensor retinaculum graft, J Hand Surg 20. Tang JB, Cao Y, Wu YF, et al: Effect of A2 pulley release on
(Am) 35:785–790, 2010. repaired tendon gliding resistance and rupture in a chicken
8. Tang JB: Indications, methods, postoperative motion and model, J Hand Surg (Am) 34:1080–1087, 2009.
outcome evaluation of primary flexor tendon repairs in Zone 21. Strickland JW Glogovac SV: Digital function following flexor
2, J Hand Surg (Br) 32:118–129, 2007. tendon repair in zone II: A comparison of immobilization
9. Elliot D, Moiemen NS, Flemming AF, et al: The rupture rate and controlled passive motion techniques, J Hand Surg (Am)
of acute flexor tendon repairs mobilized by the controlled 5:537–543, 1980.
active motion regimen, J Hand Surg (Br) 19:607–612, 1994. 22. Uchiyama S, Coert JH, Berglund L, et al: Method for the
10. Elliot D: Primary flexor tendon repair: operative repair, pulley measurement of friction between tendon and pulley, J Orthop
management and rehabilitation, J Hand Surg (Br) 27:507– Res 13:83–89, 1995.
513, 2002. 23. Tanaka T, Amadio PC, Zhao C, et al: Gliding resistance versus
11. Tang JB: Clinical outcomes associated with flexor tendon work of flexion–two methods to assess flexor tendon repair,
repair, Hand Clin 21:199–210, 2005. J Orthop Res 21:813–818, 2003.
12. Tang JB, Xie RG, Cao Y, et al: A2 pulley incision or one slip 24. Tanaka T, Amadio PC, Zhao C, et al: Gliding characteristics
of the superficialis improves flexor tendon repairs, Clin Orthop and gap formation for locking and grasping tendon repairs:
Relat Res 456:121–127, 2007. A biomechanical study in a human cadaver model, J Hand
13. Messina A, Messina JC: The direct midlateral approach with Surg (Am) 29:6–14, 2004.
lateral enlargement of the pulley system for repair of flexor 25. Zhao C, Amadio PC, Zobitz ME, et al: Gliding resistance after
tendons in fingers, J Hand Surg (Br) 21:463–468, 1996. repair of partially lacerated human flexor digitorum profun-
14. Paillard PJ, Amadio PC, Zhao C, et al: Pulley plasty versus dus tendon in vitro, Clin Biomech 16:696–701, 2001.
resection of one slip of the flexor digitorum superficialis after 26. Zhao C, Amadio PC, Tanaka T, et al: Effect of gap size on
repair of both flexor tendons in zone II: A biomechanical gliding resistance after flexor tendon repair, J Bone Joint Surg
study, J Bone Joint Surg (Am) 84:2039–2045, 2002. (Am) 86:2482–2488, 2004.
15. Zhao C, Amadio PC, Zobitz ME, et al: Resection of the flexor 27. Paillard PJ, Amadio PC, Zhao C, et al: Gliding resistance after
digitorum superficialis reduces gliding resistance after zone II FDP and FDS tendon repair in zone II: an in vitro study, Acta
flexor digitorum profundus repair in vitro, J Hand Surg (Am) OrthopScand 73:465–470, 2002.
27:316–321, 2002. 28. Coert JH, Uchiyama S, Amadio PC, et al: Flexor tendon-
16. Dona E, Walsh WR: Flexor tendon pulley V-Y plasty: An pulley interaction after tendon repair. A biomechanical study,
alternative to pulley venting or resection, J Hand Surg (Br) J Hand Surg (Br) 20:573–577, 1995.
31:133–137, 2006. 29. Amadio P, An KN, Ejeskar A, et al: IFSSH Flexor Tendon Com-
17. Bunata RE, Kosmopoulos V, Simmons S, et al: Primary tendon mittee report, J Hand Surg (Br) 30:100–116, 2005.
sheath enlargement and reconstruction in zone 2: An in vitro 30. Bunata RE, Simmons S, Roso M, et al: Gliding resistance and
biomechanical study on tendon gliding resistance, J Hand Surg triggering after venting or A2 pulley enlargement: A study
(Am) 34:1436–1443, 2009. of intact and repaired flexor tendons in a cadaveric model,
18. Tanaka T, Amadio PC, Zhao C, et al: The effect of partial A2 J Hand Surg (Am) 36:1316–1322, 2011.
pulley excision on gliding resistance and pulley strength in
vitro, J Hand Surg (Am) 29:877–883, 2004.
CHAPTER
13
CLINICAL PRIMARY FLEXOR
TENDON REPAIR AND
REHABILITATION
A The Bern Experience
Esther Vögelin, MD, PhD, Ghislaine
Traber-Hoffmann, MD, and
Véronique van der Zypen, BSC PT
OUTLINE risks of rupturing the repairs. Not only repair techniques

but also postoperative mobilization require a balance
In this chapter we present our experience with treat- between these two extremes.
ment of zone 2 flexor tendon repair using a six-strand The repair that Lim and Tsai advocated5,6 was found
repair technique combined with postoperative place- to have the mechanical strength required for unrestricted
and-hold exercise. The six-strand Lim/Tsai repair active finger flexion in vitro.5,7 We used the Lim/Tsai
technique combined with place-and-hold exercises repair with an early active tendon motion regimen and/
demonstrated better digital function compared to a or place-and-hold exercise between 2003 and 2005. We
two-strand repair without place-and-hold exercises. noted that despite the need to mobilize repaired flexor
Range of motion in the Lim/Tsai repair group appeared tendons early, an active motion protocol may not be
to be increased without a higher rate of ruptures but possible to apply in a substantial number of patients
with a shorter rehabilitation period. The fact that the due to concomitant injuries, the quality of the surgical
two groups differed in both suture techniques and repair, or patient factors such as swelling, pain, or lack
rehabilitation programs made it impossible to know of compliance. We therefore started a staged rehabilita-
whether the better results in the group of Lim/Tsai tion program using the “stop and go” principal in the
were due to the six-strand repair or the place-and-hold style of a traffic signal: early active controlled flexion
exercises or both. Despite the obvious benefit of early (green), place-and-hold (yellow), or passive flexion exer-
active mobilization, an active motion protocol may cises (red) depending on different factors of the patient
not always be possible to apply in a substantial number such as the severity of injury, the ease of repair or the
of patients due to concomitant injuries, the quality of postoperative compliance.
the surgical repair or patient factors (swelling, pain, Since August 2006, we have combined the six-strand
limited compliance). Since August 2006 a staged reha- Lim/Tsai suture repair with “stop and go” method of
bilitation program (“stop and go”) was introduced postsurgical rehabilitation in all flexor tendon repairs,
within our unit using early active controlled flexion and these methods remain our current practice of treat-
(green), place-and-hold (yellow), or passive flexion ment of tendon injuries in zone 2.
exercises (red) introduced by Kleinert-Duran. Our
experience using the six-strand suture repair technique METHODS AND OUTCOMES
and “stop and go” is outlined.
Patients
Functional results after flexor tendon repair in zone 2 We reviewed and compared results of three cohorts of
have markedly improved over the past three decades.1-4 patients with flexor tendons repairs in zone 2 in the
However, a big dilemma of flexor tendon repair in zone Hand Surgery Department of the University Hospital
2 remains the challenge between scar formation and of Bern. From 2003 to 2007, a total of 76 patients
116
Chapter 13A: The Bern Experience 117
Table 13(A)-1 Patient Details

Groups Lim and Tsai Method Kessler Method
Core suture method Lim and Tsai (six-strand) Modified Kessler (two-strand)
Postoperative care Kleinert-Duran regimen with place-and-hold Kleinert-Duran regimen
exercises
Patients 46 (8 women, 38 men) 25 (8 women, 17 men)
Age (range) 32 years (13–74 years) 38 years (16–82 years)
Injured hand Dominant 22 10
Nondominant 24 11
Unknown — 4
Injured digits 51 (13, 9, 7, 22)* 26 (6, 7, 6, 7)*
Tendon injuries
Isolated complete FDP 24 10
Complete FDP and partial FDS 9 3
Complete FDP and complete FDS 18 13
Neurovascular damage (digits) 3 13
Therapy delay (range) 0.5 day (0–2 days) 0.3 day (0–1 days)
*The numbers given in the parentheses are in the order of the index, middle, ring, and little fingers.
underwent a six-strand zone 2 flexor tendon repair and exact TAM values up to 12 weeks. After 12 weeks, the
early active motion (51 digits in 46 patients) and “stop patient files often contained only qualitative statements
and go” rehabilitation protocols (35 digits in 30 without mentioning the degrees of TAM or only giving
patients). the remaining extension deficits.
The results were compared to the results of zone 2 In case of an extension lag resisting physical therapy,
flexor tendon repair with the two-strand modified Kessler treatment with an extension splint was started only 5
repair combined with a Kleinert-Duran regimen in 25 weeks after surgery. The need for secondary surgery,
patients (30 digits) between 1998 and 2002.1 Both occurrence of tendon rupture, dehiscence, contracture
groups included consecutive patients who sustained of joints, and the use of extension splints were com-
sharp and complete flexor digitorum profundus (FDP) pared in both groups. A tendon rupture was defined as
tendon lacerations in zone 2, with or without concomi- a complete gap separation without any detectable
tant flexor digitorum superficialis (FDS) tendon lacera- tendon function clinically. When the tendon remained
tions or neurovascular damage. Injured tendons in these in continuity due to scar formation and still showed an
patients were repaired surgically within 2 days after impaired function, we defined it as a dehiscence. Their
trauma and postoperative therapies of the patients were diagnosis and difference could be confirmed during
continued for a minimum of 8 weeks (Table 13[A]-1). secondary surgery.
During the follow-up, grip strength (kg) was mea- From August 2006 to June 2007, we treated 30 con-
sured using a hand-held Jamar Dynamometer (Preston, secutive patients with flexor tendon injury in zone 2
Jackson, MI). Total active motion (TAM) of each oper- using the Lim/Tsai surgical repair and the postsurgical
ated finger without secondary surgery was recorded. The “stop and go” motion protocol. Exclusion criteria into
flexion of each involved joint was measured first when this review were the same as given earlier1; 26 long
the patient attempted to make a complete fist; the exten- finger injuries (involving 25 FDP and 14 FDS tendons)
sion deficits were measured afterward. The original and 9 thumbs were included. The surgeon initially
Strickland grading system was used to assess final TAM.8 decided on which rehabilitation protocol was used,
The functional results were recorded at a mean of 12 taking in account the severity of the injury and the
weeks postoperatively in both groups (range: Lim/Tsai quality of the repair.
repair group, 9 to 17 weeks; Kessler repair group, 8 to In this most recent cohort of patients, we imple-
16 weeks). The follow-up period was determined on the mented a new motion protocol—“stop and go” pro
basis of collected data of the Kessler repair group; the tocol, as detailed in Figure 13(A)-1. At the end of the
retrospectively collected data of this group provided therapy (postsurgical 3 months ± 1 week) the outcome
DECISION MAKING AND REHABILITATION
Day 0 Repair reliable and free of tension?
No Unclear Yes
RED: passive flexion, YELLOW: place and hold, GREEN: early active
active extension passive tenodesis flexion
Cobra splint (30° wrist flexion, MCP 0° extension), rubber band fixed to injured finger.
Day 0 to 1
Therapy starts for all: passive flexion, active extension
Patient compliant? Injury site free of additional tissue resistance?
No Yes
Control of exercises: passive Place and hold exercise,

Day 2 to 5 wrist tenodesis exercise under
flexion, active extension
surveillance of therapist
Patient compliant?
Day 6 to 24 No Yes
Tenodesis exercise with active

flexion. Active flexion in splint
3 to 5 weeks postoperatively: splint completely removed, rubber band fixed to wrist bandage
Week 3.5 Continue exercises according to red/yellow/green, wrist free active motion
5 weeks postoperatively: rubber band removed
Week 6 to 8 Continue exercises, full active flexion without resistance.
8 weeks postoperatively: start of exercises against resistance
Week 9 to 12 Increasing resistance step by step to regain force. If necessary passive full extension
12 weeks postoperatively: full resistance allowed
Figure 13(A)-1 Decision making and rehabilitation.

Figure 13(A)-2 Technique of the six-strand core and running suture tendon repairs.
was measured using the original Strickland classification and understands German, French, or English. “Stop and
for the fingers and the Buck-Gramcko classification for go” is used for lesions in zones 1 to 4; the wrist teno-
the thumbs. desis exercises are not performed for zone 5. Immedi-
ately after surgery, all patients receive a dorsal “cobra”
OPERATIVE TECHNIQUES
splint in 30° to 40° wrist flexion, with metaphalangeal
After Bruner zigzag incisions, the core suture was (MP) and interphalangeal (IP) joints in 0° (Figure
achieved with the six-strand Lim/Tsai5,6 double-loop 13[A]-3A).
technique with polyamid (4-0 Supramid; S. Jackson,
Alexandria, VA) and an epitendinous running suture Red: Passive Flexion, Active Extension.
with polypropylen (5-0 Prolene) (Figure 13[A]-2). The The patient is instructed to perform passive flexion
two slips of the FDS tendon were repaired with the use (three times a day) and active extension (hourly) of all
of simple core Kessler sutures with polyamid single fingers. The extension of involved digits should reach
suture (4-0 Supramid). No repair of the tendon sheath the dorsal splint (0° in all finger joints) (Figure 13[A]-
was performed. 3B–E). The goal of passive flexion is to make the
involved digits reach the palm.
POSTOPERATIVE CARE
The exercises are monitored by hand therapists at
Therapists decide after consulting the surgeon as to least once a week, and continue to postoperative 3.5
which protocols to be used depending on postoperative weeks. The splint is then removed to allow active mobi-
hand conditions (swelling, pain) and the compliance of lization of the wrist. The rubber band is fixed to a wrist
the patient. Therapists may change the protocols during bandage for another 1.5 weeks. After 5 weeks the patient
the process of rehabilitation (see Figure 13[A]-1). is instructed to actively flex and extend fingers. Exercises
against resistance or passive full extension are not yet
The Staged Rehabilitation Group: allowed. If a passive extension deficit is noted, a static
“Stop and Go” or dynamic extension splint is adapted. At 8 weeks,
Conditions for the “stop and go” program are that the exercises against slight resistance are started. Over the
patient is older than 12 years and that the patient speaks next 4 weeks, the resistance is gradually increased. Full
A B C
D E F
G H I
Figure 13(A)-3 A, Cobra splint and rubber band. B–E, Passive flexion. F, Place and hold (yellow). G, H, Tenodesis exercise
(yellow and green). I, Active flexion (green).
resistance is allowed after 12 weeks. The passive flexion motion, evaluated by the original Strickland classifica-
and active extension (red) is a basic program. The yellow tion system, rendered 21 of 50 excellent and 18 of 50
and green programs described next are built up on it, good results in the group of Lim/Tsai repair compared
with addition of active motion components. to 4 of 21 and 5 of 21 in the group of Kessler repair. The
TAM of the group of Lim/Tsai was 141.4°, which is
Yellow: Place and Hold significantly better (p = 0.013) than the TAM of 123.3°
To the basic program (red), place-and-hold exercises are in the Kessler group. In the group of Lim/Tsai, 14 of 50
added. The place-and-hold exercises are done after the fingers (12 of 45 patients) (28%) necessitated an exten-
basic exercises to decrease tissue resistance. In doing sion splint compared to 8 of 21 fingers (8 of 20 patients)
place-and-hold exercises, all fingers are passively flexed (38%) in the group of Kessler. On average, extension
and actively hold in the flexed position for one second splinting was applied around 8.5 weeks postoperatively.
(Figure 13[A]-3F). During the therapy session, the The average extension lag was 20.7° in the group of
splint is removed to perform wrist tenodesis exercises to Lim/Tsai and 18.8° in the group of Kessler before splint-
initiate tendon gliding: active extension of the wrist ing. Twelve weeks postsurgery, the remaining extension
while the fingers stay relaxed (Figure 13[A]-3G–I). After deficits of the interphalangeal joints were 12° and
3.5 weeks, the splint is removed. The rubber band is 16.4°, respectively, demonstrating no statistically sig-
fixed to a wrist bandage and the exercises are continued nificant difference between the two groups. Using the
in the same way. After 5 weeks, the therapy is continued linear model, in the group of Lim/Tsai, the grip strength
in the way as described in the red protocol. was significantly better (p = 0.02), and the average time
of treatment for long fingers was significantly shorter
Green: Early Active compared to the group of Kessler (p < 0.0001).
In addition to the basic exercises, the patient starts cau- In the staged rehabilitation (“stop and go”) group,
tiously with active flexion in the splint to reach a middle 48 flexor tendon repairs in 26 long fingers and 9 thumbs
position (every joint around 60° flexion). were evaluated after 3 months; 14 fingers were treated
If the patient is cooperative and able to follow the with the green, 9 fingers using the yellow and 3 using
directions given by the surgeon/therapist, he is instructed the red protocol. Of 9 thumbs, 6 were rehabilitated with
to remove the splint and to perform the wrist tenodesis the green, 1 with the yellow and 2 with the red protocol.
exercise with active finger flexion: active wrist extension Nine (35%) flexor tendon repairs were rated excellent,
with complete active finger flexion without resistance. 7 (27%) good, 6 (23%) fair, and 4 (15%) poor using
When the patient is not considered to be compliant, he the original Strickland criteria. The mean active range
is “downgraded” to the yellow or even the red protocol of motion at the end of therapy was 90° of flexion and
at any time in the course of therapy. 10° hyperextension for the MP joint, whereas it was
The control and progression of rehabilitation remain 90° of flexion but an extension lag of 10° for the PIP
the same as for red and yellow. joint and 43° of flexion and full extension for the DIP
joint. Grip strength compared to the contralateral hand
OUTCOMES
was 72%.
Our results of the two- and six-strand repair are sum- The results of the FPL repair were good or excellent
marized in Table 13(A)-2. The assessment of range of in 90% (6 excellent, 2 good, 1 fair) of digits. The mean
Table 13(A)-2 Results of Repairs of Completely Lacerated FDP Tendons Using Two Suture Methods
Evaluations Lim and Tsai Group Kessler Group p values
TAM PIP + DIP joints 141° (90°–195°)* 123° (75°–190°) .013
MP + PIP + DIP joints 232° (190°–290°) 213° (155°–290°) .013
Extension deficit 23/50 digits 11/21 digits NS
PIP + DIP joints 12° (5°–30°) 16° (10°–25°) NS
Extension 14/50 digits 8/21 digits NS
Grip strength Injured hand 34.6 kg (14–60 kg) 30.3 kg (14–60 kg) NS
Uninjured hand 45 kg (22–70 kg) 46.3 kg (22–66 kg) NS
Difference (uninjured-injured) 10.4 kg (−40 to 40 kg) 16.1 kg (−6 to 34 kg) .02
Duration of therapy 112 days (62–230 days) 209 days (83–496 days) <.001
*The numbers given in the parentheses are ranges. NS, not significant.
Table 13(A)-3 Results of Staged Rehabilitation After Flexor Tendon Repairs in 26 Fingers and 9 Thumbs
26 Fingers (Strickland Criteria) 9 Thumbs (Buck-Gramcko Criteria)
Functional Grades Results Protocol Functional Grades Results Protocol
Excellent 9 (35%*) 9 green Excellent 6 (66%) 6 green
Good 7 (27%) 4 green, 3 yellow Good 2 (18%) 1 yellow, 1 red
Fair 6 (23%) 6 yellow Fair 1 (9%) 1 red
Poor 4 (15%) 3 red, 1 green Poor 0 —
Grip Strength 72% compared to the opposite Pinch Strength 85% compared to the
site opposite site
*Percentage of the fingers rated in each grade is given in the parentheses.
Table 13(A)-4 Tendon Injury Sites and Complications Using Tang’s Division of Subzones
Numbers of Lacerations Within Time of Secondary Surgery (Months
Groups Complications Age Finger Tang’s Subzones After Last Surgery)
Lim/Tsai 2 (out of 51 fingers) 1 tenolysis — 1 rupture
30 Long 2B 9 months — —
26 Index 2B — — 2 months
Kessler 6 (out of 26 fingers) 1 tenolysis 2 dehiscence 3 ruptures
53 Index 2B 9 months — —
18 Long 2D — 7 months —
46 Ring 2B — 7 months —
30 Long 2D — — 2 months
59 Long 2B — — 4 months
82 Ring 2B — — 1 month
active range of motion of the thumb was 61° of flexion Kessler Group
and 5° hyperextension in the MP joint and 39° of The rupture rate in the group of Kessler was 3 of 26
flexion in the IP joint but with a slight extension lag of fingers (11%). The complication rate was 6 of 26 fingers
5° (Table 13[A]-3). (23%). The complication rate (including dehiscence and
tenolysis) was significantly lower (Lim/Tsai: 4%; Kessler:
COMPLICATIONS
23%) in the group of Lim/Tsai repair (p = 0.048).
All eight patients requiring secondary surgery had com- In the staged rehabilitation group “stop and go” the
plete lacerations of both the FDP and the FDS tendons. rupture rate was 2 of 48 (4%). One rupture occurred
Table 13(A)-4 details the injured finger and the lacera- while the patient was fighting with others during a
tion site within zone 2 according to Tang’s subdivision nightmare.
of zone 2.9
DISCUSSION
Lim/Tsai Group Gill and colleagues5 conducted a human cadaveric study
One 30-year-old patient with impaired flexion and and showed the superiority of the Lim/Tsai four-strand
extension of the middle finger required a tenolysis repair over two- or four-strand repair techniques with
with FDS resection 9 months after primary repair. One regard to tensile strength. Xie and coworkers7 compared
patient sustained a rupture of the repaired index FDP different six-strand suture configurations and showed
and was reconstructed with a palmaris longus tendon that in vitro the modified Savage and the Tang suture
graft 2 months after the primary repair. The rupture have greater tensile strength than the Lim/Tsai suture,
rate in the group of Lim/Tsai was 1 of 51 fingers (2%) but they also concluded that the Lim/Tsai suture has the
and the complication rate including tenolysis was 2 of mechanical strength for unrestricted active finger flexion.
51 (4%). The loop-suture technique simplifies flexor tendon
repair compared to the modified Savage repair and does of Kessler. Compared to the 50% to 100% good and
not use superficial knots like the Tang suture. Given the excellent results of other studies,13-21 the outcome in
tensile strength of the Lim/Tsai suture, our comparison the group of Kessler repair seemed to be rather poor.
of the six-strand and two-strand repair techniques1 dem- The results of the group of Lim/Tsai are in line with the
onstrated a better outcome without increasing the risk above mentioned reports of zone 2 tendon repairs, espe-
of tendon ruptures using place-and-hold exercises post- cially in view of the longer follow-up of at least at 6 to
operatively in the Lim/Tsai suture group. This group 12 months in these studies. The only report on Lim/Tsai
demonstrated a significantly better TAM. There was no sutures with place-and-hold exercises in zone 2 is by
increased rate of ruptures, nor did it differ significantly Lim and Tsai.6 They achieved 81% good/excellent results
between the two groups. Even without a statistically rel- after 7 months assessed by the revised Strickland criteria
evant difference, there may still be a clinical difference compared to 100% of good/excellent results in the
given the drop of the rupture rate from 11% to 2% group of Lim/Tsai and 91% in the group of Kessler after
between the Kessler and the Lim/Tsai groups. The 3 months in our series when using the revised Strickland
rupture rate in group of Lim/Tsai and in the group of criteria.
Kessler is in line with the published rupture rate of 4% We evaluated a six-strand suture repair technique and
to 10% in zone 2 mentioned in the review of Tang.10 the benefit of place-and-hold exercises on digital func-
Furthermore, the overall complication rate (including tion compared to a two-strand repair without place-
tenolysis and dehiscence) was significantly lower in the and-hold exercises. In an additional group of patients,
group of Lim/Tsai. “stop and go” early active mobilization protocol pro-
Tang and colleagues11 performed a biomechanical duced better outcomes compared with the previous
study showing that gliding curves of a small diameter patient groups with place-and-hold or passive flexion
and gliding over the rim of a major pulley are associated and active extension protocols. In nearly 50% of the
with an increased rupture risk. Dowd and coworkers14 patients, the surgeons and the therapists decided not to
stated that these characteristics were typically found in use the early active (green) but rather the place-and-hold
zone 2B repairs and repairs of tendons in the little finger (yellow) or Kleinert/Duran (red) rehabilitation program
(zone 2B defined by Tang9: subzone from the proximal despite the use of a strong six-strand repair. The actual
margin of the FDS insertion to the distal border of the effects of wound conditions and swelling on the resis-
A2 pulley). In the clinical study by Dowd and col- tance to tendon gliding can be difficult to estimate in
leagues,12 32 of 42 fingers requiring rerepair had injuries due course. In our experience, it is better to have a few
in zone 2B and/or in the little finger. In our study, no options for the rehabilitation protocols to select accord-
repair ruptured in the small finger. Four of six patients ing to patients’ wound conditions and degree of hand
with ruptures or dehiscences, had undergone repair in swelling. Furthermore, we should consider the capabil-
zone 2B (see Table 13[A]-4), which seems to support ity of the patient to perform the exercises to reduce the
Dowd and colleagues’ conclusion of zone 2B as the repair likelihood of repair ruptures.
site at highest risk. The remaining two patients required Our experience with “stop and go” protocols indi-
repairs in zone 2D (subzone from the proximal border cates that the protocols allow individual adjustments of
of the A2 pulley to the proximal margin of zone 2). postoperative rehabilitation, thus optimizing outcomes
Using the original Strickland classification, the group after flexor tendon repair. With these protocols, rehabili-
of Lim/Tsai demonstrated 39 of 50 (78%) good and tation can be adapted to different patients’ conditions,
excellent results compared to 9 of 21 (43%) in the group leading finally to good and excellent results.
References
1. Hoffmann GL, Büchler U, Vögelin E: Clinical results of flexor other techniques: A human cadaveric study, J Hand Surg (Am)
tendon repair in zone II using a six-strand double-loop tech- 24:1315–1322, 1999.
nique compared with a two-strand technique, J Hand Surg 6. Lim BH, Tsai TM: The six-strand technique for flexor tendon
(Eur) 33:418–123, 2008. repair, Atlas Hand Clin 1:65–76, 1996.
2. Strickland JW: The scientific basis for advances in flexor 7. Xie RG, Zhang S, Tang JB, et al: Biomechanical studies of 3
tendon surgery, J Hand Ther 18:94–110, 2005. different six-strand flexor tendon repair techniques, J Hand
3. Al-Qattan MM, Al-Turaiki TM: Flexor tendon repair in zone Surg (Am) 27:621–627, 2002.
2 using a six-strand ‘figure of eight’ suture, J Hand Surg (Eur) 8. Strickland JW, Glogovac SV: Digital function following flexor
34:322–328, 2009. tendon repair in Zone II: A comparison of immobilization
4. Trumble TE, Vedder NB, Seiler JG III, et al: Zone-II flexor and controlled passive motion techniques, J Hand Surg (Am)
tendon repair: A randomized prospective trial of active place- 5:537–543, 1980.
and-hold therapy compared with passive motion therapy, 9. Tang JB: Flexor tendon repair in zone 2C, J Hand Surg (Br)
J Bone Joint Surg (Am) 92:1381–1389, 2010. 19:72–75, 1994.
5. Gill RS, Lim BH, Shatford RA, et al: A comparative analysis 10. Tang JB: Clinical outcomes associated with flexor tendon
of the six-strand double-loop flexor tendon repair and three repair, Hand Clin 21:199–210, 2005.
11. Tang JB, Xu Y, Wang B: Repair of strength of tendons of trolled active motion regimen, J Hand Surg (Br) 19:607–612,
varying gliding curvature: A study in a curvilinear model, 1994.
J Hand Surg (Am) 28:243–249, 2003. 17. Klein L: Early active motion flexor tendon protocol using one
12. Dowd MB, Figus A, Harris SB, et al: The results of immediate splint, J Hand Ther 16:199–206, 2003.
re-repair of zone 1 and 2 primary flexor tendon repairs which 18. Lee H: Double loop locking suture: a technique of tendon
rupture, J Hand Surg (Br) 31:507–513, 2006. repair for early active mobilization. Part II: Clinical experi-
13. Bainbridge LC, Robertson C, Gillies D, et al: A comparison ence, J Hand Surg (Am) 15:953–958, 1990.
of post-operative mobilization of flexor tendon repairs with 19. May EJ, Silfverskiold KL, Sollerman CJ: Controlled mobiliza-
“passive flexion-active extension” and “controlled active tion after flexor tendon repair in zone II: A prospective com-
motion” techniques, J Hand Surg (Br) 19:517–521, 1994. parison of three methods, J Hand Surg (Am) 17:942–952,
14. Baktir A, Turk CY, Kabak S, et al: Flexor tendon repair in zone 1992.
2 followed by early active mobilization, J Hand Surg (Br) 20. Silfverskiold KL, May EJ: Flexor tendon repair in zone II with
15. Cullen KW, Tolhurst P, Lang D, et al: Flexor tendon repair in combining passive and active flexion, J Hand Surg (Am)
zone 2 followed by controlled active mobilisation, J Hand 19:53–60, 1994.
Surg (Br) 14:392–395, 1989. 21. Small JO, Brennen MD, Colville J: Early active mobilisation
16. Elliot D, Moiemen NS, Flemming AFS, et al: The rupture following flexor tendon repair in zone 2, J Hand Surg (Am)
rate of acute flexor tendon repairs mobilized by the con- 14:383–391, 1989.
B The Chelmsford Experience
OUTLINE
THE ST. ANDREW’S UNIT
This chapter reviews the research into primary flexor As a basis for modern practice, this is only likely to
tendon surgery chronologically through from 1989 to improve results if surgery is carried out by adequately
2010 in the Hand Surgery Unit of the St Andrew’s trained surgeons and followed by early mobilization by
Centre for Plastic Surgery, Chelmsford, UK, explaining skilled hand therapists, not general physiotherapists.
the changes made and the thinking behind them. The Chelmsford unit has tried to progress along these
lines for the past 20 years in both respects. The growth
Movement should be instituted with care and judgment. of specialist hand therapy during this period, both
In the first week, it will prevent the incision from healing within the unit and, more generally, throughout the
and encourage infection. If begun late, adhesions will United Kingdom, has been an essential factor in this
already have immobilized the tendon. Rough, extreme and change. The development of a dedicated all-day trauma
continuous movements will cause fibrin and scar tissue to theater and increasing numbers of consultant hand sur-
form and bind the tendons, and also cause the sutures to geons and training surgeons at a senior (fellow) level
cut out. Rest favors a natural repair, with a minimum of involved in this surgery have also been integral to main-
inflammatory reaction, but, also, allows adhesions to form taining the quality of service with increasing numbers
to all raw surfaces. Movement encourages the formation of referrals. Emergency services locally are arranged to
of synovial membranes over the raw surfaces. It would relocate these injuries almost entirely to our unit from
seem that a moderate amount of intermittent movement, the surrounding accident and emergency departments
with as long an excursion as practical, interspersed by rest, of several large peripheral towns and the suburbs of East
will yield the best results. London, which have a combined population of around
Sterling Bunnell MD, San Francisco, 1918 4 million people.
THE PROBLEMS OF PRIMARY FLEXOR
HISTORY TENDON REPAIR
Although Bunnell (1918) wrote on primary repair and Repair of the divided flexor tendon to achieve normal,
early, albeit guarded and intermittent, active mobiliza- or near normal, function is a problem that has not yet
tion, his subsequent experience in the 1920s presum- been solved. Primary flexor tendon surgery remains
ably led to the dictate that flexor tendons divided in the technically difficult, with each result still being uncer-
tendon sheath of the fingers should not be repaired tain. There have been about 20 methods of assessing
primarily but treated by delayed tendon grafting. This flexor tendon results described in the hand literature
practice dominated the practice of flexor tendon surgery since 1950.4 This repeating need to reevaluate our
for 40 years. The past 50 years is notable for the reversal methods of assessment has come not from attempts to
of this policy and recognition that results after primary keep up with improvement of the results over the years
or delayed primary flexor tendon repair, that is within but from a repeating need to quantify how much we
a few days of tendon division, can be better than after should reasonably downgrade our expectations to
delayed tendon grafting, provided early surgery is com- accommodate for the imperfections of our treatment.
bined with early mobilization of the repaired tendons, Over and above the actual technical difficulties of repair-
a change largely pioneered by Verdan,1 Young and ing tendons, we face the complications of rupture and
Harman,2 and Kleinert and colleagues.3 Although there adherence of repairs during healing and these two prob-
is ongoing debate about the details of technique, the lems have dominated thought on this subject for a
central tenet of modern flexor tendon surgery is to repair century. “Spot-welding” by scar adhesions can occur
and move the flexor tendons within a few days of injury. anywhere along the length of a flexor tendon, but it is
While all flexor tendon surgery is complicated, it is a particular problem in the fingers themselves, where
simplest in the newly injured and unscarred digit and the flexors are confined within the tendon sheath in a
the results of correctly rehabilitated primary repairs are system as finely bored as the pistons in an engine. This
likely to be the best attainable. requires that the tendons be mobilized throughout the
125
period immediately after repair when tendon continuity rehabilitation, in respect of simplifying rehabilitation to
depends almost entirely on the strength of the sutures, a level commensurate with the availability of therapy in
as healing of the flexor tendon takes about 3 months. our own unit and likely to be available worldwide. The
Unfortunately, this period is sometimes longer than that results of these, and subsequent reports throughout the
for which the hand can be kept free of activities, or 1990s, confirmed a rupture rate of around 5% when
accidents, liable to snap the repair. In this unit, our using variants of the Belfast regimen,5,26-30 which was
main research interests have been to eliminate rupture similar to that reported at the time by units worldwide
of the tendons while maintaining a policy of enthusias- using the Kleinert regimen.26,29,31-35
tic early active mobilization. The assumption support-
PASSIVE MOBILIZATION
ing this philosophy is that the results will be better with
increasing early movement through the first 5 weeks, The other alternative to the Kleinert technique of mobi-
albeit within the protective environment of a dorsal lization, introduced in the United States by Duran and
splint, provided the sutures hold and rupture does not Houser (1975) and supported by Strickland and Glogo-
occur. Our research over 20 years has aimed at liberating vac (1980), in which the fingers were only mobilized
rehabilitation from unnecessary constraints while, coin- passively by a therapist, or the patient’s other hand,
cidently, reducing the rupture rate after primary repair. was never popular in the United Kingdom as it was
very labor (therapy) intensive, with no seeming advan-
EARLY ACTIVE MOBILIZATION
tages.36,37 A common debate at the time which, to my
The author’s interest in early active mobilization comes knowledge, has never been settled, was whether the
from his training with McGrouther in Glasgow, then tendons actually moved significantly with this regimen
with Brown and Black in Newcastle, prior to arrival in or simply bunched up as the fingers were passively
the Chelmsford unit. The latter part of my training coin- flexed. Another factor that made it unattractive was the
cided with the publishing of an article by the hand fact that the first report included a 14% rupture rate,36
surgeons in Belfast, not far away, in which they described while the second had only 56% good and excellent
mobilization after routine zone 2 flexor tendon repairs results,37 both of which are unacceptable compared with
in a Kleinert traction splinting system but without the published results at the time using the Kleinert regimen
elastic bands (i.e., actively moving the fingers when and, subsequently, the Belfast regimen. The most
flexing as well as when extending).5 This was not actually common use now of the Duran Houser idea is in helping
new as many before had either never used rubber bands Kleinert and Belfast regimens push for better results at
or tried to get rid of them,6-25 although always stressing the extremes of movement.
the use of some variant of suture technique to make the
ST. ANDREW’S EARLY RESULTS—FINGERS
repair stronger, presuming this would be necessary to
withstand early active movement. What the Belfast sur- Our own early results using a two-strand Tajima modi-
geons identified was the fact that the sutures did not fication of the Kirchmayer, or Kessler, core suture19,38 of
need to be stronger to allow early active mobilization 3-0 or 4-0 polypropylene (Prolene), in which the suture
in both directions. The desire to be free of the rubber is tied with a single intratendinous knot, a simple con-
bands had been prevalent for years, largely because of tinuous running circumferential suture of 5-0 or 6-0
the problems arising from the flexed resting position of nylon (Ethilon), or polypropylene, and a modification
the proximal interphalangeal joints in Kleinert traction of the Belfast regimen (Figure 13[B]-1), were reported
and, also, because of the difficulties in managing Klein- in 1994.28 Over a period of 31 2 years, 233 patients were
ert traction. It was also realized that many patients never treated for complete divisions of flexor tendons in zones
actually used the rubber bands to passively flex but 1 and 2 within 24 hours of admission following emer-
simply flexed their fingers actively, even when the bands gency referral. The patients included 58 complete
were correctly tensioned, which was often only for 5 tendon divisions in 58 fingers in 54 patients in zone 1
minutes after leaving the therapy department. This stim- and 259 tendon divisions in 166 fingers in 149 fingers
ulated me to repeat the Belfast experiment. This is in zone 2. A later study extended this survey to include
recorded in an article26 comparing patients mobilized in 508 patients with 840 acute complete flexor tendon
a passive flexion-active extension, or “Kleinert” regimen,27 divisions in 605 fingers treated in the same manner
with patients mobilized in an active flexion-active exten- between June 1989 and December 1996.29 These reports
sion, or “Belfast” regimen,5 after the same repair with a were both focused on the problem of rupture. In the
two-strand modified Kessler core suture and a simple first report, an overall rupture rate of 5.8% was achieved,
running circumferential suture. This study, performed with a rupture rate for zone 2 injuries of 5.4% and for
between 1986 and late 1987 (although only published zone 1 injuries of 6.8%, confirming our belief that the
much later), and the study from Sheffield, UK, reporting regimen was safe for use as an alternative to Kleinert-
the results of their repeat of the Belfast experiment28 type regimens for mobilization of zone 1 and 2 finger
convinced me that this was the way forward for flexor tendon injuries. In the larger survey, after
Chapter 13B: The Chelmsford Experience 127
had also reached the conclusion that argument over

which was the best of the two active regimens was prob-
ably unproductive.
THE 5% RUPTURE RATE
Throughout this period, we were concerned by the
seemingly static state of acute flexor tendon repairs
being reported worldwide in those units publishing
results. With few exceptions, most studies discussing
acute flexor tendon repair and early mobilization
reported a rupture rate of between 3% and 6%. In
studies of less than 100 patients, these figures indicated
A negligible differences in the number of patients with
ruptured tendon repairs in different units in different
countries and continents, using a multitude of suture
techniques and variations of the basic regimens of early
postoperative mobilization. Even taking into account
the variations in methods of assessment used at the
time,4,39-41 the similarity of the results in different studies
showed that an adequately trained, but not necessarily
experienced, surgeon, using a routine repair of divided
flexor tendons, whether using the Kirchmayr/Kessler
core suture or following the technique described by
Tsuge,42,43 and with good therapists, would achieve 70%
to 80% excellent, or good, results and suffer a rupture
rate of about 5%. The only identifiable way of improv-
B ing results in the early 1990s, although having little
effect on rupture rate, seemed to be to increase post
Figure 13(B)-1 Original Billericay/Chelmsford variation of operative supervision, generally believed to be the
the Belfast splint with (A) the fingers resting in extension,
explanation of the excellent results achieved by Chow
and (B) the fingers actively flexing.
and his colleagues, dealing with military personnel.32 It
was thought at the time that this was unattainable in
exclusion of 68 patients who did not complete the civilian practice, until the civilian surgeons and thera-
8-week rehabilitation program, 440 patients with 728 pists in Göteborg, in Sweden, showed that—with a
complete tendon divisions in 526 fingers were assessed. stronger technique of circumferential suturing and a
Twenty-three patients suffered rupture of 28 tendons in more rigorous therapy regimen, incorporating features
23 fingers, an overall rupture rate of 4%. One hundred of the Kleinert, the Duran-Houser, and the Belfast
and twenty-nine fingers with zone 1 injuries had a regimens—this was not true.44 However, this study still
rupture rate of 5% and 397 fingers with zone 2 injuries included two ruptures in 55 repairs: stronger sutures
had a rupture rate of 4%. The good and excellent results and more complex rehabilitation still had not solved
in the final year of the first study, assessed using the first the problem of rupture of primary repairs.
Strickland method of assessment,37 of 62.5% for zone 1
ETIOLOGY OF RUPTURES
injuries and 79.4% for zone 2 injuries confirmed that
these rates of rupture were not being achieved at the Our second article was intended to look further at this
expense of increased protection and poor mobility. seemingly unconquerable rupture rate by examining the
These studies confirmed that early active motion was as third factor in the problem of rupture: the patient. We
safe as any current regimen, with results comparable to analyzed the 23 patients whose primary repairs rup-
those of previous studies in terms of both rupture and tured between 1989 and 1996: two tendons ruptured
mobility in a considerable number of fingers, most during sleep, four patients had an accident that was not
other studies in the literature being much smaller in their fault, and five patients claimed they were exercising
size. At the time, we wrote that we believed the Belfast as instructed at the time of rupture. There were reasons
type of rehabilitation was both simpler and less expen- to doubt the truth of this information in three cases.
sive to maintain than the Kleinert type of rehabilitation However, we gleaned definite information that 11
regimen. We were no longer concerned about the safety patients’ repairs ruptured while using the hand for a
of the Belfast regimen, something, which still persists variety of tasks, ranging from lightweight activities such
elsewhere, particularly in the United States. However, we as lifting a newspaper to unreasonable activities such as
moving a wardrobe. In other words, just under 50% of

the ruptures had occurred as a result of patient noncom-
pliance. This injury mainly occurs at an age and in a
social group for which improving compliance is likely
to be difficult. Nevertheless, all patients have subse-
quently been told the causes and incidence of failure
before 2 months, with need for further surgery, by the
author on the morning after surgery as a routine. In this
era, it would seem reasonable that the patient should
have the likely consequence of noncompliance spelled
out clearly before rehabilitation begins!
The group labeled “uncooperative patients” includes A
adults and children who do not cooperate and small
children who cannot. As adults constitute by far the
greater proportion of patients who sustain flexor tendon
injuries, they are the major concern. In any group of
patients, there will always be rule breakers, those who
resent authority, and those without the discipline to
adhere to the strict rehabilitation regimen demanded
after this injury. Psychological manipulation and more
time are the only direct means we have of improving
the results of these patients and it is debatable whether
we can change this factor more than a little. However,
among this group are some with low pain thresholds, B
poor social circumstances, or a low level of comprehen-
sion and we can, sometimes, help these individuals Figure 13(B)-2 Illustration of the current Billericay/
more, given adequate resources. Chelmsford variation of the Belfast splint with (A) the fingers
resting in extension, and (B) the fingers actively flexing.
Most ruptures in our study occurred with the splint
in place. These tendon repairs might have been pro-
tected from rupture by better mechanical obstruction of
the palm. Rubber bands across the palm have a definite
obstructing action, which was not present in the original we have not had time to research this fully and have
technique of early active motion.5 However, all of our only gone halfway from the original flexed position
patients at that time wore a modified Belfast splint, to a straight wrist splint. The actual therapy regimen
which included wide thermoplastic bars across the open has not changed since that described in 1994 (Box
side of the splint, running from the distal edge back to 13[B]-1).30 The time in the splint remains 5 weeks, fol-
the volar aspect of the wrist and known locally as “beer- lowed by 3 weeks weaning from the splint. Light activi-
can bars” (see Figure 13[B]-1).30 These provided a ties start at 8 weeks, with heavy lifting only after 12
similar obstruction to grasping to that of the rubber weeks. This 5-week period of total protection seems to
bands of the Kleinert splint. Attempts to increase this be in accord with our findings in respect of the timing
feature of splinting and/or attempts to make splints of rupture of repairs.4,28,46
impossible to remove might interfere with rehabilita-
RUPTURE RE-REPAIR
tion and would probably still fail in a proportion of
patients. They would certainly have little effect in those Our interest in the rupture of repairs was taken further
who remove the splint to use the hand for grasping. In in a more recent review of all ruptures of zone 1 and 2
the last five years, the ‘beer-can bars’ on our splints have primary flexor tendon repairs performed in our unit
given way to a sheath of lightly elasticated material between 1989 and 2003.46 Although concern about
which holds the fingers in extension against the dorsal tendon rupture had been one of the major determinants
splint for most of the time, with the sheath being rolled in the evolution of the various techniques of tendon
down into the palm for exercising of the fingers (Figure suture and early postoperative mobilization throughout
13[B]-2). the past 10 years of the twentieth century, there was still
almost no information in the literature about the etiol-
THE SPLINTED WRIST POSITION
ogy of tendon rupture.28,47 The intention of our 2006
While accepting the work of Savage that the best posi- report46 was to analyze in further detail (1) the reasons
tion for the wrist in respect of minimum firing of both for tendon rupture during the early mobilization period
the flexor and extensor muscles is in slight extension,45 and (2) the outcome of immediate re-repair, with a view
Box 13(B)-1 The St. Andrew’s Early experienced in the emergency theater, was certain that
Active Mobilization Regimen (1994) venting was correct and necessary in many cases. The
discussion of “venting” is taken further and, I believe,
Week 1—Discharged from hospital when pain controlled
by simple oral analgesics, patient able to do dressings to its logical conclusion in other chapters of this book
and achieving full extension to splint and active flexion and in two review articles in the recent past.48,49 Analyz-
to 25% of full flexion. Instructed to carry out 10 active ing the sites along the tendon sheath were tendon injury
flexion and extension exercises per hour. commonly occurs, Dr. Tang has described appropriate
pulley releases for each injury and accords this process
Week 2—Seen by surgeons and therapists. Full extension of pulley “venting” equal importance as the use of stron-
to splint and active flexion to 50% of full flexion. Ten ger repairs in increasing the margin of safety of early
exercise repetitions per hour. Passive flexion exercises active mobilization.49 We believe the results of zone 1
started. primary flexor tendon surgery are equally dependent on
judicious venting of the A4 pulley.50
Weeks 3 and 4—Seen weekly by therapists only. Full
extension to the splint and progression to full range of STRONGER REPAIRS
active flexion as soon as possible (usually achieved by
the end of week 3). Ten exercise repetitions per hour. At that time, increasing the strength of our sutures
Passive exercises. Ultrasound started if necessary in seemed likely to be the most effective preventative of
week 3. tendon rupture in this group of patients. The ability of
tendon sutures to withstand the forces of early move-
Week 5—Seen by surgeons and therapists. Splint removed, ment is, probably, the most fundamental limitation to
except at night and when risk to the hand (e.g., in what can be achieved by early movement of primary
crowds). Wrist extension started, with fingers relaxed at flexor tendon repairs by any technique. This has been
first. the second prong in the mechanical way forward since
Harmer, in Boston, in 1917, introduced a flexor tendon
Weeks 6 and 7—Seen weekly by therapists. Progression
core suture that he believed was sufficiently strong
to full range of movements of wrist and fingers.
to resist rupture and commenced immediate free
Week 8—Splint discarded completely. Passive extension movement of the fingers postoperatively without any
exercises and dynamic extension splinting started if nec- splints,14 and, in the same year, Kirchmayr presented
essary. All but heavy activities allowed, including driving. his stronger suture, with the same purpose in mind.38
Return to work (except heavy manual workers). Our work on ruptures had convinced us, like others,
that we needed stronger sutures to continue aggressive
Weeks 10 to 12—Progressive return to heavy work by early active mobilization without this 5% rupture rate.
week 12. In the recent past, there had been numerous studies,
mostly experimental, describing a variety of means by
which this might be achieved. The suture changes can
be split, broadly, into those modifying the core suture
to identifying whether this should be an invariable and those modifying the circumferential suture. Our
policy, whenever possible. Discussion of our views on examination of the patients who had ruptured our
the management of ruptures of primary repairs of flexor repairs simply confirmed what everyone had assumed
tendons in zones 1 and 2 in the fingers are considered and highlighted a need to move toward clinical applica-
further in Chapter 19. tion of the laboratory research into stronger sutures and
identify which of these suture modifications was suffi-
VENTING THE PULLEYS
ciently practical to be used in clinical practice. Regret-
In retrospect, a factor in achieving these results that tably, few of the laboratory experiments of suture
received no attention at the time but was, possibly, of configurations of the nineties have since been pro-
significance was that, from the earliest of the studies in gressed to clinical studies by their authors.
which I was involved, it had been routine to “vent”
ZONE 2 AS A BLACK BOX
pulleys as necessary to allow repairs to travel through a
full range of excursion on passive movement of the Throughout the 1990s, we were not entirely happy with
finger after repair without impinging on the A2 or A4 the zone 2 model for investigation of the problem
pulleys. The conviction that this “made sense” followed further, although zone 2 had become the accepted
a private conversation as a trainee in the mid-1980s at testing ground for mobilization techniques—and for
the Derby Hand Course with Dr. Strickland. At the time, individual units! It was obvious that most studies
Lister and others were quite adamant that these pulleys reported less than 50 cases and that it was difficult to
should remain entirely intact. Dr. Strickland seemed collect sufficient cases of zone 2 injuries alone in a
less certain and I, knowing the problems I personally single unit to make a series. As a result, three things had
happened. The first was that the total number of studies However, we realized that the higher rupture rate might
remained small. The second was that most studies were make the FPL a good clinical model to test new sutures
small in themselves and, in many cases, too small to be and suture techniques. Using this model, we were able
of scientific value. The third was that the available to examine some of the new suture configurations being
numbers were too small to analyze exactly what was described in laboratory experiments in a series of
going on in the “black box” we called zone 2, as all the studies,52-54 which are described in Chapter 16. Although
results had to be put together to achieve a publishable these reports elaborate an increasingly safer technique
total. Zone 2 is far from homogeneous: there are eight for dealing with division of the FPL tendon, they were
permutations of tendon injury in what we call a zone 2 undertaken largely to examine possible ways forward in
injury. We ignore the three partial injuries and put all respect of the finger flexors. Ultimately, these clinical
those with at least one complete tendon division into experiments with the divided FPL achieved zero rupture
the black box marked “zone 2 injury”: there are actually rates using two different suture techniques (a combina-
five different injuries in this box. In the 1990s, we tion of a four-strand core suture55 and a Silfverskiöld
looked at this briefly and it looked as if there might be circumferential suture56) and Tang’s three Tsuge suture
differences in results for different injuries, with a com- repair.57,58
plete flexor digitorum profundus (FDP) and partial FDS To us, this confirmed the likelihood that increase
division faring worse with our current mobilization in suture complexity would successfully reduce the
than any other combination of tendon lacerations. rupture rate during early mobilization after repair of the
Another fact that we ignore is that fingers with both finger flexor tendons and, like most others, we have
tendons cut with the finger flexed have two repair lines gone the way of increasing suture complexity. After a
that are a long way apart when the finger is extended dalliance with more complex circumferential sutures,
and only come together in flexion. By contrast, when we came to the conclusion that these were too compli-
the finger is cut in extension, the tendon repairs remain cated for trainees, who are likely to operate on these
together all the time throughout flexion and extension. cases both in our own unit and worldwide. The combi-
It might reasonably be expected that the results would nation of a four-strand core suture and a complex cir-
differ between these two injuries. A third fact about cumferential sutures also gave rise to concern about the
zone 2 that we ignore in putting all the results together bulk of the repairs and possible problems of resistance
is that the sheath is not a cylinder of unchanging topog- to movement of the repaired tendon.59 This was sug-
raphy along the length of the zone. This is equally true gested by a slight drop in the excellent and good results
of zone 1.50 So, the tendon environment is varying in this group of FPL repairs compared with previous
quite dramatically along both zones. Unfortunately, the results. However, this problem was small. Of more sig-
circumstances in respect of analysis of zone 2 injuries nificance was the fact that these complex sutures are
have not changed. The fact that it is difficult to collect more difficult to use in clinical practice. In our FPL
even 50 acute zone 2 finger flexor injuries in a single studies, this led to the use of Tang’s triple Tsuge suture
unit makes for an ongoing problem for those research- technique57,58 for FPL repair, as this is a less complicated
ing new suture configurations in this field: if only 2 or suture technique.
3 in every 50 repairs rupture, then it takes a long time
STRONGER SUTURES—DILEMMAS
before we can be sure that any innovation has achieved
anything. Four-strand repairs have become the order of the day
for zone 1 and 2 finger flexor repairs at present in
THE FLEXOR POLLICIS LONGUS MODEL
Chelmsford. However, there remain two causes for
The flexor pollicis longus (FPL) tendon had been concern as we all move to more complex suturing. Reex-
researched very little over the previous 30 years, but the amination of the clinical series reported over the past
extensive literature of an earlier era (1937 to 1960) 25 years identifies the study in 1989 by Savage and Risi-
clearly identified a much higher rupture rate after tano,25 which introduced Savage’s six-strand suture and,
primary repair than that of the finger flexors.51,52 Sur- with it, the search for the ideal multistrand suture that
geons at that time recognized this and debated whether would have the strength of the Savage suture but be
to repair this tendon by insertion of a tendon graft or simpler to put into the tendon, as the series with the
by lengthening the proximal tendon.52 When we lowest rupture rate of one rupture in 31 zone 2 fingers
reported our results of zone 1 and 2 finger flexors in and 2 thumbs (3%). The next lowest rupture rate was
1994,30 we also looked at the FPL results and found a in our series from Chelmsford in 1999, which reported
rather horrific rupture rate of 17% in 30 thumbs when 17 ruptures after zone 1 and 2 primary flexor tendon
mobilized in the Belfast regimen of active flexion/active repairs in 397 fingers (4%).31 This much larger series of
extension of the repairs. At that time, we recommended cases were repaired with only two-strand Kirchmayr/
that this technique of mobilization not be used in its Kessler core sutures and simple running circumferential
present form after repair of the long thumb flexor. suturing, making the hard evidence for improvement of
clinical results by more complex core suturing question- patients, the distribution of hand casualties, availability
able. A very interesting laboratory study from Manches- of therapists, the training of more hand surgeons and
ter may identify a further, previously unknown, factor therapists, and so on. Regrettably, our government and
that is concerning.60 It showed that even a single suture immediate administrators, in keeping with many others,
passed through a tendon significantly affected the teno- have reduced facilities for treatment of this group of
cyte cell population of the tendon around it. The suture patients progressively over the past few years. Neverthe-
foreign body caused the tenocytes to move away. So, less, it is probably still true to say that, globally, the
perhaps, we are unwittingly making tendon repair number of good hand units continues to increase, with
breakdown more likely as we put in more sutures! the result that primary flexor surgery is being carried
out to higher standards in more places now than 20
ECONOMIC FACTORS
years ago.
It is possible that the current small but constant remnant
CONCLUSION
of repairs that rupture relates more closely to factors
such as the degree of cooperation of the individual However, given that 10 of every 100 patients undergoing
patient (discussed earlier) and the ability of surgical surgery in a good unit will still either experience rupture
units to maintain a continuing high quality of surgical of the repair or require a tenolysis to free stuck tendons,
repair and rehabilitation. In the United Kingdom, as in we should not be satisfied with current practice. While
most parts of the world, the availability of a high level we are still obliged to call results “excellent” when they
of expertise to this patient group remains a medicopo- are only 85% of normal,37 the search for better treat-
litical battle over unit budgets, accommodation for ment should continue!
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42. Tsuge K, Ikuta Y, Matsuishi Y: Intra-tendinous tendon suture suture tendon repair, J Hand Surg (Br) 17:699–703, 1994.
in the hand—a new technique, Hand 7:250–255, 1975. 58. Tang JB, Gu YT, Rice K, et al: Evaluation of four methods of
43. Tsuge K, Ikuta Y, Matsuishi Y: Repair of flexor tendons by flexor tendon repair for postoperative active mobilisation,
intratendinous suture, J Hand Surg 2:436–440, 1977. Plast Reconstr Surg 107:742–749, 2001.
44. Silfverskiöld KL, May EJ: Flexor tendon repair in zone II with 59. Kubota H, Aoki M, Pruitt DL, et al: Mechanical properties of
a new suture technique and an early mobilization program various circumferential tendon suture techniques, J Hand Surg
combining passive and active flexion, J Hand Surg (Am) (Br) 21:474–480, 1996.
19:53–60, 1994. 60. Wong JK, Cerovac S, Ferguson MW, et al: The cellular effect
45. Savage R: The influence of wrist position on the minimum of a single interrupted suture on tendon, J Hand Surg (Br)
force required for active movement of the interphalangeal 31:358–367, 2006.
joints, J Hand Surg (Br) 13:262–268, 1988.
C The Mayo Clinic Experience
Robert R.L. Gray, MD, and Peter C. Amadio, MD
OUTLINE traumatic tendon injury who desired surgery after an

explanation of the risks, benefits, and alternatives is
This chapter presents the indications, methods, and offered the procedure. In addition to the tendinous
postoperative care for flexor tendon repair that are injury, associated bony and neurovascular injuries are
followed at the Mayo Clinic. repaired as indicated. Typically, this included primary
neurorrhaphy with or without a nerve conduit and arte-
Flexor tendon injuries in the hand, especially in zone 2, rial repair if both proper digital arteries are injured. If
have proved to be a difficult clinical entity to manage, soft tissue coverage is lacking, this is addressed first,
with humbling results in many cases. Advances in repair though often recently through microsurgical techniques
technique, suture material, and rehabilitation have that have allowed skin cover and tendon repair to be
improved outcomes over historic controls, but the accomplished simultaneously.
typical result remains a finger with motion that is less
OPERATIVE TECHNIQUES
than normal.
Many basic science studies have looked at various There are currently 12 hand surgeons at the Mayo Clinic.
biomechanical aspects of tendon repair, as well as Although there are some shared practices, each surgeon
biologic aspects of tendon healing and adhesion manages his or her own patients. As time has progressed,
formation.1-4 Manipulation of these biologic processes, there has been a trend toward repair techniques with
in an effort to speed healing, limit scarring, or both, greater numbers of core suture strands.2 Currently, for
has come the fore of tendon repair research, as flexor digitorum profundus (FDP) repairs in zone 2,
biomechanical gains are providing relatively modest many surgeons use a double Tsuge repair of 3-0 Supra-
clinical improvements in comparison with initial mid, with a running peripheral suture of 6-0 Prolene
breakthroughs.5 (Figure 13[C]-1). Others prefer a double modified Pen-
In our research in flexor tendon repair, we similarly nington repair of 3-0 or 4-0 Ticron, Supramid, or, more
investigated methods of improving healing as well as recently, Fiberwire, again with a running suture of 6-0
improving motion and lowering work of flexion. Pri- Prolene in the epitenon (Figure 13[C]-2). Less com-
marily, in our lab, we have focused on lowering gliding monly, some surgeons use the Strickland six-strand
resistance by improving repair methods and by the addi- technique, a Tajima modification of a Kessler two-strand
tion of bioactive compounds to limit scar formation technique, or a cruciate four-strand technique.13 We find
and decrease friction. The results are encouraging and the locking loops of the Pennington repair to be particu-
will direct future efforts by serving as benchmark and larly effective, especially when they are tightened sepa-
model for comparison of new techniques.6-9 rately prior to tying the knot. For those who use it, the
Examination of our clinical experience with flexor speed of the Tsuge repair is an attraction, especially in
tenorrhaphy reveals some emerging trends, but more cases of polytrauma.
significantly, illuminates some limitations in our ability While a running simple epitendinous suture of 6-0
to address these injuries. Without dedicated prospective Prolene is most commonly used to tidy the FDP repair,
data collection, much of the outcome information is occasionally a running locked suture is used for this
not standardized. In addition, as part and parcel of purpose. In cases with transections of the FDP and both
the patient population who experience these injuries, slips of the flexor digitorum superficialis (FDS), we
frequently young men, not always steadily employed seldom repair all three tendons. Most commonly, one
and often, at our center, being referred from a great slip of FDS (the smaller or less easily repaired side, if
distance for surgery, with aftercare provided closer to there is a difference) is excised to minimize bulk at the
home, compliance, and follow-up have been variable. repair site.10-12 When all three tendons are repaired, the
What follows is a resume of our current approach to most common repair of the FDS slips is a single figure-
these problems. of-eight stitch.
In all repair techniques, efforts are made to keep any
INDICATIONS
surface knots and suture loops limited, especially on the
Our indications for primary flexor tenorrhaphy are rela- volar surface. If the knots and loops are not buried in
tively simple and inclusive. Any patient with an acute the repair site (modified Kessler), they are positioned
133
A B
C D
E F
G H
Chapter 13C: The Mayo Clinic Experience 135
Figure 13(C)-1 A, Nerve cutting box is used to freshen and prepare tendon edge. B, Tendon edges are opposed without
tension. Note the repaired FDS slip beneath and the Keith needle used to prevent the proximal FDP tendon stump from
retracting. C, The lateral third of the distal stump is grasped with the first stitch. D, The stitch is locked through the looped
end. E, The next throw is begun just distal to the grasping loop, taking care to center it within the tendon. The loop should
be pulled securely flat prior to completing the repair. F, The second Tusge stitch is placed in the same fashion. One side of
the suture loop is cut at this point. G, Approximately one-third of the tendon is grasped in the next throw. The two suture
ends are now tied for each suture loop to complete the repair. H, Completion of core suture repair. Note the absence of
gapping or bunching at the repair site. An epitendeninous repair is then performed at this point with fine (6-0)
nonabsorbable monofilament suture.
A B
C D
Figure 13(C)-2 A, Proximal stump is entered for modified

Kessler repair. Note that the tendon is grasped within
the stump so that the surface is not damaged by the
forceps—a “no-touch” technique. B, A grasping stitch is
completed and a transverse stitch is placed across the
midsubstance of the tendon. C, Another grasping stitch
exiting the proximal stump completes that side. The
grasping loop on the distal stump is thrown. D, The distal
stitch is completed. The strands are tied together so that
the knots are completely within the repair site. E, The
repair is completed and a running epitendinous repair is
E
completed with 6-0 nylon suture.
laterally (Tsuge) so that they do not interfere with extension with IP flexion and wrist flexion, MCP exten-
tendon gliding.14 Lateral position of the suture knots sion, and IP extension. In this protocol, which allows
has been shown to lower substantially the work of passive pull both proximally and distally in zone 2,
flexion. Less frequently, knots of the Tsuge repair are the MCP joints are separately mobilized by alternating
buried in slits made in the tendon substance. this modified synergistic pattern with the normal syner-
Neurovascular injuries are quite common, occurring gistic motion of wrist extension with fist alternating
in nearly two-thirds of our patients. Typically, all proper with wrist flexion and finger extension. For patients who
digital nerves are repaired when feasible, but usually live close to the clinic, biweekly or every-other-day
isolated proper digital artery injuries are not repaired. therapy visits are scheduled in the first few weeks post-
Mangled hands of course must be managed separately, operatively. The patient is seen by the surgeon at a
often with delayed repair or secondary reconstruction. minimum of once weekly. Patients who live at a dis-
tance pose more problems, because it is difficult to
POSTOPERATIVE CARE
supervise their rehabilitation.
The postoperative protocol used nearly universally in
SUMMARY
our historical series was the modified Duran protocol
as described in the Indiana Hand Center guide to hand The experience with primary flexor tendon repair at the
therapy.15 While this is still preferred by several in our Mayo Clinic is probably typical of most institutions.
group, others now prefer early protected mobilization These are a challenging clinical entity in isolation and
with synergistic wrist motion flexor tendon rehabilita- more often than not are accompanied by a neurovascu-
tion protocols.16 Some prefer the use of hinged dorsal lar injury that further hinders the results. Repair tech-
splints that, while effective, are expensive to fabricate. niques have tended to increase the number of core
Patients are usually seen for their initial visit 3 to 6 suture strands over time, as well as those that use a
days postoperatively.17 The initial postoperative dressing locking stitch as opposed to a grasping stitch. Most
is usually a well-padded dorsal splint with the wrist in surgeons are now choosing a four-strand technique with
30° of flexion and the metacarpophalangeal (MCP) a trend toward the Tsuge being the repair of choice.
joints in flexion, with the interphalangeal (IP) joints Epitendinous stitches are nearly universally used with a
blocked at 0°extension. Using IP motion is allowed in 6-0 nonabsorbable monofilament suture. When both
this splint, although some prefer full immobilization slips of the FDS and the FDP are transected in zone 2,
for the first few days postoperatively. This initial dress- one slip of the FDS is often, but not always, resected to
ing is removed at the first postoperative visit, and the reduce bulk at the repair site.
wounds are examined. A protective dorsal-blocking Flexor tendon injuries remain an important clinical
thermoplastic splint is then usually fabricated. Depend- problem due to their frequency and complex manage-
ing on the level of swelling present in the digits, the ment. As repair techniques and rehabilitation protocols
standard Duran passive motion protocol is initiated at have improved, increasing attention is being placed on
this point or, if swelling is minimal, place-and-hold biologic interventions to improve healing and decrease
exercises are begun immediately.18 Several surgeons adhesion formation. Improvements in results will likely
now use the modified Tanaka method, in which the be seen once these adjunctive methods leave the labora-
synergistic motion includes alternating wrist and MCP tory and enter the clinical sphere.
References
1. Momose T, Amadio PC, Zhao C, et al: The effect of knot loca- and gelatin-modified intrasynovial allografts: study of a
tion, suture material, and suture size on the gliding resistance primary repair failure model, J Bone Joint Surg (Am) 92:2817–
of flexor tendons, J Biomed Mater Res 53:806–811, 2000. 2828, 2010.
2. Momose T, Amadio PC, Zhao C, et al: Suture techniques 6. Akasaka T, Nishida J, Araki S, et al: Hyaluronic acid dimin-
with high breaking strength and low gliding resistance: exper- ishes the resistance to excursion after flexor tendon repair: An
iments in the dog flexor digitorum profundus tendon, Acta in vitro biomechanical study, J Biomech 38:503–507, 2005.
Orthop Scand 72:635–641, 2001. 7. Sun Y, Chen MY, Zhao C, et al: The effect of hyaluronidase,
3. Yang C, Zhao C, Amadio PC, et al: Total and intrasynovial phospholipase, lipid solvent and trypsin on the lubrication
work of flexion of human cadaver flexor digitorum profundus of canine flexor digitorum profundus tendon, J Orthop Res
tendons after modified Kessler and MGH repair techniques, 26:1225–1229, 2008.
J Hand Surg (Am) 30:466–470, 2005. 8. Zhao C, Sun YL, Kirk RL, et al: Effects of a lubricin-containing
4. Tanaka T, Amadio PC, Zhao C, et al: Gliding characteristics compound on the results of flexor tendon repair in a canine
and gap formation for locking and grasping tendon repairs: model in vivo, J Bone Joint Surg (Am) 92:1453–1461, 2010.
A biomechanical study in a human cadaver model, J Hand 9. Yoshii Y, Villarraga HR, Henderson J, et al: Speckle tracking
Surg (Am) 29:6–14, 2004. ultrasound for assessment of the relative motion of flexor
5. Zhao C, Sun YL, Ikeda J, et al: Improvement of flexor tendon tendon and subsynovial connective tissue in the human
reconstruction with carbodiimide-derivatized hyaluronic acid carpal tunnel, Ultrasound Med Biol, 35:1973–1981, 2009.
Chapter 13C: The Mayo Clinic Experience 137
10. Paillard PJ, Amadio PC, Zhao C, et al: Gliding resistance after tendon repair: An in vitro biomechanical study, J Hand Surg
FDP and FDS tendon repair in zone II: An in vitro study, Acta (Am) 34:87–92, 2009.
Orthop Scand 73:465–470, 2002. 15. Cannon NM: Diagnosis and Treatment Manual for Physicians and
11. Paillard PJ, Amadio PC, Zhao C, et al: Pulley plasty versus Therapists. Upper Extremity Rehabilitation, ed 4, Indianapolis,
resection of one slip of the flexor digitorum superficialis after Indiana, 2001, Hand Rehabilitation Center of Indiana, p 296.
repair of both flexor tendons in zone II: A biomechanical 16. Zhao C, Amadio PC, Zobitz ME, et al: Effect of synergistic
study, J Bone Joint Surg (Am) 84:2039–2045, 2002. motion on flexor digitorum profundus tendon excursion,
12. Zhao C, Amadio PC, Zobitz ME, et al: Resection of the flexor Clin Orthop Relat Res 396:223–230, 2002.
digitorum superficialis reduces gliding resistance after zone II 17. Zhao C, Amadio PC, Tanaka T, et al: Short-term assessment
flexor digitorum profundus repair in vitro, J Hand Surg (Am) of optimal timing for postoperative rehabilitation after flexor
27:316–321, 2002. digitorum profundus tendon repair in a canine model, J Hand
13. Strickland JW: Flexor tendon injuries: II. Operative technique, Ther 18:322–329, 2005.
J Am Acad Orthop Surg 3:55–62, 1995. 18. Boyer MI, Strickland JW, Engles D, et al: Flexor tendon repair
14. Silva JM, Zhao C, An KN, et al: Gliding resistance and strength and rehabilitation: state of the art in 2002, Instr Course Lect
of composite sutures in human flexor digitorum profundus 52:137–161, 2003.
D The Nantong Experience
Jin Bo Tang, MD, Jun Tan, MD, and Ren Guo Xie, MD
OUTLINE underlying these methods. Our current methods are

illustrated in more detail next.
In this chapter, we review our experience and the
current methods of flexor tendon repair (in zone 2 in Anesthesia and Skin Incisions
particular) in our hand surgery service. We discuss We mostly use axillary regional block anesthesia when
methods of tendon repair and postsurgical rehabilita- performing flexor tendon repairs in the digits and palm.
tion, particularly procedures that may be critical to General anesthesia is used in some patients with exten-
optimal tendon function. sive wounds or with injuries involving multiple sites. A
tourniquet is applied to the upper arm in all patients to
Our hand center is a part of the university hospital ensure a bloodless operation field. We prefer a Bruner’s
system located in Nantong, serving about 7 million zigzag incision to expose the tendons (Figure 13[D]-1).
people in the Yangtze River Delta area and neighboring A midlateral incision is rarely used in primary or delayed
industrial and metropolitan cities, Suzhou and Shang- primary tendon repair. For a clean-cut injury, the inci-
hai. Injuries involving tendons that are seen at our clinic sion usually does not exceed 3 cm longitudinally, a
vary from simple clean-cut injuries to major limb or length of a field just sufficient for surgical tendon repair.
digital amputations. Three kinds of injuries—tendon We include the laceration in the skin as a part of this
divisions in the digits and palm, tendon lacerations incision in primary tendon repair. In delayed primary
in the wrist or forearm, and tendon injuries in digital repair, the skin wound is closed primarily and is healed
amputations—undergo primary, delayed primary, or in 1 or 2 weeks, and we do not usually include the
secondary repairs, respectively. Tendon transfer opera- original wound into the incision.
tions are performed for late functional reconstruction Lacerations through the skin and sheath are either
following nerve injuries or neurological disorders. There transverse or oblique and, in most cases, do not overlie
are 150 to 200 operations for these tendon injuries per- the site of tendon transection. The tendon ends can
formed annually, which constitutes 7% to 10% of the mostly be brought into vision by passive flexion of the
total number of operations in our hand service. During digits. For zone 1 tendon injuries, the proximal flexor
2011, the total number of operations for hospitalized digitorum profundus (FDP) tendon end does not
patients in our hand center was 2132 (day surgery cases retracted far proximally and flexion of the metaphalan-
not included), of which tendon injuries in the digits and geal (MP) and proximal interphalangeal (PIP) joints
palm, or dorsal hand, accounted for 68 cases (3.2%); usually can bring the tendon end into the wound. In
tendon injuries in the wrist, 44 cases (2.1%); and digital some cases, a separate incision in the proximal part of
(or limb) replantations, 84 cases (3.9%). Established as the digit or palm is necessary to find the retracted
an independent department with 100 beds devoted tendon. For zone 2 tendon injuries, those in the proxi-
solely to surgery of the hand and upper extremity, our mal part of the fingers, in particular, often retract into
unit has the capacity to hospitalize patients for 10 days the palm (see Figure 13[D]-1). During surgery for
to 2 weeks after tendon surgery. This system allows the delayed primary repair, about half of our zone 2 repairs
patients to be cared for and supervised within the hospi- require an additional incision to find the retracted prox-
tal as they initiate early active digital motion exercises. imal tendon end; an incision at the distal palmar crease
Our treatment of tendon injuries in wrist and distal usually reveals the tendon end (see Figure 13[D]-1).
forearm and those associated with digital replantation
surgeries are discussed in other chapters. We presented Zone 2 Flexor Tendon Repairs
here our methods of flexor tendon repairs in the digits Incisions in the Sheath and Pulleys
and palm. By pulling the skin and subcutaneous flaps created by
the Bruner incision with retractors, the flexor sheath is
CLINICAL METHODS
exposed. The major annular pulleys (the A1, A2, and A4
Table 13(D)-1 summarizes the methods that we have pulleys) are easily recognizable and are distinguished
used over past decades, as well as the conceptual changes from the remainder of the sheath by their thickness and
138
Chapter 13D: The Nantong Experience 139
Table 13(D)-1 Clinical Methods Used Over the Past Two Decades in Our Unit
1989–1994 The First Period
Tendon: repaired with two-strand modified Kessler, double, or six-strand looped suture methods.1,2
Sheath: closure, leave it open without repair, or interposing sheath graft reconstruction.2
New methods/concepts used: (1) Zone 2 subdivisions for recording sites of tendon lacerations and
analysis of treatment results; (2) stronger surgical repair methods.1-3
Investigations: (1) clinical results of double or multiple looped suture repairs;1 (2) analysis of clinical
outcomes in zone 2C;2,3 (3) results of sheath enlargement plasty.
Results: Zone 2C had the worst outcomes compared with other parts of zone 2, and 4% repair ruptures
occurred even with strong (six-strand) surgical repairs.1,3
1995–2002 The Second Period
Tendon: repaired with double or six-strand looped suture methods.
Sheath: closure, leave it open without repair, or interposing graft reconstruction.
New methods/concepts used: partial A2 pulley release or release of the entire A4 pulley.
Investigations: examination of finger movement after partial release of the A2 or A4 pulley.4
Results: release of a part of the A2 pulley or the A4 pulley, does not lead to clinically noticeable tendon
bowstringing, when other annular pulleys are intact.4
2003–2011 The Third Period
Tendon: repaired with a modified six-strand looped suture method (M-Tang repair).5
Sheath: leave it open without repair in most cases, but avoid opening sheath-pulley >2 cm.
Pulley: in cases when tendons are cut in or just distal to major pulleys, the A2 pulley is vented partially,
or the A4 pulley is vented entirely.5,6
New methods/concepts used: (1) a modified six-strand suture repair,5,6 (2) an early passive-active
motion regimen.6 and (3) definitions of length and limit of judicious pulley-sheath release.6
Subjects of interest: pulley-release may be a key to reducing resistance to tendon.
Loosely supervised early active motion may be feasible and safe clinically.
Investigations: examination of the cases treated with pulley-venting, strong core suture, and the new
passive-active motion regimen.
Results: Combination of stronger surgical repair, proper treatment (release) of the major pulley, and a
combined passive-active motion regimen favors near-ideal recovery.
Proper release of the constrictive part of the pulleys probably is most critical.
appearance as condensed, white fibrous structures. The pulley. In other words, some part of the sheath is pre-
thin annular pulleys (the A3 and A5 pulleys) are not served between the A2 and A3 pulleys.
seen clearly and, sometimes, appear indistinguishable In many other cases, the tendons are cut at the loca-
from the adjacent sheath. The cruciform pulleys are tion of one, or more, of the strong annular pulleys (e.g.,
usually not identifiable. However, the location of the A3 a little distal to the A2 pulley, through the A2 and/or A1
pulley has little variation and is almost always at the pulleys and in the vicinity of the A4 pulley). We cut the
level of the PIP joint. It is not necessary to identify the entire A4 pulley and a major part of the A2 pulley
A5 pulley or any of the cruciform pulleys. around tendon repair sites, while leaving the synovial
The injured tendons are approached by incisions in part of the sheath and the other pulley structures intact.
the sheath-pulleys at different sites according to the When the tendons are cut slightly distal to the A2 pulley,
level of the tendon laceration. When the level of tendon within zone 2B, we open the sheath longitudinally for
laceration is judged to be in the vicinity of the PIP joint, 1 cm distal to the A2 pulley and also open the distal
we incise the synovial sheath longitudinally, or even half of the A2 pulley (see Figure 13[D]-3). When repair-
excise a portion of it, to create a window in the sheath. ing the tendon at the distal edge, or in the distal part,
When the tendon is cut at the level of the A3 pulley, we of the A2 pulley, we cut open a part of the sheath distal
open the sheath between the A2 and the A3 pulleys. The to the A2 pulley together with the distal two-thirds of
A3 pulley can be incised as well, but the incision should the A2 pulley.
not extend distally to the A4 pulley. A part of the syno- When repairing a tendon under the middle or proxi-
vial sheath is kept intact distal to the PIP joint. When mal part of the A2 pulley, we cut open the proximal
the cut is between the PIP joint and the A4 pulley, we two-thirds of the A2 pulley. Because the excursion of the
frequently have to include the A3 pulley in the sheath FDP tendon within this part of zone 2 is usually about
incision, but preserve the sheath proximal to the A3 2 cm, the lengths of release of the A2 pulley and the
C
A
Figure 13(D)-1 Skin incisions for primary or delayed primary repairs: A, skin incisions used in the hand to exposed the
injured tendons; B, Bruner’s zigzag incision is used to expose the wound in delayed primary repair; C, additional small
transverse incision proximal to the tendon cut level may be required if the proximal end of the tendon retracted proximally.
The retracted tendon end is lead through the synovial sheath tunnel by insertion of a silicone tube (or a catheter) to
approximate the distal tendon stump.
adjacent sheath referred to above are, in most cases, suf- ends are temporarily fixed using a needle proximal to
ficient to free the tendon repair from restriction by the the laceration site, but the distal tendon ends do not
pulley, or catching on rims of the remaining parts of the usually need temporary fixation because passive flexion
pulleys, during movement of the finger joints through of the DIP joint during surgery by an assistant easily
a full range of motion. brings the ends into the center of the operation field.
Tendons lacerated proximal to the A2 pulley are the If the tendon ends are untidy, the tendon ends are
least difficult to access. They can be approached through trimmed using a pair of scissors or a scalpel. In delayed
an incision in, or excision of, the sheath proximal to the primary repairs, the tendon ends are usually covered by
A1 pulley, or an incision over the A1 pulley. Extending granulation tissues or collagen clots. These are removed
the skin incision proximally may help expose the to refresh the tendon ends. Then, the core sutures are
retracted tendon end. placed into the tendon when the two tendon ends pulled
together tightly, with the distal joints of the finger held
Tendon Repair Techniques in flexion by an assistant. Looped sutures carried on a
After making the incisions in (or excisions of) the sheath single needle are used for the core suture. In repairing
and pulleys, the tendon lacerations are exposed. The the FDP tendons, we currently use a modified six-strand
distal tendon ends are brought into the operation field repair, performed by passing two looped 4-0 sutures
by flexion of the distal interphalangeal (DIP) joint and through the tendons. A U-shaped repair is created first
the proximal tendon ends are brought into the field to connect the tendon ends using one looped suture,
by, either flexion of the metacarpophalangeal and PIP and the second looped suture is then placed at the
joints, or through a separate proximal incision (see center of the tendon, making a six-strand M-shaped
Figure 13[D]-1), as illustrated. The proximal tendon core suture repair. For the flexor digitorum superficialis
A
B
B
C
D
C
D
F
Figure 13(D)-2 Summary of repair methods we use
in repairing flexor tendons: A, modified Kessler repair;
B, cruciate repair; C, U-shaped repair; D, cross-lock repair
(a four-strand repair made with one needle carrying two
E
separate double suture strands); E, Tang technique of three
Tsuge suture repairs; F, M-Tang repair; the two-strand Figure 13(D)-3 Illustrations of how to make a six-strand
Kessler repair is now used in repairing tendons in zone 5. In core suture using a looped suture repair (M-Tang method),
repairing the tendons, in zones 1 to 4, four- or six-strand which forms an M-shaped configuration within the tendon.
repairs are used. C, D, Two four-strand repairs developed in
our unit.
We complement the core repair with simple periph-

eral suturing, with a simple running peripheral suture
(FDS) tendons, and some parts of the FDP tendon (such or a few interrupted sutures most often being used.
as in zone 1 or in the little fingers), we use only a four- Peripheral sutures serve to smooth the junction site of
strand U-shaped repair using one looped suture. the two tendon ends. We are able to put six to eight
Figure 13(D)-2 summarizes the methods we use in loops of the running stitch in tendons of larger diameter
repairing tendons in zones 2 to 5. A two-strand Kessler using 6-0 monofilament nylon. However, adding even
repair is used only sometimes in repairing tendons cut the simplest peripheral suture to the dorsal aspect of the
in zone 5. We currently do not use two-strand repairs tendon is difficult in some cases. Instead, we sometimes
in zone 2 or 3. Figure 13(D)-3 details our method of add a few interrupted sutures on the palmar and dorso-
making a six-strand M-shaped repair. The method of lateral aspects of the tendon. Nevertheless it also seems
placing three Tsuge looped sutures is illustrated in Figure reasonable not to supplement the repair with peripheral
13(D)-4. This technique was simplified to the M-shaped sutures when a strong six-strand core suture is used.
repair (see Figure 13[D]-3) that we currently use. Although we have no experience with “core-suture only”
Box 13(D)-1 Critical Technical Points
In Approaching the Tendon:

1. Small sheath incision and preservation of majority of the
sheath
2. A sheath incision less than 2 cm is allowed, which may
include a part of the A2 pulley (up to two-thirds) or
entire A4 pulley.
3. At least a portion of the A2 pulley should be maintained,
and loss of more than two annular pulleys should be
particularly avoided.
4. Additional small incisions in the sheath may be neces-
sary to find the retracted tendon ends. Avoid a lengthy
incision of the sheath, which will damage the pulley
function.
A
In Suturing the Tendon:
1. Use strong repairs: a four- or six-strand core suture
repair, or a strong suture material.
2. Ensure sufficient length of core suture—about 0.7 to
1.0 cm in either tendon stump.
3. Add some tension to the repair site by tightening the
core suture.
4. Only simple (or no) peripheral sutures are needed when
a strong core suture is used.
is the easiest and most effective way to provide the

tendon repair with greater strength. Maintaining suffi-
B cient length of the core suture purchase ensures that the
suture is anchored reliably in sufficient amount of the
Figure 13(D)-4 Two operative views showing the methods tendon substance that will not soften during the early
of placing three looped sutures into the tendon (the Tang period after repair. Otherwise, the core suture may slip
method). The pictures show a case repaired by the authors
or be pulled out, particularly when the tendon ends
in 1989. This repair method was replaced by the M-shaped
soften after repair.
repair in the early 2000s.
Adding slight tension to the repair site can greatly
decrease the chances of gapping of the tendon repair.
The tendon repair site may look a little bulky when
tendon repairs, this simplifies the surgery and does not proximal pull of the muscles is eased by temporary
appear to decrease tendon strength. needle fixation of the proximal tendon during surgery.
In performing core sutures, we are careful to (1) use However, this is not the case after release of the tempo-
multistrand (four- or six-strand), rather than conven- rary fixation. Adding such a baseline tension to the
tional two-strand, repairs; (2) ensure the length of core repair sites produces appropriate tension after surgery,
suture purchase is greater than 0.7 cm (0.7 to 1.0 cm in as this counteracts the tension of the muscles proxi-
most cases); and (3) add some tension to the repair site mally during active motion. If tension has not been
by tightening the core suture, producing a roughly 10% added to the repair site, the repair may overstretch and
shortening of the tendon segment encompassed by the gap after surgery during active digital mobilization. We
core suture (Box 13[D]-1). We avoid making a loose, or consider that adding a little tension is as important as
tension-free, tendon repair. We no longer use conven- adding a peripheral suture to resisting gaps between
tional two-strand repairs in repairing tendons in the tendon ends. With appropriate pretension of the repair
fingers or palms. site, the chance of gapping, or the size of the gap, can
We believe that the above three points are crucial to be decreased, thereby lowering the risk of catching of
the strength of a surgical flexor tendon repair. These the repair sites on any edge of the sheath.
three measures may be particularly necessary when one
considers that the tendon ends usually become softened Treatment of the FDS Tendon
after injuries and tensioned during active tendon The FDS tendon bifurcates under the middle part of the
motion, before biological healing is accomplished. A2 pulley and only injury in the proximal part of the
Increasing the number of strands across the repair site finger can produce a complete FDS tendon laceration.
The FDS tendon does not always need repair. A partial and locally excised to accommodate tendon movement
laceration of the FDS tendon does not need repair at all. in the other (see Figure 13[D]-6), which was an end-
Complete laceration of the FDS tendon does not require to-end repair of the FDP tendon 3 weeks after rupture
surgical repair if the FDP tendon is intact. For complete of the primary repair of the tendon. In both cases, the
FDS and FDP tendon lacerations, least problematic is A2 pulley was either vented or partially excised.
repair of the FDS tendon cut proximal to the bifurca-
tion. Injuries to this part of the FDS tendon can be Treatment of the FDP and FDS Tendons
treated almost identically to those of the FDP tendon, in the Palm (Zone 3)
except that the FDS tendon is flatter and does not Injuries in zone 3 involve the flexor tendons to several
accommodate more than four suture strands. The bifur- fingers in most cases, and are often complicated by
cating part of the FDS tendon (the segment within zone nerve and vascular injuries. However, the treatment of
2C) is much more difficult to treat. We use two sepa- the flexor tendons in the palm is not as difficult as in
rated Tsuge sutures (a two-strand repair in each FDS zone 2, because no sheath or pulleys are present in this
slip) to repair FDS injuries in zone 2C. In repairing the region and the proximal tendon ends are not retracted
FDS tendon within zone 2B, we use a variety of tech- too proximally. In making core and epitendinous sutures
niques, including repair with a tendon-to-bone junction in the FDS and FDP tendons, we follow the principles
(as for reattachment of the FDP tendon to the distal and methods that are described for zone 2 injuries.
phalanx) if the residual distal stump is very short, or Repair of both the FDP and FDS tendons is usually
repair with a two-strand core suture for each slip if the possible and less difficult than in zone 2. We use either
distal stump is long enough. When one slip is com- a four- or a six-strand core suture, using looped sutures
pletely cut, but the other is uninjured, repair may not together with a simple running peripheral suture. Both
be necessary. Quite often, we find that one, or both, slips the superficialis and profundus tendons are repaired in
of the bifurcated FDS tendon are partially severed. In almost all cases, when no soft tissue loss is present.
this situation, we make a judgment according to the Nevertheless, it should be particularly noted that com-
length of the distal stump and the extent of the tendon pound injuries with nerve and vascular injuries, or soft
division. The partial cut is left untreated, or one or two tissue loss are quite frequent, and repair of the nerves
stitches are placed, to prevent triggering of the FDS and, in some cases, vascular anastomoses, are integral
tendon during tendon movement. to these surgeries.
Repair of the FDS tendon together with the FDP
tendon may favor gain of the strength of finger flexion Treatment of the FDP Tendon in Zone 1
and prevent hyperextension of the PIP joint. Neverthe- In our clinic, we see patients with an injury to the FDP
less, observations indicate that these benefits may not tendon in the distal part of the digits (zone 1 injury)
be substantial. Repair of only the FDP tendons in our much less frequently than injuries in zones 2 and 3.
patients have not led to a significant loss of power of Treatment of FDP tendon lacerated about 1 cm proxi-
finger flexion, and daily use of the hand has not been mal to the insertion is the same as for the FDP tendon
affected after repair of only the FDP tendon. Develop- in zones 2 or 3. For the tendon laceration in which end-
ment of hyperextension of the finger joints usually is to-end repair is not possible, we advance the tendon to
not notable. During surgery, after FDS tendon repairs, anchor it to the distal phalanx with mini-anchors
we noted that the repaired FDS tendon is sometimes (Figure 13[D]-7) or reinforced suture repairs (such as
entrapped by the narrow pulleys and the repair decreases placement of two cross-stitch repairs, one on each of the
motion of the FDP tendon. Therefore, in primary repairs, two FDP tendon bundles, using Fiberwire, or, rarely,
we only repair the completely lacerated FDS tendon passing sutures through a transverse drill hole through
when such repairs appear not to decrease or impair FDP the distal phalanx).
tendon gliding. Repair of both FDS and FDP tendons is The conventional pull-out repair method was used in
more difficult when the surgery is delayed by 1, or more, our clinic for many years and had problems of trauma-
weeks after injury. When the cut is at, or just distal to, the tizing the nail in a significant proportion of the cases.
A2 pulley (zones 2C and 2B), we find it almost impos- The pull-out repair method is arguably not an ideal
sible to repair both tendons after such a delay. The FDS method. Reattachment of the FDP tendon to the phalanx
tendon retracts far proximally, and it is hard to pass both using mini-anchors or to the residual distal stump with
tendons under the A2 pulley, or even a residual part of reinforcement with two cross-stitches to create a strong
this pulley. We usually leave the FDS tendon unrepaired, tendon junction appears as efficacious as the pull-out
or excise it locally, in delayed primary tendon repair. repair. Because the distal end of the FDP tendon does
Figures 13(D)-5 and 13(D)-6 illustrate two cases of not glide, reinforcing suture repairs that might lead to
delayed primary repair of the FDP tendon with the six- tendon bulkiness elsewhere cause no problem of tendon
strand repair method. The partially injured FDS tendon function here. With currently available repair materials
was left unrepaired in one case (see Figure 13[D]-5) (such as Fiberwire), we can easily achieve a strong repair
A B
C D
E F
Figure 13(D)-5 A case of delayed primary repair in zone 2C. A–D, The partially cut FDS tendon was left unrepaired. The FDP
tendon was repaired with the M-Tang method. The distal two-thirds of the A2 pulley was vented. E and F, Postoperative
digital extension and flexion.
that allows protected early active finger motion after one flexor tendon is present; (2) the FPL tendon is
repairing the distal FDP tendon. The opened sheath is among the largest in diameter in the digits; (3) the
not repaired in zone 1. pulleys in the thumb are not as broad, narrow, and rigid
as in the fingers; and (4) the flexor sheath is relatively
Treatment of the FPL Tendon short. Surgical repairs of this large flexor tendon are
A number of facts should be considered in flexor pollicis perhaps the easiest. Nevertheless, its gliding path in the
longus (FPL) tendon repairs within the thumb: (1) only hand is unique, and flexion force transmitted along this
A B
C D
E F
Figure 13(D)-6 A to D, A case of repair of a ruptured tendon 3 weeks after rupture of the primary repair of this tendon. The
FDS tendon was excised locally during the repair and the A2 pulley was shortened. E and F, Postoperative digital extension
and flexion.
tendon is perhaps the highest, subjecting the repaired access the tendon. Keeping two pulleys amply maintains
FPL tendon to greater danger of rupture when moved tendon function.
actively. Consequently, a strong surgical repair is par- It is common to find the proximal tendon end
ticularly necessary. This tendon can easily accommodate retracted, under the thenar muscles or in the carpal
a six-strand repair, which we use regularly to repair it, tunnel, particularly with delayed repair. Because there is
even in children (Figure 13[D]-8). no sheath over the FPL tendon in the thenar muscles,
We preserve at least two pulleys in the thumb, and we usually attempt to find the retracted FPL end without
most often we have to incise one annular pulley to incising the muscles, but by retracting the thenar muscles
to expose the FPL tendon underneath. When the FPL

tendon retracts more proximally, sometimes a small
incision is made just distal to the transverse carpal liga-
ment to locate the FPL tendon.
Flexor Tendon Repairs in Children

Flexor tendon injury in children (i.e., patients under 12
years of age) is less common than in adults. Among our
cases, flexor tendon injuries in children account for
about 15% of the acute tendon injuries treated. Func-
tional recovery of children with flexor tendon injuries is
usually satisfactory. In approaching the tendons, we take
particular care not to violate the annular pulleys, which
are usually not as rigid as in adults, and pulley venting
Figure 13(D)-7 A mini-anchor was used to anchor the is usually not necessary. However, we do not usually
tendon to the distal phalanx in distal zone 1. This method repair FDS tendons in children, as such repairs (particu-
has recently replaced the pull-out suture method in our larly in the bifurcated part of the FDS) are difficult, or
practice. even impossible, in many cases. The FDP tendon is
repaired with either a four-strand repair using one
looped suture to make a U-shape repair, or two looped
sutures to make a double Tsuge repair. In patients over
A C
B D
Figure 13(D)-8 Repair of a lacerated FPL tendon in a 9-year-old child with a six-strand M-shaped repair.
7 or 8 years old, we sometimes use a six-strand repair; to disrupt; (4) we start motion exercise 3 days (or as late
4-0 looped nylon suture is used in all cases. as 5 days in cases with remarkable edema in the hand
We perform primary repair of the tendon in children or with soft tissue repair as well) after surgery, and we
whenever possible, or try to carry out the repairs within perform only four or five sessions of exercise each day,
2 or 3 days of injury, without a long delay, because their rather than require patients to move hourly; and (5) we
wounds heal quickly. After a long delay, the tendon ends emphasize full extension of the fingers in the early
may retract quite far proximally, due to inability to weeks after surgery when tendon healing is still weak,
prevent contraction of the flexors. We treat flexor tendon and then shift our emphasis to active flexion in later
injuries in young patients older than 12 years identically weeks, when tendon healing is stronger.
to those in adults. At postoperative 2 1 2 weeks, we change the protective
position of the hand and shift the emphasis to active
POSTOPERATIVE REHABILITATION
flexion. We encourage partial active digital flexion first,
We currently adopt a combined active and passive finger and then proceed to full active flexion of the fingers
flexion regimen in postoperative care, except in (1) the when no resistance is perceptible. Regarding the timing
patients younger than 12 years old; (2) the patients with of change of the hand position, we consider that tendon
flexor division(s) associated with fractures; and (3) in healing strength has only started to increase at that time
rare instances, in which the patients are judged to be and that immobilization of a joint for 2 1 2 weeks would
unable to cooperate. not cause contracture of soft tissues of the joint. Never-
A few changes can be noted between our current theless, we also believe that such a change in protective
practice and those described by other surgeons: (1) we hand position may be made any time between 2 1 2 weeks
do not use rubber band traction because we believe that and 3 weeks.
it contributes to extension deficits of the fingers; (2) we The details of our method is as follows: the hand
emphasize that active motion should proceed after mul- is protected in a dorsal thermoplastic splint, with the
tiple cycles of passive motion in each session of exercise, wrist in slight flexion (20° to 30°), the MP joints in
to reduce the resistance to the active movement; (3) we slight flexion, and the interphalangeal joints in exten-
do not encourage full active flexion in the early weeks sion (or minimal flexion), for the first 2 1 2 weeks (Figure
after surgery, as tendons with marked flexion are easiest 13[D]-9). We do not encourage patients to move the
First 2.5 weeks Exercise of full

finger extension
Wrist flexion
Full passive flexion Active finger flexion-limited range Active finger flexion-limited range
Figure 13(D)-9 The protective position of the hand and methods of rehabilitation in the first 2 12 weeks after surgery. Full
finger extension is emphasized, but only partial active finger flexion is encouraged. Inclusion of thumb in the splint is not a
necessity, but it prevents unintentional pinch action of the hand.
finger during the first few postoperative days, because

the hand is painful, edema is more prominent and, Second 2.5 weeks
more importantly, adhesions have not yet developed.
Decreasing the number of days of motion decreases the
chance of repair rupture.
The First Period (Surgery to

2 1 2 Weeks Postsurgery)
Exercise starts at 3 to 5 days after surgery. Before each
episode of active digital flexion, the finger is passively
flexed 10, or more, times to lessen the overall resistance
of the finger joints and soft tissues—a “warming up”
process—after which active flexion should encounter
lower resistance. The patient is then instructed to flex the
fingers actively with gentle force 20 to 30 times during
each morning, noon, evening and before sleep session,
up to the range with which the patients feels comfort-
able. The motion range is usually from full extension to
one-third, or half, of the full flexion range, although this
may even increase to two-thirds of the full range if this
can be achieved with ease. Active flexion over the full
range is not encouraged, unless it can be achieved very
easily. Patients may increase the number of motion epi-
sodes up to five or six per day, but we do not require
patients to move hourly. In this first period, full active
Figure 13(D)-10 The protective position of the hand and
extension is particularly encouraged and the fingers are
methods of rehabilitation in the second 2 12 weeks after
passively stretched against the splint if full extension is
surgery. Full active digital flexion is encouraged and
not achieved. Prevention of extension deficits rather emphasized.
than full active flexion is a major goal during this period.
The Second Period (2 1 2 to

5 Weeks Postsurgery) encouraged through the first 5 weeks, with separated
At 2 1 2 weeks, a new thermoplastic splint is made, with active flexion of the two interphalangeal joints.
the wrist splinted at 30 degrees of extension (Figure After 5 weeks, full active finger flexion is encouraged.
13[D]-10). Finger flexion, both passive and active, This can be started earlier if flexion in the final part of
is emphasized during this period. The patients are the flexion range is judged to have less resistance. After
instructed to actively flex after a passive warm-up, as 5 to 6 weeks, the splint is discarded or used only at
earlier. Active flexion up to the mid-range is required as night. Patients can return to normal use of the finger
a minimum and is encouraged further, up to two-thirds, from 8 weeks.
or the full, range of flexion, depending on the patient’s The mechanical basis of the protocol design is synergy
ability to perform resistance-free motion. Digital flexion between wrist and finger actions: with the wrist flexed,
from the mid-range to the full range, in particular over full finger extension is achieved with less tension on the
the final one-third of the flexion range, is usually carried flexor tendons, while full finger flexion can be achieved
out passively if the fingers encounter resistance. Our with less tension on the repairs with the wrist extended.7,8
studies show that finger flexion over the final one-third Active finger flexion to full flexion encounters much less
of the full range of motion range encounters 5 to 10 resistance when the wrist is extended than when the
times more resistance than in the previous two-thirds of wrist is flexed. This, effectively, avoids overload of the
the range of motion. Thus, ruptures are much more repaired tendons. However, we do not encourage
likely in this final part of the flexion range. Ensuring full maximal active flexion of the finger when the exercise
passive flexion, to prevent dorsal ligament tightening meets remarkable resistance, but instead suggest incor-
and extensor tethering, and encouraging finger flexion porating active finger flexion up to the mid-range and
actively, while avoiding flexing the finger forcefully over passive motion from mid- to maximal flexion into indi-
the final flexion range, are guidelines during this second vidual motion cycles.
period. Our experience indicates that repair rupture can be
If both FDS and FDP tendons are repaired at the minimized using this exercise regimen, which is aimed
same level, differential FDS and FDP motion exercise is at avoiding placing high levels of tension on repairs
while achieving sufficient active motion, together with of the A2 pulley. The zone 2C tendon repairs were asso-
release of the sheath and pulleys and an increase in ciated with the worst recovery of function.
surgical repair strength. In a series of later cases, repaired with a six-strand
For children, we immobilize both the wrist and the repair by experienced surgeons with venting of either a
MP joints in slight flexion after surgery for 3 weeks, and part of the A2 or the entire A4 pulley when necessary,
a protective splint to immobilize the patient for an addi- 91% of repairs in 36 fingers were given a Strickland
tional 1 week or 10 days is usually prescribed. Active rating of good or excellent,5 and the results of zone 2C
flexion exercise of the fingers starts in the fourth week. repairs were no different from those in other parts of
For an incomplete tendon cut and repair, we immo- zone 2. No tendon ruptures were noted. Since 2005, we
bilize the hand in a protective position for 2 weeks, and have used a modified six-strand repair (referred to as the
early active finger motion is initiated immediately after “M-Tang” method in our department because of its
surgery. Patients return to normal use of the hand 4 to M-shaped configuration inside the tendon) using looped
5 weeks after surgery. suture to repair the FDP tendon.6 The restricting part of
For FPL tendon repair, we immobilize the thumb any annular pulley was released through either a midline
with the MP joint flexed at about 45°, the interphalan- incision or partial excision, when necessary. For clean-
geal joint slightly flexed, and the wrist in a resting posi- cut tendon injuries in the thumb, index, middle, and
tion (extension of about 20°). Active thumb flexion ring finger, or those wounds that could be converted to
starts 2 or 3 days after surgery. Full active flexion is clean-cut wounds, the current authors—all experienced
encouraged if no noticeable resistance is encountered. in primary tendon surgery—have achieved good or
The hand is brought out of the splint to assume wrist excellent results in almost all cases. We had less satisfac-
flexion when active extension is ordered to ease the tory recovery of function (graded as “fair”) in some
tension. The splint is removed 5 weeks after surgery, and tendon repairs in the little finger, and in fingers with
normal thumb motion is initiated in week 6 or 7. more extensive loss of soft tissues and untidy tendon
For tendon repairs with fixation of a fracture, we lacerations (occurring in the palm area). When injuries
prescribe early motion exercise of the fingers only when in the palm involve tendon injuries to three or more
the fixation is stable, and motion is initiated 10 days to digits, not all digits are likely to achieve good or excel-
2 weeks after surgery. The protective splint is applied for lent recovery. Good or excellent recovery of function was
4 or 5 weeks. With screw fixation of bones, or placement achieved in 84% of primary and delayed primary repairs
of mini-plates on the lateral aspect of the shafts of pha- in the thumb, fingers, and palm, including those with
langes or metacarpus, early active finger flexion is pos- borderline indications. We note that the expertise level
sible after edema subsides and preliminary fracture of the operator exerts a significant influence on the out-
healing is achieved. In cases of simultaneous repair of comes. When treated primarily by junior surgeons (resi-
the vascular structures, we delay motion exercise for 7 dents) who fail to consult with the senior attending
to 10 days after surgery. In cases with tension-free nerve surgeons, the outcomes are hardly able to reach “excel-
repairs, we do not usually modify our motion regimen lent.” However, when treated by experienced surgeons,
or timing of exercise initiation. adhering to established principles of treatment, and
given a clean-cut wound (or a wound that can be con-
OUTCOMES
verted into a clean-cut wound after débridement and
Our results have been separately presented in several trimming), good or excellent recovery is fairly predict-
reports.1-5 Of particular note, our first series of cases with able, and almost all the cases recover good or excellent
use of four- or six-strand repairs had a rupture rate of function, except in some little fingers. No repair rupture
4%. In 1994, we reported the results of using double was found in this period. Careful examination also
or multiple looped suture tendon repairs in 51 fingers revealed no perceivable tendon bowstringing after the
(46 patients).1 By the White criteria, 76.5% of cases had venting or shortening of the A2 or the A4 pulley (Figure
the good or excellent results, with 4% of the finger 13[D]-11).
repairs rupturing. In an earlier report, we analyzed the Factors that worsen the results roughly by “one grade”
results of a series of 72 tendon injuries in 54 fingers in include (1) tendon repairs in a finger with a fracture;
43 patients by subdivisions. Tendon injuries in zone 2C (2) tendon repairs in the little finger; (3) crush injuries
(16 fingers), which constituted one-third of the injuries in fingers or the palm causing extensive tissue damage;
in zone 2, had only 69% good or excellent results by and (4) tendon repairs by less experienced surgeons.
Strickland criteria, compared with 84% good or excel-
DISCUSSION
lent results in the other three subzones of zone 2.2 The
tendons in this series of cases were repaired with one of Mastery of anatomy and careful dissection. Repair of
the four methods: two-strand modified Kessler, two- flexor tendon injuries is a perfect test of the technical
strand Tsuge, four-strand double Tsuge, or six-strand and intellectual competence of a hand surgeon. To
triple loop-suture method, without purposeful release achieve satisfactory functional recovery is a challenge for
A B C
Figure 13(D)-11 Examination to confirm the absence of perceivable tendon bowstringing during active finger flexion (A and
B) and resisted finger flexion (C) in a patient following venting of the A2 pulley up to two-thirds of its entire length.
even an experienced hand surgeon. Detailed anatomical six-strand core suture repairs provide strong surgical
knowledge and meticulous dissection and repairs are repair. Although a number of factors affect the strength
essential to both the success of the surgery and later of surgical repairs, not all exert a clinically significant
functional recovery. Optimal surgical outcomes (rather influence. Among the factors that most notably influ-
than just completed surgeries—“success of surgery”) ence strength are (1) adequate strength of the suture
require us to master the anatomy of the flexor tendon materials, (2) increased number of repair strands, or
system with great precision. When we begin a flexor alternatively larger caliber sutures, and (3) secure anchor
tendon repair, we should have a clear mental picture of of sutures to the tendon. Increasing the number of
the location of each of major pulleys and its length and stands across the repair site is the most straightforward
diameter, and which parts of the sheath and pulley are way to achieve stronger and safer repairs. Maintaining a
the narrowest. Knowing the locations of the A2 and A4 sufficient number of sutures passing through the repair
pulleys is only the minimal requirement. sites, ensuring adequate purchase length of all sutures,
Most surgeons do know the nomenclature, number, and secure tendon-suture junction sites ensure a strong
and rough distribution of the pulleys in the fingers, but repair. We recommend a strong surgical repair (four-
frequently do not master the anatomical details of these strand or beyond) be always used. Suture configuration
pulleys to the extent of knowing their lengths and exact within the tendon does not alter the strength very drasti-
locations. These details are imperative to appropriate cally, given an equal number of suture strands passing
exposure of the tendon, release of the resistance to across the repair site. For this reason, given the available
tendon motion after repair and prevention of tendon four-, six-, or even eight-strand repairs described, sur-
bowstringing. The two most essential anatomical points geons actually have ample freedom to choose any one
are (1) the A2 pulley, of length about 1.5 to 1.7 cm in when implementing a strong repair.
the adult middle finger, spans the proximal two-thirds Currently, we use four- or six-strand repairs in repair-
of the proximal phalanx and the middle and distal part ing the tendon, and believe that an eight-strand repair
of this pulley is the narrowest; and (2) the A4 pulley is is probably not necessary, although it is a valid option.
much shorter, of a length about 0.5 to 0.7 cm, and is The FPL tendon and the FDP tendon in the adult index,
located in the middle part of the middle phalanx. It is middle, and ring fingers can easily accommodate four-
also narrow. We advise that surgeons, junior surgeons or six-strands repairs. The FDP tendon in the little finger
in particular, take time to review relevant diagrams, or and the FDS tendon in all fingers may easily accom-
textbooks, before surgery. During surgery, the A1, A2, modate a four-strand repair. All repairs using four-strand
and A4 pulleys appear as easily recognizable white (or greater) core sutures provide sufficient strength for
dense bands. early active digital motion.
Stronger surgical repair is always recommended. A Release of the pulleys as a means to reduce “inter-
great number of repair techniques are available cur- nal” resistance to tendon motion. Free tendon gliding
rently. Two-strand core suture repairs (using either 4-0 without repair rupture and restrictive adhesion remains
or 3-0 sutures) provide weak tendon repairs. Four- or the ultimate goal of flexor tendon repair. Such free
tendon motion may be achievable through implemen- distinct from those in the other fingers, the anatomical
tation of strong surgical repair, and decrease of tension features and biomechanics of the tendon system in the
over the repaired tendon by decreasing the resistance to little finger merit more thorough study, and different
tendon motion. Release of the narrow, constricting approaches to treatment may be necessary. The anatomy
pulleys that may present a “constricting band” during should be further investigated and treatment be further
tendon motion may be an effective way to release resis- documented, to provide repairs specifically designed for
tance to tendon motion internally within the finger. A the little finger.
pulley release takes only a few minutes, and multistrand Not repairing the FDS tendon facilitates return of
surgical repairs add only 10 to 15 minutes to the total function in cases of delay or cases of unfavorable
time of surgery, as compared to a conventional surgical conditions. Repairing both the FDS and FDP tendons
repair. Proper release of the pulleys and use of stronger under favorable wound conditions may produce the
surgical repairs are much easier and more economical most ideal results—in terms of digital motion, strength,
than achieving increase in delicacy and expertise of and prevention of PIP joint hyperextension. However,
hand therapy. A pulley-release procedure or a multi- repairing all structures is not always possible and may
strand repair cost less than 20 minutes of surgery, but not be a necessity for ordinary use of the hand. In most
elaborate rehabilitation costs much greater efforts over delayed repair cases, or with wounds that include some
weeks. degree of soft tissue loss, we suggest repairing the FDP
We suggest consideration of such simple procedure tendons alone. For injuries to both the FDS and FDP
as releasing the critical parts of the pulley to decrease tendons in the A2 pulley area, we recommend repair of
the resistance to tendon gliding internally. We believe only one slip of the FDS, or removal of both slips of the
that pulley release procedures and increasing repair FDS tendon.
strength are two effective measures for achieving safe Repair of only the FDP tendon usually produces ade-
postoperative active tendon motion, and releasing the quate function for patients, restoring normal daily use
critical part of pulleys eventually allows tendon motion of the hand. A more complicated surgery sometimes
free from major internal resistance during active tendon risks finger motion; adhesions formed between the
motion. tendons and pulleys can render the tendons totally
Tendon repairs in the little fingers are worth par- immovable under unfavorable wound conditions.9,10
ticular attention. The little finger is shorter and smaller Loosely supervised hand rehabilitation—a future
than the other digits. Its tendons and sheath have a direction? This is a topic we would like to raise, but,
much smaller diameter than those of the other fingers. thus far, have insufficient clinical data to recommend it
We have noted poorer outcomes of flexor tendon repairs for widespread use. In recent years, in a number of cases,
in the little finger. Not surprisingly, injuries in the little we were confident that we had reduced resistance to
finger are more difficult to treat, given that (1) the tendon gliding by venting critical parts of the pulleys,
cross-sectional area of the tendon is only 60% to 70% and early active motion after surgery was only loosely
that of the other fingers, (2) the diameters of the pulleys supervised. We prevented the patients from active finger
are quite small, and (3) the tendons are bent in multi flexion against external resistance but did not instruct
ple directions during finger flexion, gliding over paths patients to follow the number of exercise sessions and
not only bent palmarly, but also bent medially. The sequence of passive-active motion in each session.
tendons in the little finger are subject to major bending Rather, the patients were allowed rather large or nearly
forces in at least two directions; the tendons in other full range of active finger flexion with greater freedom
fingers are also subject to bending in two directions, but if they could move their fingers actively with ease. These
not as extensively as the little finger. An additional patients experienced no repair rupture and returned to
difficulty in carrying out repairs in the little finger is normal function.
the narrow space available in which to perform the We cannot yet generally recommend this “loosely
surgery. The distance between each pair of annular supervised regimen,” but we do bring it to the attention
pulleys is much shorter, and accessing the lacerated of surgeons and therapists with regard to an eventual
tendon through an incision in the sheath is much more goal of simplifying rehabilitation regimens and allow-
demanding technically and requires precise dissection. ing more freely active motion in selected individuals in
Openings of the sheath are frequently insufficient to whom surgeons have confidence. We urge surgeons and
allow surgery, requiring extension of these windows in therapists to expand our experience and explore the
the sheath. usefulness of simplified motion regimens. Of course,
In the little finger, we have adopted repair methods such a loosely supervised exercise program can only
similar to those used for other fingers thus far, but these be safely established when relatively resistance-free
methods are often more difficult to use and are not tendon motion is ensured internally, no resistance to
always adequate for the little finger. As we begin to finger flexion is applied externally, and the tendons have
consider injuries in the little finger as qualitatively undergone a strong surgical repair.
References
1. Tang JB, Shi D, Gu YQ, et al: Double and multiple looped 6. Tang JB: Indications, methods, postoperative motion and
suture tendon repair, J Hand Surg (Br) 19:699–703, 1994. outcome evaluation of primary flexor tendon repairs in Zone
2. Tang JB, Shi D: Subdivision of flexor tendon “no man’s land” 2, J Hand Surg (Eur) 32:118–129, 2007.
and different treatment methods in each sub-zone. A prelimi- 7. Tanaka T, Amadio PC, Zhao C, et al: Flexor digitorum pro-
nary report, Chin Med J (Engl) 105:60–68, 1992. fundus tendon tension during finger manipulation, J Hand
3. Tang JB: Flexor tendon repair in zone 2C, J Hand Surg (Br) Ther 18:330–338, 2005.
19:72–75, 1994. 8. Savage R: The influence of wrist position on the minimum
4. Tang JB, Shi D, Shen SQ, et al: An investigation of morphol- force required for active movement of the interphalangeal
ogy and function of flexor tendons in zone IIC in the hand joints, J Hand Surg (Br) 13:262–268, 1988.
and treatment of flexor tendons, Chin J Surg (in Chinese) 9. Amadio P, An KN, Ejeskar A, et al: IFSSH Flexor Tendon Com-
37:639, 1999. mittee report, J Hand Surg (Br) 30:100–116, 2005.
5. Tang JB: Clinical outcomes associated with flexor tendon 10. Elliot D, Barbieri CH, Evans RB, et al: IFSSH Flexor Tendon
repair, Hand Clin 21:199–210, 2005. Committee Report 2007, J Hand Surg (Eur) 32:346–356, 2007.
E The Singapore Experience
Alphonsus K.S. Chong, MBBS, MRCS (Ed), MMed (Orth), FAMS,
Beng-Hai Lim, MD, and Yeong-Pin Peng, FRCS
OUTLINE 1978 showing its efficacy in our setting.3 At that time,

the practice was to perform the Bunnell technique repair
We used looped sutures to make a six-strand core using a 4-0 wire suture with a 6-0 epitendinous suture.
suture repair supplemented with running epitendi- Rehabilitation consisted of a dynamic protocol using a
nous suture in repairing the lacerated flexor digitorum dorsal splint and rubber band traction. Currently, our
profundus tendon. After surgery, we performed passive practice involves the use of a strong surgical repair fol-
flexion and active extension exercise. In our initial lowed by early protective motion protocol. With special-
experience, in 32 fingers that underwent this tendon ist hand surgeons performing primary tendon repairs
repair, there were 41% excellent, 41% good, and 16% and dedicated hand therapists supervising rehabilita-
fair results according to the revised Strickland criteria. tion, our clinical results are similar to results obtained
The rupture rate was 3% (1 of 32 digits). One case with elsewhere.
a fair result underwent tenolysis, with no improve- Despite this, our results mirror that of other centers
ment after the procedure. Our results in more recent in that there are still a significant proportion of patients
case series with this technique are similar to our initial with poor clinical results. Beyond the ultimate result,
results. there is also a large socioeconomic burden in terms of
time off work and other opportune costs.4 This is due
Flexor tendon injuries are common work injuries in to the long rehabilitation time required before the
Singapore because there is a large manufacturing and patient returns to having function of the injured hand.
construction sector in our economy. Home accidents Improvement of the results following flexor tendon
and assault with sharp objects are other common mech- injury has long been an important research focus in
anisms of injury. Singapore’s small physical size means Singapore. In 1974, Dr. Chacha described his results
that our population has easy access to specialist care by with free composite autologous tendon grafts in pri-
hand surgeons following the initial injury. In addition, mates and humans5 as a method to combat the problem
compliance with postoperative rehabilitation by hand of adhesions following flexor tendon injuries and
therapists is high because of this accessibility. As a result, primary repair. We have been trying to improve the
acute flexor tendon injuries that require primary flexor outcome of primary repair of the injured flexor tendon
tendon repairs form the bulk of our clinical experience and to reduce adhesion formations after primary or
with flexor tendon injuries. Secondary or late repairs secondary tendon surgery since then.
requiring staged procedures are uncommon in our Our research strategy to address the limitations with
practice. current repair and rehabilitation techniques has been
Flexor tendon injuries occur in isolation or in asso- on two fronts: (1) improving the strength of the repair
ciation with other injuries like fractures, nerve, and to enable early active motion and shorter rehabilitation
vessel injuries. In more serious injuries, such as amputa- and (2) research into biological methods to improve
tion, a strong tendon repair is also critical to allow early the results of flexor tendon healing. One of our aims in
mobilization and return of digital function.1 Great the primary repair is to enable a splint-free flexor tendon
improvements in the results following primary flexor repair and rehabilitation.6 A more robust repair will
tendon repairs have been obtained with better repair allow splint free, unprotected use of the hand during
techniques and rehabilitation protocols.2 the rehabilitation phase. This will reduce the costs of
Our community’s practice pattern for flexor tendon such an injury and possibly improve the ultimate
repairs has closely paralleled the experience of estab- outcome. We collaborated with our Finnish colleagues
lished hand centers worldwide. The practice of the to evaluate different materials, such as nickel-titanium
primary repairs started taking off in the 1970s, and Pro- alloy, to assess its suitability for use in flexor tendon
fessor Robert W.H. Pho published his experience in repairs.7
153
A variety of approaches have been taken to address technique, a 90-cm length of polypropylene can be used
the biologic aspects of primary tendon healing. The to make three 15-cm strands of looped suture. This
ability to increase the rate of healing or to improve allows the surgeon to capitalize on the advantages of a
the ultimate quality of the healed tendon would be loop suture with minimal effort.
extremely beneficial to patients. Our research in this In the original description of the technique,11 the
area has focused largely on the use of cells, primary repair used two strands of looped suture for the repair.
bone marrow–derived mesenchymal stem cells (bMSCs), We have since modified the technique to use only one
to enhance primary flexor tendon healing. Mesenchy- looped suture per repair. This results in a repair with
mal stem cell marrow–based therapies show promise in six-core sutures to readily allow for dynamic postopera-
improving outcomes in a tendon injuries.4 Our interest tive rehabilitation. For larger flexor tendons in the wrist,
in this area began with the finding from our collabora- an 8- to 10-strand repair may be possible.
tors that these bMSCs could be used to enhance the The technique needs all the usual requisites of a good
histological and biomechanical properties of a tissue- tension-free repair. The dorsal half of the epitendinous
engineered tendon graft.8 We applied this strategy to a repair can be done first to allow good approximation of
primary tendon healing model in the rabbit Achilles the tendon ends. The core suture repair itself is then
tendon with encouraging results.9 We are currently per- performed as shown (Figure 13[E]-1).
forming the experiments using bMSCs to promote the The flexor digitorum superficialis (FDS) tendon is
healing in a digital flexor tendon model. repaired with a simple Tsuge loop suture technique if it
The strength of a primarily repaired flexor tendon is is near the insertion or in zone 2C with the knot on the
correlated with the number of core sutures. We favor six dorsal side. If the FDS tendon is cut more proximally
core sutures in digital flexor tendon repairs. While this (i.e., it lies on superficial to the deep flexor tendon), a
may increase the bulk at the repair site, the gliding six-strand repair is made.
characteristics are not compromised.10 Biomechanical
testing of six-strand repair techniques has also been Postoperative Care
favorable. A human cadaveric tendon study demon- The patient is often discharged the same or next day if
strated that the six-strand repair technique using a loop the injury was uncomplicated. For more complicated
suture had a higher tensile strength compared to tech- cases, such as microvascular repair or mutilating inju-
niques such as the modified Kessler (two-strand), the ries, the patient will remain as an inpatient as required.
Tsuge technique (two-strand), and the four-strand loop The protective backslab and dressing is replaced with a
suture technique.11 removable splint within 5 days of surgery by the hand
therapist. Protected dynamic rehabilitation is started
METHODS AND OUTCOMES then. The splint is removed at about 4 weeks postinjury
by the therapist. Return to full activities occurs at about
Operative Techniques 12 weeks.
Our procedure for primary flexor tendon repairs is to In the first 4 weeks, a dorsal blocking splint is applied
perform surgery with the patient under general or for the wrist and digits for continuous wear. The splint
regional anesthesia. The final choice depends on the places the wrist in a neutral position, with metacarpo-
patient and the anesthetist. phalangeal joints flexed 45°, and interphalangeal (IP)
We favor a six-strand core repair technique joints in full extension (Figure 13[E]-2). The patient is
co-developed by our senior author.12 This repair tech- advised to strap the fingers in flexion during the day and
nique uses a looped suture made of nylon (Supramid loosely in extension within the splint at night.
4/0; S. Jackson Inc., Alexandria, VA, USA) for the core With the splint in place, the patient performs the fol-
sutures. During the core suture repair, we add an epiten- lowing exercises hourly: (1) 20 repetitions of passive
dinous repair using polypropylene (Prolene 5-0 or 6-0, flexion and extension of the distal IP (DIP) joint, (2) 20
depending on tendon size). repetitions of passive flexion and extension of the proxi-
The use of a loop suture brings three advantages: it mal IP (PIP) joint, and (3) passively bringing all fingers
doubles the number of core sutures with each pass, into hook position (full IP joint flexion) and actively
simplifies suture locking to the tendon, and reduces the holding down the finger lightly for 5 seconds, followed
number of passes and tendon handling. Our clinical by active extension of the fingers to fully straighten the
and published experience involves using the commer- fingers against the splint for 5 repetitions. This last exer-
cially available Supramid sutures. However, we realize cise is done only when edema is resolved. Edema control
that these looped sutures may not be universally avail- is achieved using Coban wrapping (a self-adherent tape)
able, or the cost may be prohibitive in some countries. or fingerstalls, in addition to limb elevation.
We have described a technique to create a looped suture Therapy sessions are given three times a week. In
using a straight 23-gauge hypodermic needle, pliers, and addition to supervision of the patient’s therapy, the
available sutures such as polypropylene 4-0.13 Using this therapist manages the wound and scar and edema and
Chapter 13E: The Singapore Experience 155
Figure 13(E)-2 The operated hand in a splint during the

first 4 weeks following tendon repair. The digital strap is
removed during exercises. Passive flexion of the digits is
done, followed by an active hold for 5 seconds.
D performs passive tenodesis exercises to prevent joint

stiffness.
At 4 to 6 weeks postsurgery, the dorsal block splint is
removed during the daytime. The patient wears the
splint at night and while going into crowded places. A
night gutter splint is worn if there is flexion contracture
of the PIP joints. The exercise program includes (1)
active flexion and extension of fingers (to initiate
blocked active hook, perform straight fist and full fist
exercises) and (2) blocking exercises to improve gliding
of the FDP and FDS tendons.
E At 6 to 8 weeks, the following activities are performed:
(1) light activities of daily living (e.g., writing, eating,
and combing hair are encouraged), (2) progressive
strengthening (e.g., putty, hand helper), (3) light resis-
tive exercises (e.g., light putty, light Velcro), (4) gentle
stretching of flexors to reduce tightness and adhesion,
and (5) gliding of flexor tendons and positioning at the
end of elastic limit.
At 8 to 12 weeks, work conditioning and hardening
may be initiated. Normal use of hand is allowed. Heavy
F lifting is allowed only after 12 weeks.
Figure 13(E)-1 A, Application of a superficial locking
OUTCOMES
suture in the proximal tendon 1.25 cm from the tendon
end. B, Placement of the first pair of core sutures, with the In our initial experience, we found that in 32 fingers that
needle inserted close to the locking suture and proceeding underwent this tendon repair, there were 41% excellent,
parallel to the tendon fibers, from proximal to distal, 41% good, and 16% fair results using the revised Strick-
surfacing 1 cm from the distal tendon end. C, Application land criteria.12 Twenty-one cases were repaired primarily
of a superficial locking suture in the distal tendon 1.25 cm
(within 24 hours), while 11 cases underwent delayed
from the tendon end. D, Placement of second pair of core
primary repair. The rupture rate was 3% (1 of 32 digits).
sutures across repair site in a similar fashion and locking
suture applied. E, Application of final pair of core sutures. One case with a fair result underwent tenolysis, with no
Note that one strand is divided at the repair site, while the improvement after the procedure. Our results in more
other strand crosses into the proximal end and is locked recent case series with this technique are similar to our
before being passed into the repair site. The dorsal initial results.
epitendinous running suture is applied. F, The loop suture
repair is knotted in the repair site.
suture. The rehabilitation technique we use affords suf-

SUMMARY
ficient protection of the repair, with the advantages of
In an independent study, Hoffman and his colleagues early mobilization. Effective management of edema
compared this technique with the modified Kessler and good communication between patient, surgeon,
repair, combined with a Kleinert/Duran mobilization and therapist enhance the rehabilitation process. There
regimen.14 After a follow-up of 8 to 17 weeks, the loop remains much to be done to improve the clinical
suture technique group had a better grip strength and a outcome following these injuries, which typically occur
significantly better total active motion of 141° com- in the young and socioeconomically active. Efforts to
pared with 123°. In addition, the complication rate improve repair materials, techniques, rehabilitation,
was significantly lower and the average time of treat- and biologic methods to modulate healing will all con-
ment was significantly shorter using the loop suture tribute to the improvement of flexor tendon healing
technique. The rupture rate was lower in the loop suture results in the future.
technique (1 of 51 versus 3 of 26), although this did not
reach statistical significance. The results of Hoffman and
ACKNOWLEDGMENTS
his colleagues are similar to results of our case series
using similar repair techniques. Ms. Tan Lay Lay, principal hand therapist, and the Hand
The repair technique we describe using the looped Occupational Therapy Workgroup of National Univer-
Supramid suture adheres well to well-established prin- sity Hospital, Singapore, are acknowledged for the flexor
ciples and brings with it the advantages of using a loop tendon rehabilitation protocol.
References
1. Lim BH, Tan BK, Peng YP: Digital replantations including 9. Chong AK, Ang AD, Goh JC, et al: Bone marrow-derived
fingertip and ring avulsion, Hand Clin 17:419–431, 2001. mesenchymal stem cells influence early tendon-healing in a
2. Boyer MI, Strickland JW, Engles D, et al: Flexor tendon repair rabbit Achilles tendon model, J Bone Joint Surg (Am) 89:74–
and rehabilitation: state of the art in 2002, Instr Course Lect 81, 2007.
52:137–161, 2003. 10. Sanders DW, Milne AD, Johnson JA, et al: The effect of flexor
3. Pho RWH, Sanguin R, Chacha PB: Primary repair of flexor tendon repair bulk on tendon gliding during simulated active
tendons within the digital theca of the hand, Hand 10:154– motion: An in vitro comparison of two-strand and six-strand
160, 1978. techniques, J Hand Surg (Am) 26:833–840, 2001.
4. Chong AK, Chang J, Go JC: Mesenchymal stem cells and 11. Gill RS, Lim BH, Shatford RA, et al: A comparative analysis
tendon healing, Front Biosci 14:4598–4605, 2009. of the six-strand double-loop flexor tendon repair and three
5. Chacha P: Free autologous composite tendon grafts for divi- other techniques: A human cadaveric study, J Hand Surg (Am)
sion of both flexor tendons within the digital theca of the 24:1315–1322, 1999.
hand, J Bone Joint Surg (Am) 56:960–978, 1974. 12. Lim BH, Tsai TM: The six-strand technique for flexor tendon
6. Peng YP, Lim BH, Chou SM: Towards a splint-free repair for repair, Atlas Hand Clin 65–76, 1996.
flexor tendon injuries, Ann Acad Med Singapore 31:593–597, 13. Wong M, Sebastin SJ, Lim BH: A simple technique of making
2002. a looped suture for flexor tendon repair, J Hand Surg (Eur)
7. Karjalainen T, He M, Chong AK, et al: Nickel-titanium wire 34:409–410, 2009.
in circumferential suture of a flexor tendon repair: A compari- 14. Hoffmann GL, Büchler U, Vögelin E: Clinical results of flexor
son to polypropylene, J Hand Surg (Am) 35:1160–1164, 2010. tendon repair in zone II using a six-strand double-loop tech-
8. Ouyang HW, Goh JC, Thambyah A, et al: Knitted poly-lactide- nique compared with a two-strand technique, J Hand Surg
co-glycolide scaffold loaded with bone marrow stromal cells (Eur) 33:418–423, 2008.
in repair and regeneration of rabbit Achilles tendon, Tissue
Eng 9:431–439, 2003.
F The Stanford Experience
Arash Momeni, MD, Emily Grauel, MS, and
James Chang, MD
OUTLINE Several studies have demonstrated the effect of the

following intraoperative factors on repair strength and
This chapter summarizes some of the important con- functional outcome:7
siderations and current methods of primary repairs of
the injured flexor tendons in the authors’ unit. The 1. Number of core suture strands
preferred postoperative rehabilitation protocols are An increase in the number of core sutures (at least
presented and discussed. four strands) has been demonstrated to result in
an increased resistance to gap formation at the
Management of flexor tendon injuries represents one of repair site when compared with conventional two-
the most demanding challenges in hand surgery. The strand repairs.8-10 As a result of a stronger repair,
complexity of the task is reflected by the fact that despite early active motion protocols may be instituted
excellent technical execution numerous complications postoperatively.
may be experienced postoperatively.1 Particularly, repair 2. Caliber of core suture
of zone 2 injuries has been an area of great controversy Several authors have demonstrated that the use of
since Bunnell’s proposal that “it is better to remove the a larger caliber core suture (greater than 4-0) is
tendons entirely from the finger and graft in new tendon paralleled by an increased strength and stiffness of
throughout its length.”2 the repair.11,12
Flexor tendon repair confronts the surgeon with a task 3. Tendon purchase
that is two-fold, namely reestablishment of not only Adequate tendon purchase when placing the core
tendon continuity but also the gliding mechanism of the suture is critical for a successful repair. The optimal
tendon and its surrounding structures. Achieving both length of purchase has been shown to be between
goals is equally important for a satisfactory functional 0.7 and 1.0 cm.13 Similarly, placing the epitendi-
outcome.3 The various factors that affect functional nous suture 2 mm from the cut end results in
outcome can be classified into preoperative, intraopera- increased repair strength compared with a 1-mm
tive, and postoperative factors (Table 13[F]-1), of which purchase.
the latter two can be influenced by the surgeon. 4. Locking of core suture
Particularly with regard to surgical technique, the The superiority of a locking core suture with resul-
scientific literature is replete with technical modifica- tant increased tensile strength and reduced risk of
tions proposed for improved functional outcome.4 suture pull-out was initially reported by Penning-
The multitude of available approaches along with the ton and has since been confirmed in numerous
nuances of flexor tendon repair make it particularly dif- reports.14,15
ficult for the trainee to identify and learn a reliable 5. Epitendinous suture
technique, which allows for reproducible results with a Although it was initially assumed that the epiten-
satisfactory functional outcome. In particular, zone 2 dinous suture would merely contour the repair site,
injuries are associated with poorer functional outcomes it has been demonstrated that it contributes to the
and a higher complication rate compared with injuries strength of the repair as it bolsters repair strength
in other zones.5 and prevents gap formation.16 Implementing an
Despite the myriad of reported techniques, several epitenon-first technique further enhances repair
principles of repair should be regarded as established. strength when compared with a modified Kessler
These principles include early primary repair whenever and epitendinous running suture.17
possible, performance of a multistrand repair (at least
four strands) combined with an epitendinous suture, The complexity of flexor tendon repairs along with a
use of locking stitches, and adequate tendon purchase. “no-error tolerance” environment in the operating room
Furthermore, an early motion protocol should be used represent significant challenges to resident training. As
in compliant patients to minimize extrinsic scarring and such, surgical training is increasingly making use of
adhesion formation and to promote intrinsic healing.6 lessons learned from the aviation industry and has
157
Table 13(F)-1 Factors Affecting Outcome After

Primary Flexor Tendon Repair Epitendinous stitch Slit with #11 blade
Preoperative Intraoperative Postoperative
Factors Factors Factors
 Type/  Atraumatic  Postoperative
mechanism of tissue handling rehabilitation
A B
trauma  Multistrand (i.e., early
 Degree of core suture active Modified Kessler Locking stitch
wound  Locking stitch motion)
contamination  Epitendinous
 Associated suture
injuries (e.g.,  Tendon
concomitant purchase C D
fractures, etc.)  Suture material 0.7 to 1 cm
2 mm
endorsed simulator-based training models. Organiza-

tions such as the American College of Surgeons (ACS)
as well as the Accreditation Council for Graduate Medical
Education (ACGME) have underlined the importance of E F
such training models in surgical education.
Surprisingly, the challenges of flexor tendon repair
Horizontal mattress
have not been met by appropriate simulation models.
Recently, colleagues in our unit introduced a curriculum-
based simulation model for teaching zone 2 flexor
tendon repairs. Combining a tutorial addressing con-
temporary literature along with providing a standard- G
ized approach to flexor tendon repair incorporating Figure 13(F)-1 Authors’ preferred flexor tendon repair
best evidence principles with hands-on experience using epitenon-first suture (A) followed by a modified
using human cadaver tendons resulted in significantly two-strand Kessler core suture (B–E) in locking configuration
improved flexor tendon repairs. Key aspects of this sim- and buried knot (F). Subsequently, two-strand horizontal
ulation model include inexpensive hands-on experi- mattress suture is added (G), to complete a four-strand core
ence, review of the primary literature, and standardization suture.
of the technique. This model is amenable to incorpora-
tion into training programs as part of a hand surgery
simulation curriculum.18 an epitendinous running suture using a 6-0 nonabsorb-
able monofilament suture on a tapered needle. The
OPERATIVE TECHNIQUE
tendon is purchased 2 mm from the cut end for place-
The authors’ preferred approach to flexor tendon inju- ment of this suture. This results in optimal tendon align-
ries, particularly those in zone 2, is early exploration and ment and prevents the excessive bulging observed when
repair via Bruner zigzag incisions. Every effort should be placing the core suture first. Next, a longitudinal slit is
made to repair each injured tendon, even in the setting made with a No. 11 blade at least 1 cm away from the
of combined flexor digitorum superficialis (FDS) and repaired edge. Using this slit as the entry point, a 3-0
flexor digitorum profundus (FDP) injuries. Although nonabsorbable, braided suture is placed in a modified
some authors recommend repair of only the FDP tendon, Kessler technique with a locking loop. In the end, the
the authors believe that excessive scar formation origi- knot should lie in the depth of the previously created
nating from the free ends of an unrepaired FDS tendon slit, which will limit irritation of the tendon sheath.
may result in functional compromise of the digit. Fur- Finally, a four-strand repair is obtained by placement of
thermore, repair of both tendons will still allow proxi- a horizontal mattress stitch with a 3-0 nonabsorbable,
mal interphalangeal (PIP) joint flexion should the braided suture. The knot of this suture should be placed
repaired FDP tendon rupture during postoperative reha- away from the A2 and A4 pulleys. The repaired digit
bilitation. During the repair, care should be taken to should then be placed under passive range of motion
preserve the A2 and A4 pulleys to prevent postoperative (ROM) intraoperatively to assess for triggering. If trig-
bowstringing, which would result in loss of function. gering at one of the pulleys is observed, partial release
The authors’ preferred method of flexor tendon repair of the affected pulley is indicated. Postoperatively, early
is illustrated in Figure 13(F)-1. The repair begins with active motion protocols are initiated.
Chapter 13F: The Stanford Experience 159
at all times until its removal is recommended by the

therapist. Patient education about the proper way to
Early mobilization protocols are now established com- undergo active motion exercises is addressed in detail at
ponents of the comprehensive care provided to patients the first therapy visit.
following flexor tendon repair as they have been dem- Five therapeutic exercises are begun between days 3
onstrated to result in superior functional outcomes and 7 postoperatively.
compared with prolonged immobilization. Among the
1. Passive range of motion composite wrist flexion.
proposed benefits are improved tendon gliding in the
2. Passive MCP flexion to 90° and active extension
postoperative period with resultant decreased adhesion
of IP joints to neutral; Passive PIP/DIP extension
formation and risk of joint stiffness.18 Early mobiliza-
with MCP flexed.
tion also improves healing and revascularization leading
3. Place and hold flexion of digits in palm with active
to an increased strength of the repair.19 Numerous
extension to DBS.
studies indicate that initiation of mobilization is most
4. Passive wrist flexion with active extension to
successful in the first week; however, recommendations
neutral.
for the specific day within that week vary.20,21 In vivo
5. Active flexion and extension of unaffected digits
animal studies suggest days 3 to 5 as the best choice to
within the DBS while maintaining the affected
begin a postoperative mobilization regimen based on
digit in passive flexion.
the strength of the repair and the resistance to digital
motion.21,22 Although the concept of early postoperative In clinic, the therapist performs retrograde massage, scar
mobilization represents a central dogma, a myriad of massage, and skin care as needed. Precautions during
rehabilitation protocols can be found in the literature.24 this stage of therapy include: no active flexion of the
Standardization of protocols based on best available affected digit, no active extension of MCP beyond 60°,
evidence will lead to greater success of flexor tendon no active PIP extension unless MCP is flexed at 90°, and
repairs and allow comparative analyses of functional no active wrist extension past neutral.
outcomes.
There are two categories of early mobilization: early Weeks 4 to 5
passive motion and early active motion. Early passive The patient should continue to wear the DBS at all times
motion includes passive flexion (e.g., with rubber band and is instructed in new therapeutic exercises:
traction) with either active or passive extension. Early
active motion includes active flexion and extension of 1. Begin active digital flexion of affected digit within
the affected digit. A subtype of early active mobilization the DBS with active extension to hood of splint;
includes “place and hold” techniques where the digit is the therapist may consider buddy taping affected
passively flexed and then held in place by the patient.23 to adjacent digit within the splint for active flexion
Early controlled active finger flexion with place and if the affected digit is stiff.
hold exercises is becoming a more popular treatment 2. Continue passive range of motion digital flexion.
compared to early passive flexion by rubber band 3. During week 5 include full digital extension to
traction.24 neutral.
Recently, Trumble et al conducted the first random- 4. Tenodesis of wrist out of DBS.
ized prospective trial comparing active place-and-hold
therapy with passive motion therapy.6 A total of 103 In clinic, the therapist performs edema management
patients (119 digits) were included in the study. The techniques (retrograde massage, 3M Coban Self-
authors demonstrated that active motion therapy pro- Adherent Wrap application), scar management tech-
vided significantly better range of motion, smaller niques (use of silicone gel sheet if needed), and skin
flexion contractures, and greater patient satisfaction. care. The main precaution during this stage of therapy
This study provides strong scientific support for the is avoidance of forceful flexion.
combination of multistrand tendon repairs and early
active motion protocols postoperatively.6 Week 6
At this point, the DBS can be removed except at night
AUTHORS’ PREFERRED POSTOPERATIVE and with lifting or higher risk activities. Therapeutic
REHABILITATION PROGRAM exercises for week 6 include:
Weeks 0 to 3 1. Begin active isolated joint blocking.

Postoperatively, the patient’s affected hand is placed in 2. Active digital extension to neutral.
a dorsal blocking splint (DBS) with the wrist neutral, 3. If lacking full PIP extension, a static PIP extension
metacarpophalangeal (MCP) joints at 70° to 90° splint can be fabricated.
flexion, and IP joints neutral. The DBS should be worn 4. Active wrist flexion and extension.
5. May begin ultrasound/neuromuscular electrical

SUMMARY
stimulation as needed for scar management if not
obtaining tendon glide. A growing body of evidence supports the combination
6. Encourage use of hand for light functional of multistrand (at least four strands) repairs and early
activities. active motion rehabilitation protocols for management
7. Continue edema management techniques as of flexor tendon injuries. Incorporating simulation
needed. modules into the hand surgery curriculum is an impor-
tant step in allowing the trainee to familiarize with the
Week 8 technical complexity of flexor tendon repairs prior to
The DBS can be fully discharged at this point. Strength- execution in the operating room. Standardization of
ening exercises should be begun at this point and should treatment protocols based on best available evidence
gradually increase as the patient can tolerate. Return to will lead to greater success of flexor tendon repairs and
sports activities should be discussed with the physician, also allow comparative analyses of functional outcomes
as full return is sports specific. Generally, full release for across various institutions.
sports is at 12 weeks.
References
1. Momeni A, Grauel E, Chang J: Complications after flexor 13. Tang JB, Zhang Y, Cao Y, et al: Core suture purchase affects
tendon injuries, Hand Clin 26:179–189, 2010. strength of tendon repairs, J Hand Surg (Am) 30:1262–1266,
2. Bunnell S: Repair of tendons in the fingers and description 2005.
of two new instruments, Surg Gyencol Obstet 26:103–110, 14. Pennington DG: The locking loop tendon suture, Plast Recon-
1918. str Surg 63:648–652, 1979.
3. Beredjiklian PK: Biologic aspects of flexor tendon laceration 15. Hotokezaka S, Manske PR: Differences between locking loops
and repair, J Bone Joint Surg (Am) 85:539–550, 2003. and grasping loops: effects on two-strand core suture, J Hand
4. Strickland JW: Development of flexor tendon surgery: twenty- Surg (Am) 22:995–1003, 1997.
five years of progress, J Hand Surg (Am) 25:214–235, 2000. 16. Wade PJ, Muir IF, Hutcheon LL: Primary flexor tendon repair:
5. Karlander LE, Berggren M, Larsson M, et al: Improved results the mechanical limitations of the modified Kessler technique,
in zone 2 flexor tendon injuries with a modified technique J Hand Surg (Br) 11:71–76, 1986.
of immediate controlled mobilization, J Hand Surg (Br) 17. Papandrea R, Seitz WH, Shapiro P, et al: Biomechanical and
18:26–30, 1993. clinical evaluation of the epitenon-first technique of flexor
6. Trumble TE, Vedder NB, Seiler JG 3rd, et al: Zone-II flexor tendon repair, J Hand Surg (Am) 20:261–266, 1995.
tendon repair: A randomized prospective trial of active place- 18. Amadio P, An KN, Ejeskar A, et al: IFSSH Flexor Tendon Com-
and-hold therapy compared with passive motion therapy, mittee report, J Hand Surg (Br) 30:100–116, 2005.
J Bone Joint Surg (Am) 92:1381–1389, 2010. 19. Strickland JW, Glogovac SV: Digital function following flexor
7. Kim HM, Nelson G, Thomopoulos S, et al: Technical and tendon repair in Zone II: A comparison of immobilization
biological modifications for enhanced flexor tendon repair, and controlled passive motion techniques, J Hand Surg (Am)
J Hand Surg (Am) 35:1031–1037, 2010. 5:537–543, 1980.
8. Savage R, Risitano G: Flexor tendon repair using a “six strand” 20. Tottenham VM, Wilton-Bennett K, Jeffrey J: Effects of delayed
method of repair and early active mobilisation, J Hand Surg therapeutic intervention following zone II flexor tendon
(Br) 14:396–399, 1989. repair, J Hand Ther 8:23–26, 1995.
9. Viinikainen A, Goransson H, Huovinen K, et al: A compara- 21. Zhao C, Amadio PC, Paillard P, et al: Digital resistance and
tive analysis of the biomechanical behaviour of five flexor tendon strength during the first week after flexor digitorum
tendon core sutures, J Hand Surg (Br) 29:536–543, 2004. profundus tendon repair in a canine model in vivo, J Bone
10. Thurman RT, Trumble TE, Hanel DP, et al: Two-, four-, and Joint Surg (Am) 86:320–327, 2004.
six-strand zone II flexor tendon repairs: An in situ biome- 22. Xie RG, Cao Y, Xu XF, et al: The gliding force and work of
chanical comparison using a cadaver model, J Hand Surg flexion in the early days after primary repair of lacerated flexor
(Am) 23:261–265, 1998. tendons: An experimental study, J Hand Surg (Eur) 33:192–
11. Barrie KA, Tomak SL, Cholewicki J, et al: Effect of suture 196, 2008.
locking and suture caliber on fatigue strength of flexor tendon 23. Pettengill KM: The evolution of early mobilization of the
repairs, J Hand Surg (Am) 26:340–346, 2001. repaired flexor tendon, J Hand Ther 18:157–168, 2005.
12. Taras JS, Raphael JS, Marczyk SC, et al: Evaluation of suture 24. Tang JB: Indications, methods, postoperative motion and
caliber in flexor tendon repair, J Hand Surg (Am) 26:1100– outcome evaluation of primary flexor tendon repairs in Zone
1104, 2001. 2, J Hand Surg (Eur) 32:118–129, 2007.
G The Australian Experience
Michael A. Tonkin, MD, FRCS Ed Orth, FRACS, and
Richard D. Lawson, MBBS, FRACS
OUTLINE followed by supervised active movement within the

inner range, once or twice a day. The splint was main-
This subchapter describes the contribution of Austra- tained for 5 weeks.
lian authors to the basic science and clinical manage- These methods of repair and rehabilitation were still
ment of flexor tendon injuries. It then discusses the the mode of practice until the early 1970s. Since then,
current surgical management and rehabilitation of flexor tendon surgery has evolved significantly and Aus-
flexor tendon injuries in Australia and ends with a tralian hand surgeons have made many contributions
brief outline of our preferred approach to flexor to the development of the increasingly sophisticated
tendon repair. techniques currently practiced.
Perhaps one of the most important but basic contri-
In Australia, hand surgery developed in parallel with butions was David Pennington’s recognition in 1979
and perhaps because of the necessity for hand surgery that a locking loop tendon suture increased the tensile
services created by limb injuries sustained in World War strength of the repair and decreased gapping at the
II. Sir Benjamin Rank, from Melbourne, though mostly repair site.2 He demonstrated that the alteration in the
involved in secondary reparative surgery during and relationship of the transverse and longitudinal intraten-
immediately after the war years, established the place of dinous parts of the suture technique of Mason and
primary repair for hand injuries which became rife with Allen,3 modified by Kessler and Nissim,4 was vital to
the mushrooming of light industry. Rank and Alan prevent pullout of the suture under load. Now termed
Wakefield published Surgery of Repair as Applied to Hand the modified Kessler suture, the longitudinal compo-
Injuries in 1953,1 being joined for the last two of five nents of the suture configuration must pass deep to the
editions by John Hueston. Their recommendations for transverse limb. As tension is increased, the loops
the place of primary and secondary flexor tendon recon- tighten and lock. In fresh cadaveric flexor tendons, he
struction and the techniques of the time are documented demonstrated that failure of the locking loop suture was
in this text, which can best be summarized in the fol- due to breakage of the suture, rather than suture pullout
lowing: Primary repair in the digit was practiced for that occurred with a nonlocking technique. Pennington
flexor digitorum profundus (FDP) division only if the also performed some experimental repairs of cadaveric
repair did not interfere with the intact flexor digitorum tendons with wire and monofilament nylon, conclud-
superficialis (FDS). If the primary repair of an FDP ing that the stiffness of wire made it an unsuitable
tendon was likely to compromise FDS function, the FDP material.2
was not repaired, relying on a tenodesis or an arthrod- The modified Kessler suture became the “work horse”
esis of the distal interphalangeal joint; alternatively, a core suture for many years and is still favored by many,
primary or delayed tendon graft from palm to terminal although the use of monofilament nylon was largely
interphalangeal joint was used. If both tendons were superseded by braided polyester sutures, and more
divided, a graft was indicated. Results from primary recently by other materials such as Fiberwire (Arthrex,
grafting did not compare favorably with those of sec- Naples, FL).
ondary grafts. This became one of the exceptions to Pennington’s innovative approach to improving
the rule of primary repair in a tidy wound, which was flexor tendon surgical techniques included a discussion
championed for all other soft tissue injuries. Primary of the use of a suction catheter technique to deliver the
skin closure with delayed or secondary grafting was retracted proximal end of a severed tendon to the repair
favored. For primary repair, the suture used was a 5-0 site when proximal digital milking of the tendon failed.5
polyester suture, inserted according to the method Perhaps the most common technique in current practice
described by Bunnell. The 6-0 sutures were used for is that described by McGrouther and colleagues, from
auxiliary apposition stitches, so as not to leave any open the United Kingdom, in 1987, in which a fine Silastic
tendon end exposed. Post-operative treatment main- catheter is passed up the tendon sheath from a proximal
tained absolute immobilization until the third week, palmar wound and is sutured to the retracted tendon,
161
1
Pull to
advance
tendon
A 2
Secure
tendon
distally
B
3 4 5
Pull to Pull to Pull to
release undo remove
knot suture catheter
(distal (distal
catheter catheter
counter counter
traction) traction)
C D
Figure 13(G)-1 Diagram for tendon retrieval technique described by Michael J. Sandow. A, Loop release knot using 4-0
nylon is tied with a double throw first. B, Loop release knot: second throw. C, Loop release knot: completed securing catheter
to tendon. D, Catheter is pulled distally advancing tendon, the tendon is secured distally, the loop release knot is disengaged
by pulling on the trailing suture tail, the suture is removed, and the catheter is disengaged leaving the tendon in a good
position for repair. (From Sandow MJ: A further tendon retrieval trick, J Hand Surg [Br] 22[1]:125-127, 1997.)
which is then drawn into the repair site.6 Michael release knot is disengaged by pulling on the trailing tail
Sandow, from Adelaide, suggested a modification of this suture at the palmar wound (Figure 13[G]-1A–D).
technique in his article “A Further Tendon Retrieval Wayne Morrison, from Melbourne, has been another
Trick,” published in 1997.7 Instead of a simple knot to major contributor to many aspects of flexor tendon
secure the catheter to the tendon, a loop release knot is surgery in Australia. Writing with Pribaz and Macleod,
used, which allows the tendon to be advanced with the he reported satisfactory results using the Becker repair
tube; once the tendon is delivered and stabilized dis- and early active motion.8 Becker’s beveling and overlap-
tally, the knot can be released without the need to allow ping of the tendon ends reduced the problem of gap
the tendon to retract to the proximal wound. The loop formation but did require profundus tendon shortening
Chapter 13G: The Australian Experience 163
of around 7 mm. Morrison’s ruptures (3 of 43) occurred 8000

in those patients with crush injuries and stiff joints.
Morrison, in collaboration with Callan, described a
new and simple approach to gain access to the divided
flexor tendons within the flexor tendon sheath.9 They 6000
recommended a transverse incision 1 cm distal to the Strong
Force in grams
distal stump of the severed tendon. This allows delivery grip
of 1 cm of distal tendon through the sheath incision, be 6-strand
4000
it within the synovial sheath or within a pulley. The
proximal segment is retrieved and delivered through 4-strand
the same incision by whatever technique is necessary,
2000
including milking, flexion of proximal joints, and Light 2-strand
catheter-assisted delivery, and is stabilized with a active
23-gauge needle, allowing the core suture to embrace Passive
1 cm of each end of the tendon, with ready access pro- 0
vided to the front and back walls for insertion of the Repair 1 week 3 weeks 6 weeks
epitendinous suture. These authors claim that the lon- Time in weeks
gitudinal component of Lister’s L-shaped sheath inci-
sions created the possibility of narrowing the sheath Figure 13(G)-2 A strength-versus-force graph showing
two-, four-, and six-strand repairs plotted against passive,
with repair, however many still prefer the increased
light active flexion, and strong grip. The data are adjusted for
access gained by the L-shaped incisions. Tonkin and
friction, edema, and stress. (Data from Strickland JW: 25th
Lister found no clinical evidence in their study to anniversary presentation: Development of flexor tendon
support the necessity for closure of the synovial compo- surgery: Twenty-five years of progress, J Hand Surg [Am]
nent of the tendon sheath.10 25[2]:214-235, 2000.)
Morrison, O’Brien, and co-authors investigated a
number of innovations designed to improve the results
of staged flexor tendon surgery. They developed a model continued at a hectic pace. Most “improvements” have
in which a flexor tendon was placed into bone prior to centered on the development of stronger core and epi-
using that tendon as a flexor tendon graft.11 Incorpora- tendinous suture constructions which allow early post-
tion of the tendon into bone allowed the bone block to operative active mobilization. Savage, from the United
be used as superior fixation into the digital phalanx at Kingdom, demonstrated the significantly improved
the time of tendon grafting. This prefabricated bone- strength of repair gained by increasing the number of
tendon graft offered some theoretical advantages per- strands within the core suture.15 Strickland’s graph is a
taining to distal pullout strength but has not been very helpful illustration of this concept comparing the
commonly adopted. Another fascinating study from the force generated by different postoperative rehabilitation
same group compared the results of vascularized and programs with the tensile strength of two-, four-, and
nonvascularized tendon grafts in a primate experimen- six-strand core sutures16 (Figure 13[G]-2). Descriptions
tal model.12 The authors concluded that the concept of of modifications, all claiming some improvement in
vascularized tendon grafting may be advantageous in one or more of the measured parameters, abound within
scarred tendon beds. This work was developed during a the current hand surgery literature. One is reminded of
time of euphoria associated with the application of the words of Guy Pulvertaft, in whose Derby hand unit
microsurgical techniques to hand surgery but, although many Australian surgeons were trained: “it is not diffi-
it has some significant theoretical advantages, it has not cult to suture tendons and prepare the ground for sound
displaced the conventional approach of staged flexor union; the real problem is to obtain a freely sliding
tendon grafting. Honner and Meares confirmed the reli- tendon capable of restoring good function.”17 Pulver-
ability of this technique in their review of 100 cases in taft’s point is pertinent. No tendon repair, regardless of
1977.13 The consistency of the results of flexor tendon the number of strands in the core suture, technique of
grafting performed with precise attention to detail was epitendinous suture, or gauge of suture, will protect
also reported by Tonkin and Hagberg’s review of the against inappropriate postoperative activity against
experience of Kleinert’s Louisville center, a fertile train- resistance. Gelberman and others, from the United
ing ground for Australian hand surgeons.14 States, have shown that the amount of movement
required to gain optimal promotion of tendon healing
RECENT ADVANCES, 2000–2010
and overcome adhesion formation is small.18,19 It would
More recent Australian contributions relate to biome- seem logical to balance the determination to improve
chanical testing of alternative suture configurations. the strength of repair against the increases in adhesion
The search for optimal flexor tendon repair results has formation, bulk, and resistance to glide, which may
follow excessive handling of the tendon when placing

more sophisticated suture configurations. Increased
adhesion formation was not found in the experimental
studies of Tonkin’s group in Sydney, which compared
adhesion formation in two- and four-strand configura-
tions with and without epitendinous sutures in a live A
chicken model.20 However, this group concluded that
the expertise of the surgeon may play a substantial role
and suggested that complicated techniques in inexperi-
enced hands increased the potential for a less than sat-
isfactory result. It would seem appropriate to establish
surgical techniques that obtain reproducible results in
the hands of those who, although competent, may have B
less experience than those who are able to confidently
perform more complex techniques.
Sandow found the 6-strand Savage configuration to
be too complex. His modification is similar to that
made by others and involves a 4-strand repair.21 This
“Adelaide” repair has been adopted by many Australian
hand surgeons. It provides four strands to the core
suture, is less likely to gap than a modified Kessler core
suture, is relatively easy to place in the tendon ends, and
may be combined with most of the currently preferred C
epitendinous suture configurations. Its strength permits Figure 13(G)-3 A, Modified Kessler core stitch. B, Inherent
protected active postoperative mobilization (Figure gapping of modified Kessler under load. C, Adelaide
13[G]-3). tenorrhaphy (four-strand single-cross grasp repair). (Adapted
Many Australian hand surgeons have collaborated from Sandow M, Kay S: Flexor tendon injuries. In Prosser R,
with William Walsh’s biomechanical laboratory at the Conolly WB [eds]: Rehabilitation of the Hand & Upper Limb,
London, 2003, Elsevier Health Sciences, p. 47.)
University of New South Wales in Sydney. Dona and
Gianoutsos, along with Walsh and others, investigated
the ideal size bite of locking loops for cruciate core laboratory, applied a cyclical testing protocol to a com-
repairs, finding that each loop should optimally include parison of in vitro repairs using a modified Kessler core
25% of the tendon’s width.22 In an earlier publication suture or a four-strand modified Savage core suture,
they demonstrated the biomechanical superiority of an with two different epitendinous techniques. They found
interlocking horizontal mattress epitendinous suture the modified Savage repair to be superior.
technique over that of an interlocking cross stitch, a Vizesi and colleagues analyzed the stress relaxation
simple cross stitch, and a simple running repair.23 There and creep properties of three materials used for flexor
were statistically greater loads to failure, 2-mm gap for- tendon repair—Prolene (monofilament polypropyl-
mation, and stiffness within those cadaveric tendons ene), Ethilon (monofilament nylon), and Ticron
repaired with the interlocking horizontal mattress (braided polyester).26 Their study addressed the selec-
repair. Both studies used single progressive tensile tion of suture material based on the temperature- and
loading rather than cyclic loading when testing to time-dependent mechanical properties of a single-
mechanical failure. Sandow and colleagues compared strand suture. They reported that, based on static and
the theoretical and actual repair strength of a multiple viscoelastic mechanical properties, Ticron was the most
strand repair in a single tension test with the strength suitable suture for flexor tendon repairs compared with
of a repair subjected to cyclic loading, finding a signifi- Prolene and Ethilon.
cant decrease in ultimate tensile strength when the A number of studies from the same department have
repair was subjected to cyclical loading.24 This reduction investigated optimal methods of securing the FDP
equated to the number of strands multiplied by the tendon distally following avulsion. Schreuder et al
strength of the knotted strand and was explained by the found that gap formation in such repairs was signifi-
change in stiffness of the knotted strand after cyclical cantly less when Ethibond (a braided polyester) was
loading. They concluded that cyclic loading is more used compared with Prolene or Supramid (a synthetic
representative of physiological loading after acute flexor polyfilament ensheathed by Caprolactin).27 Latendresse
tendon repair and suggested that this should be the et al28 compared the repair of FDP tendons using a
testing model of choice in suture tenorrhaphy studies. single micro-Mitek anchor with a modified Bunnell
Matheson et al,25 again in collaboration with Walsh’s two-strand pullout technique, using a monofilament or
a braided polyester suture. Load to failure in the modi- epitendinous repair applied to the palmar surface was
fied Bunnell technique was superior to the micro-Mitek effective in improving the strength of repair compared
anchor technique. Significant gap formation was present with a core suture alone and was effective in decreasing
when a monofilament suture was used but this problem gap formation. However, the load to failure was signifi-
needed to be balanced against the difficulty of removal cantly less than that of a core suture combined with a
of a braided polyester pullout suture. In the search for full circumferential suture.
alternatives to pullout sutures, with their potential for Hile and colleagues34 were concerned about the prev-
creation of nail plate deformities, nail fold necrosis, and alence and consequences of piercing the thread of a
infection, this group studied the influence of anchor braided polyester suture with the needle during complex
orientation when inserting the micro-Mitek anchor.29 In multistrand repairs. They concluded that cutting needles
an in vitro biomechanical study using 3-0 Ethibond should not be used in tendon repairs because they can
suture anchors in cadaver specimens, they did not find damage or completely sever core sutures. They also
any support for the theory that varying the angle of found that crushing of the suture between the teeth of
anchor insertion improved the load to failure. However, a needle holder significantly weakened the involved
inserting the anchor in a retrograde fashion at 45° segment.
appeared to result in fewer failures at the bone anchor The work of the investigators that was just outlined
interface, with failure more likely to occur at the join is not inclusive of all such work that has been and is
between suture and the eyelet of the anchor. Other sur- being performed by Australian surgeons and their col-
geons in the same laboratory advised avoidance of nail leagues. However, the time and effort directed toward
problems following reinsertion of FDP tendons distally obtaining optimal results from flexor tendon repair
by placing the suture through two drill holes in the base within Australia and worldwide are indicative of the
of the distal phalanx.30 They demonstrated that this importance of this pursuit. Although some thought
repair method was biomechanically sound with compa- needs to be given to the worth of in vitro cadaveric
rable gap formation and load to failure to other com- model experiments in which biology is removed from
monly used repairs, was technically straightforward, and the assessment, it is undeniable that such studies have
did not impair the integrity of the distal phalanx. resulted in an improved understanding of the most
In 2006, Dona and Walsh31 described a V-Y plasty appropriate suture material, its gauge, and, importantly,
within pulleys to increase the cross-sectional area within the surgical techniques and configurations of core and
the pulley and thus decrease the friction of the repaired epitendinous sutures that best prevent rupture, avoid
tendon, allowing easier glide but maintaining a mechan- adhesions, and allow an optimal postoperative rehabili-
ically sound pulley. They did not advocate this tech- tation program. Despite these improvements, future
nique for routine use but as an alternative to venting or advances would appear to rely on our ability to modify
resection in those circumstances in which gliding of the healing processes at a molecular level to increase early
repaired tendon was found to be unsatisfactory. strength of repair and to avoid adhesion formation.
Much of the above experimental work relates to the
CURRENT PRACTICE IN FLEXOR TENDON
optimal types of suture material and techniques of core
REPAIR AND REHABILITATION
and epitendinous sutures for flexor tendon repair. A
number of recent Australian studies have contributed to To understand the current state of primary flexor tendon
an improved understanding of some other nuances of repair in Australia, we conducted a survey of the mem-
flexor tendon surgery. Stewart and coauthors reminded bership of the Australian Hand Surgery Society. Approx-
us of the ability of intact vincula to flex interphalangeal imately 40% of the active membership responded. A
joints despite tendon division.32 In an experimental very wide range of approaches was apparent, particu-
cadaveric model, they demonstrated that in the immedi- larly in the more controversial areas such as manage-
ate postinjury period, the vinculum breve can hold a ment of the critical pulleys, and in methods of
divided tendon within a few millimeters of its insertion. postoperative rehabilitation.
In these circumstances they quantified the motion In Australia, hand surgeons perform on average one
present at proximal and distal interphalangeal joints or two repairs a month (mean of 17 per year). Surgeons
as being 93% and 69% of normal, respectively. They with a large trauma practice perform substantially more.
emphasized that testing of the injured digit against resis- Many other repairs are done by training residents and
tance is important if one is to avoid missing the diag- by plastic, orthopedic, and general surgeons.
nosis of a tendon injury. The most commonly used core suture material is
Lawson and coworkers addressed the difficulty of per- some form of braided polyester suture, typically Ticron
forming a full circumferential epitendinous repair when or Ethibond. For a large tendon, such as the FDP to the
the tendon injury comes to lie beneath the A4 pulley middle finger, around two thirds prefer to use a 3-0 core
and access to the dorsal aspect of the tendon is com suture, but a significant minority prefer to use a 4-0 core
promised.33 They reported that a half-circumferential suture. Around 20% of the respondents who used a
braided suture as their core stitch preferred to use a Australian hand surgeons. Our current practice is sum-
nonbraided suture for contaminated wounds. marized as follows:
There were two core suture configurations commonly
used: the four-strand modified Savage (often referred to 1. The approach to the flexor sheath begins with
as an Adelaide repair) was used by 40% of the surveyed débridement of the existing wound, followed by
surgeons and a four-strand modified Kessler was also extension using a combination of Bruner, hemi-
used by around 40%. Other favored techniques included Bruner, and midlateral incisions.
the six-strand Savage repair, and the Tsai-Lim six-strand 2. The A2 and A4 pulleys are preserved during the
technique taught at Kleinert’s center in Louisville. Flex- approach, with access to the tendon achieved via
ibility in the choice of core suture is practiced by some, Lister’s L-shaped windows between these critical
depending on the ease of access to the cut ends of the pulleys. This technique acts to funnel the tendon
tendon around the pulley system. beneath the pulley and maximize the chance of
The epitendinous suture of choice was polypropylene smooth running of the repair.
(Prolene), with 60% of respondents preferring 6-0 3. If access to the tendon ends is adequate, a modi-
Prolene and 25% favoring 5-0 Prolene. A simple running fied Savage four-strand (Adelaide) repair is per-
epitendinous repair was performed by 70% of surgeons, formed, using 3-0 Ticron in larger tendons and 4-0
with the next most popular technique being the Silfver- or 5-0 Ticron in smaller tendons (usually little
skiöld technique, used by around 20%. finger FDP and pediatric tendons, respectively).
Management of the A2 and A4 critical pulleys varied, A simple running or Silfverskiöld epitendinous
with forcefully held and disparate opinions; 12% of the repair using 6-0 Prolene with a taper needle is
surveyed surgeons would not release any part of the performed, depending on access. The back wall
critical pulleys, while 88% would perform partial or full repair is ideally done first to keep the tendon ends
releases. Of those who released the A4 pulley, 20% snugly opposed. If access to the back wall is par-
would do so at the beginning of the repair as part of ticularly difficult or not possible because of the
their exposure; the remainder would do so if exposure proximity of the A4 pulley, only the front half of
proved difficult during the repair or if the repaired the tendon receives an epitendinous suture.
tendon did not glide adequately. 4. If the distal tendon ends lies beneath the A4 pulley,
Two-thirds of respondents did not attempt to repair combined proximal/distal repairs as described by
divided pulleys, with some stating that they thought a Lister are used. This technique precludes the use
satisfactory repair was not possible; some of those who of the modified Savage repair in our hands, and
would try to repair the pulley stated they would perform instead a modified Kessler with a supplementary
a V-Y plasty to increase the diameter of the repaired horizontal mattress core suture is performed. This
pulley. Closure of the synovial sheath/A3 pulley was technique permits retention of the A4 pulley while
advocated by 55%. allowing for a 10-mm purchase with the core suture.
Teaching of flexor tendon repair to trainees should 5. If gliding of the repair is impeded, the pulleys can
involve a sound grounding in basic principles, and 60% be stretched with pediatric urethral dilators. Small
of the surgeons surveyed believed, some very strongly, strands of tendon projecting from between the
that junior physicians should not be taught to release epitendinous sutures can be carefully removed
the critical pulleys, believing they should first learn to with microscissors.
perform good repairs while working around the pulleys, 6. The incised sheath is laid over the tendons but no
and perhaps when more expert would be able to make formal repair is performed if there is any threat to
an informed choice with respect to pulley release. gliding.
Rehabilitation protocols varied widely: 25% of 7. Postoperative rehabilitation is tailored to the
respondents used the same protocol for all of their quality of the repair, and the compliance of the
patients, while the other 75% tailored their approach to patient, with a tendency to err toward a less aggres-
the demands of each patient. The most popular regimen sive form of mobilization. In cooperative patients
was some form of immediate active motion, used by with high quality repairs an active range of motion
65%. Passive flexion/active extension (Duran-Hauser) technique is used; in the less optimal repair or
was used by 19%, passive flexion/active hold (place and patient a modified Duran regimen with passive
hold) was used by 11%, and Kleinert traction was used flexion and active extension is prescribed. A dorsal
by 6%. Unrestricted use was allowed by 55% at 12 extension blocking splint is used to protect the
weeks, by 15% at 8 weeks and, by 15% at 6 weeks. repair. In all cases it is particularly important to
guard against the development of a proximal
AUTHORS’ PREFERRED APPROACH
interphalangeal joint flexion contracture.
As shown, there is a considerable variety of approaches 8. The splint is typically removed at 6 to 8 weeks, at
to the management of flexor tendon injuries by which point a gentle strengthening program is
started. Full grip is prohibited until 3 months post by Rank, Morrison, and Pennington. The methods of
repair. repair used by hand surgeons in Australia include use
of a four-strand core suture, careful consideration of
SUMMARY
pulley management, and a trend toward active move-
Australian surgeons have made important contributions ment in rehabilitation, but the precise methods vary
in the field of flexor tendon repair, including key work widely and are the subject of healthy debate.
References
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Injuries, Edinburgh, 1953, E & S Livingstone. 1999.
2. Pennington DG: The locking loop tendon suture, Plast Recon- 20. Strick MJ, Filan SL, Hile M, et al: Adhesion formation after
str Surg 63:648–652, 1979. flexor tendon repair: A histologic and biomechanical com-
3. Mason ML, Allen HS: The rate of healing of tendons: An parison of 2- and 4-strand repairs in a chicken model, J Hand
experimental study of tensile strength, Ann Surg 113:424– Surg (Am) 29:15–21, 2004.
459, 1941. 21. Sandow M, Kay S: Flexor tendon injuries. In Prosser R,
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1969. cal performance of the 4-strand cruciate flexor tendon repair,
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a severed digital flexor tendon, Plast Reconstr Surg 60:468– 23. Dona E, Turner AW, Gianoutsos MP, et al: Biomechanical
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22:125–127, 1997. vivo porcine study, Hand (NY) 4:113–118, 2009.
8. Pribaz JJ, Morrison WA, Macleod AM: Primary repair of flexor 25. Matheson G, Nicklin S, Gianoutsous MP, et al: Comparison
tendons in no-man’s land using the Becker repair, J Hand Surg of zone II flexor tendon repairs using an in vitro linear cyclic
(Br) 14:400–405, 1989. testing protocol, Clin Biomech (Bristol, Avon) 20:718–722,
9. Callan PP, Morrison WA: A new approach to flexor tendon 2005.
repair, J Hand Surg (Br) 19:513–516, 1994. 26. Vizesi F, Jones C, Lotz N, et al: Stress relaxation and creep:
10. Tonkin M, Lister G: Results of primary tendon repair with viscoelastic properties of common suture materials used
closure of the tendon sheath, Aust N Z J Surg 60:947–952, for flexor tendon repair, J Hand Surg (Am) 33:241–246,
1990. 2008.
11. Singer D, Doi K, Morrison WA, et al: Comparative study of 27. Schreuder FB, Scougall PJ, Puchert E, et al: Effect of suture
the use of prefabricated bone tendon grafts and conventional material on gap formation and failure in type 1 FDP avulsion
tendon grafts in flexor tendon reconstruction, J Hand Surg repairs in a cadaver model, Clin Biomech (Bristol, Avon)
(Am) 14:830–836, 1989. 21:481–484, 2006.
12. Singer DI, Morrison WA, Gumley GJ, et al: Comparative study 28. Latendresse K, Dona E, Scougall PJ, et al: Cyclic testing of
of vascularized and nonvascularized tendon grafts for recon- pullout sutures and micro-mitek suture anchors in flexor digi-
struction of flexor tendons in zone 2: An experimental study torum profundus tendon distal fixation, J Hand Surg (Am)
in primates, J Hand Surg (Am) 14:55–63, 1989. 30:471–478, 2005.
13. Honner R, Meares A: A review of 100 flexor tendon recon- 29. Schreuder FB, Scougall PJ, Puchert E, et al: The effect of mitek
structions with prosthesis, Hand 9:226–231, 1977. anchor insertion angle to attachment of FDP avulsion inju-
14. Tonkin M, Hagberg L, Lister G, et al: Post-operative manage- ries, J Hand Surg (Br) 31:292–295, 2006.
ment of flexor tendon grafting, J Hand Surg (Br) 13:277–281, 30. Stewart DA, Smitham PJ, Nicklin S, et al: A new technique for
1988. distal fixation of flexor digitorum profundus tendon, J Plast
15. Savage R: In vitro studies of a new method of flexor tendon Reconstr Aesthet Surg 61:475–477, 2008.
repair, J Hand Surg (Br) 10:135–141, 1985. 31. Dona E, Walsh WR: Flexor tendon pulley V-Y plasty: An alter-
16. Strickland JW: Development of flexor tendon surgery: Twenty- native to pulley venting or resection, J Hand Surg (Br) 31:133–
five years of progress, J Hand Surg (Am) 25:214–235, 2000. 137, 2006.
17. Pulvertaft RG: Repair of Tendon Injuries in the Hand: Hunt- 32. Stewart DA, Smitham PJ, Gianoutsos MP, et al: Biomechani-
erian Lecture delivered at the Royal College of Surgeons of cal influence of the vincula tendinum on digital motion after
England on 6th February, 1948, Ann R Coll Surg Engl 3:3–14, isolated flexor tendon injury: A cadaveric study, J Hand Surg
1948. (Am) 32:1190–1194, 2007.
18. Boyer MI, Gelberman RH, Burns ME, et al: Intrasynovial 33. Ansari U, Lawson RD, Peterson JL, et al: Effect of partial versus
flexor tendon repair. An experimental study comparing low complete circumferential repair on flexor tendon strength in
and high levels of in vivo force during rehabilitation in cadavers, J Hand Surg (Am) 34:1771–1776, 2009.
canines, J Bone Joint Surg (Am) 83:891–899, 2001. 34. Ihsheish W, Smith BJ, Hile MS, et al: Suture handling reduces
19. Silva MJ, Brodt MD, Boyer MI, et al: Effects of increased in suture strength. 2010 Australian Hand Surgery Society Annual
vivo excursion on digital range of motion and tendon strength Scientific Meeting, March 17-20, 2010, Canberra, Australia.
H The Wellington Experience
Mark A. Rider, MBChB, FRCS, FRACS
OUTLINE impinging on the tendon repair. The A2 and A4 pulleys

were preserved during suturing of the tendons. However,
A series of prospective reviews is presented, showing subsequent venting was allowed if there was impinge-
how stepwise changes in repair techniques lead to ment of the repaired tendon during passive on-table
dramatic improvements in outcomes. Our currently testing. There was a varying degree of consultant super-
preferred technique, and the rationale for it, is dis- vision, with most of the work done by trainees. The
cussed. Some aspects of working as a hand surgeon in rehabilitation protocol was unchanged throughout all
New Zealand are mentioned. Finally, some guidelines periods (“modified Belfast” early active, commencing at
for preventing repair rupture are offered. 48 hours). The main outcome measures were rupture
Multiple revolutions of the audit cycle are a power- rate and range of movement by original Strickland at 12
ful means of improving outcomes. The outcomes have weeks, assessed by the hand therapists in a standard
been improved drastically with progressive decreases manner. After review of each period’s results, one or two
in the rupture rates of the tendons over the past 10 aspects of the repairs were changed, and the process
years with different surgical repair methods. Currently repeated. The results of these are summarized in Table
the four-strand Adelaide repair with Fiberwire and 13(H)-1.
postoperative controlled active motion is a successful The first review was conducted in September 2000
combination in our practice. and was retrospective over the previous 6 months. No
protocols existed in the unit at that time, resulting in a
“If you cannot measure it, you cannot improve it” is one wide range of repair and suture types, modified Tajima
of many quotes attributed to Lord Kelvin. It is certainly with 3-0 and 4-0 Prolene predominating. The data were
possible to measure the results of flexor tendon repair, markedly incomplete, but of the 10 patients who were
but this is not commonly done by surgeons. I submit followed, 2 had rupture. The initial recommendation
that measuring the results of our current practice, and was to start a prospective audit.
then making incremental changes based on the outcomes An 18-month prospective review was completed in
and literature reviews, may yield great benefits for our October 2002. The repairs were mainly modified Tajima
patients. Some surgeons rarely change their techniques, with 3-0 and 4-0 Ticron or Ethibond, and a simple
ignoring important new developments; some change running epitendinous, on 37 patients with 49 tendons.
constantly, following every fashion but having little idea The follow-up rate was low, but of the 21 patients fol-
of their results. For me, a middle way has proved useful, lowed up, 7 had rupture! The obvious recommendation
and I present a series of flexor tendon reviews to illus- was to move to a multistrand repair. We selected a cross-
trate this. locked cruciate repair (Figure 13[H]-1).
The next review covered a 2-year period to August
2005. The repairs were all Adelaide with 3-0 or 4-0
THE AUDITS
Ethibond, plus a variable epitendinous repair, most
The research method was the same for each period. All usually Silfverskiöld. The rupture rate plunged to 1 of
adult patients presenting with completely divided flexor 23 patients, with 82% excellent or good.
tendons within zone 2 of the fingers were enrolled. The For the next audit, the repair type was left unaltered
study patients were treated in the same way as all other but the suture material was changed to 4-0 Fiberwire
patients with hand injuries who were admitted to the (Arthrex Naples, FL). This final review covered an
unit; although the aim was to perform surgery on the day 18-month period. There were no ruptures, and 96% of
of presentation, delays of up to 48 hours were common. fingers achieved Strickland excellent or good results.
Both deep and superficial tendons were repaired. If
the flexor digitorum superficialis (FDS) was large enough DISCUSSION
to accept a core suture, this was the same type as used
for the flexor digitorum profundus (FDP). Partial inju- Benefits of Serial Audit
ries of critical pulleys were not repaired. The synovial I hope the improvement in our (initially appalling)
sheath was loosely repaired if this could be done without results is a convincing demonstration of the benefits of
168
Chapter 13H: The Wellington Experience 169
Table 13(H)-1 The Results of Tendon Repairs for Each Period Reviewed
Ruptures
Patients Fingers
Lost to Fingers Good or Rate (%,
Year Patients Fingers Tendons Follow-Up Followed-Up Excellent (%) Patients Fingers Fingers)
2000 15 21 26 5 15 7 2 3 20
2002 37 42 49 16 23 43 7 7 33
2005 33 41 61 10 28 82 1 1 4
2007 32 39 43 10 28 96 0 0 0
serial audits. Much of the improvement was no doubt The Nature of Hand Injuries and Their
due to the change to a four-strand repair. However, I Management in New Zealand
think there are other, less tangible benefits, particularly New Zealand has in the past had a much higher
the greater involvement by senior surgeons and the incidence of occupational injury than the safest of
general focus on quality and excellence by the whole the Northern European countries, although rates are
unit. improving. The occupations with the highest rate of
hand injuries are machine operators, construction, for-
The Change to a Four-Strand Repair estry workers, and meat processing workers.5 The last
We anticipated that the selection of the cross-locked two occupations are relatively common in New Zealand
cruciate repair (known locally as the Adelaide repair) compared to more industrialized countries and may in
would provide a good compromise between strength part explain the high numbers of hand injuries. Perhaps
and difficulty of insertion. Our unit is typical of many surprisingly considering the high cost of these injuries,
large public hospital services in that many of the flexor etiological and preventable factors for work-related
tendon repairs are performed by unsupervised, rela- hand injuries are poorly studied worldwide.6 In our
tively junior trainees. More complex repair patterns may experience, meat processors were the group with the
be stronger when performed by experts, but in our “real highest work-related cause of flexor tendon injury. Pos-
world” situation are also more likely to be poorly sible risk factors include blunt knives, removing protec-
inserted. Studies confirming the favorable properties of tive gloves, the cold environment, and the high turnover
the Adelaide repair are now starting to appear.1 rate of staff. From a surgeon’s point of view, the injuries
were usually sharp and tidy, although they carried a risk
Fiberwire of infection from raw meat.
As we completed our penultimate audit, we became
interested in Fiberwire. Some early reports attested to its Targets
high strength compared to preexisting suture materials, An essential part of audit is to identify best practice from
Fiberwire showing less gap formation at all loads and the literature. Establishing a realistic target for rupture
the greatest load to failure. A subsequent study con- rates is not a simple matter. During the 1990s, rates of
firmed its strength with locking repairs.2 Some of the well over 4% were regularly reported. It is difficult to
benefit may be illusory due to its nonstandardized size: judge these. On the one hand, they came from well-
a 4-0 Fiberwire may be much stronger than a 4-0 Ticron, known centers and could perhaps be presumed to be
but it is also thicker.3 We remain happy to use Fiberwire, best practice. On the other hand, many of the larger
but note some recent studies raising caveats, in particu- series were from British public hospitals and undoubt-
lar poor knot holding requiring more throws (and edly included the results of unsupervised junior
therefore greater bulk of suture material).4 surgeons.
In reviewing more recent publications, we can con-
clude that rupture rates from two-strand repairs are not
improving with time. However, there are a number of
reports of multistrand repairs with very low rupture
rates, although with small numbers of patients. One of
the largest recent reports of four-strand repairs gives a
headline rupture rate of 2%.7 If we extract from the
authors’ results only the zone 2 repairs, the rate rises
to 3.7%. Almost all the repairs were performed by
Figure 13(H)-1 Four-strand locked cruciate repair method. trainees.
It seems likely that ruptures will continue for the zone 2 of less than 4% and Strickland good/excellent
foreseeable future, despite improvements in repair types result of greater than 80%. An experienced hand surgeon,
and ongoing research into biological factors. We cer- reviewing his or her own repairs, should aim for a
tainly do not expect our rupture rate to remain at zero. rupture rate approaching zero and good/excellent results
Patient irresponsibility is a factor in many ruptures.8 In in greater than 90%.
our series, we saw early ruptures in one patient playing
CONCLUSION
competitive rugby and another using a chainsaw having
first climbed a ladder. These incidents occurred despite We have shown how multiple revolutions of the audit
presumably adequate education from an expert and cycle are a powerful means of improving outcomes. We
well-staffed hand therapy service. believe this should be a mandatory activity in every
I suggest that a specialist hand unit, with some repairs hand unit. The Adelaide repair Fiberwire and controlled
performed by trainees, should obtain a rupture rate in active motion is, for us, a successful combination.
References
1. Croog A, Goldstein R, Nasser P, et al: Comparative biome- 6. Sorock GS, Lombardi DA, Courtney TK, et al: Epidemiology
chanic performances of locked cruciate four-strand flexor of occupational acute traumatic hand injuries: A literature
tendon repairs in an ex vivo porcine model, J Hand Surg (Am) review, Saf Sci 38:241–256, 2001.
32:225–232, 2007. 7. Caulfield RH, Maleki-Tabrizi A, Patel H, et al: Comparison of
2. Miller B, Dodds SD, deMars A, et al: Flexor tendon repairs: zones 1 to 4 flexor tendon repairs using absorbable and
the impact of fiberwire on grasping and locking core sutures, unabsorbable four-strand core sutures, J Hand Surg (Eur)
J Hand Surg (Am) 32:591–596, 2007. 33:412–417, 2008.
3. Scherman P, Haddad R, Scougall P, et al: Cross-sectional area 8. Harris SB, Harris D, Foster AJ, et al: The aetiology of acute
and strength differences of fiberwire, prolene, and ticron rupture of flexor tendon repairs in zones 1 and 2 of the fingers
sutures, J Hand Surg (Am) 35:780–784, 2010. during early mobilization, J Hand Surg (Br) 24:275–280,
4. Waitayawinyu T, Martineau PA, Luria S, et al: Comparative 1999.
biomechanic study of flexor tendon repair using Fiberwire,
J Hand Surg (Am) 33:701–708, 2008.
5. Burridge JD, Marshall SW, Laing RM: Work-related hand
and lower-arm injuries in New Zealand, 1979 to 1988, Aust
N Z J Pub Health 21:451–454, 1997.
CHAPTER
14
PARTIAL TENDON
LACERATIONS
Morad Askari, MD, and Peter C. Amadio, MD
OUTLINE on complete laceration of flexor tendons with much

smaller focus on partial tendon laceration.
Many patients with partial tendon laceration come The controversy centered on the repair of partial
to the clinic several weeks after the injury due to tendon laceration was initiated by the work of Wray and
persistence of symptoms, by which time the cutane Weeks2 in a chicken model where nonrepaired partially
ous wound may be healed and closed. Evidence of lacerated flexor tendons were deemed better than those
triggering or entrapment is adequate indication for repaired. This result was similarly confirmed by Reyn
exploration of the wound. Partial tendon lacerations olds et al3 in a similar model. Just a few years later, the
can also be seen in a large wound together with com concept of not repairing partially lacerated tendons was
plete lacerations of other tendons, which are easy to challenged by Kleinert and others.4 They advocated that
diagnose. partially lacerated tendons should be treated similarly
The degree of laceration directly impacts tensile to complete lacerations, emphasizing that this type of
strength of the injured tendon. However, with even injury required the same diligence in surgical repair and
larger degrees of laceration, the tendon retains enough postoperative care. In their series, they reported signifi
tensile strength to withstand most active motion. The cant rise in complications following nonrepair of partial
volar location of the laceration may lower a clinician’s flexor tendon lacerations. Similarly, around the same
threshold for surgical repair. A lesser degree laceration time, Janecki5 reported on two cases of entrapment fol
(<40% to 50%) may not need surgical repair. A tendon lowing nonoperative treatment of partially lacerated
laceration >50% to 60% usually needs surgical repair. flexor tendons. The sentiment to repair this type of
Repair of partial tendon lacerations decreases the tendon injury was further echoed by Schlenker and
chance of tendon triggering and improves tendon coworkers,6 who reported a significant increase in trig
excursion. The partially lacerated tendon can be treated gering, entrapment, and rupture among other complica
with a circumferential suture with or without core tions when these lacerations were not repaired. They
suture technique. Core sutures are used in large degree recommended the repair of all lacerations greater than
(>60% to 75%) partial laceration. The lacerated parts 25%. They favored modified Kessler core suture tech
can be trimmed to reduce triggering in partial tendon nique along with a running epitendinous suture for
lacerations up to 75%. Complications of untreated lacerations greater than 50% while for those between
lacerations include triggering, entrapment, and rupture 25% and 50%, a running braided polyester suture was
of the tendons. suggested. For laceration less than 25%, excision of the
distally based flap was recommended to avoid triggering
While little controversy exists today on necessity of or entrapment in the pulley. However, since these
complete tendon laceration repair, the topic of treating studies, a series of in vitro biomechanical studies along
partial tendon laceration remains a subject of debate in with in vivo animal studies has resulted a better under
hand surgery. Opinions are divided on whether man standing of the properties of partially lacerated tendons
agement of partial tendon laceration is best achieved and a shift in paradigm of treatment of partial tendon
through surgical or nonsurgical approach.1 This con injury.
troversy, in part, stems from fewer in vivo studies of
DIAGNOSIS AND PHYSICAL EXAMINATION
partial as opposed to complete tendon laceration in the
literature many with conflicting results. In part, this Clinically most patients have normal active motion, and
could also be due to fewer cases of partial tendon lacera cutaneous wounds are either rather small or healed.
tion properly diagnosed in clinical practice. Thus, major Identifying partial tendon laceration is a challenge.
ity of studies have used in vitro cadaveric or animal Partial tendon laceration classically presents as painful
models. Additionally, a majority of these studies focus and weakened tendon excursion as opposed to absence
171
of active finger flexion or any excursion as would be tendon with 30% laceration had histological evidence
expected with complete laceration. However, without of amorphous connective tissue in the tendon gap with
direct visualization through an open wound or an nascent collagen fibers bridging across the tendon edges,
imaging modality, determining the degree of laceration the 60% and 90% lacerated tendons showed little evi
based on clinical exam is not possible. In majority of dence of healing with no collagen present in the gap at
cases, an opening in the skin at the site of trauma can 35 days.
serve as a window for initial examiner to characterize
BIOMECHANICAL PROPERTIES OF PARTIAL
the degree of tendon laceration as a percentage of intact
TENDON INJURY
tendon width. This measurement is commonly done
using a caliper. Interestingly, it has been showed that The majority of experimental data on partial tendon
neither caliper measurement nor estimation with naked- injuries is the result of years of investigation using in
eye provides consistent and reliable means of assessing vitro cadaveric and animal tendons in addition to a
the degree of laceration when managing partial tendon smaller number of in vivo studies in animal models.
injuries.7 Yet, these are tools used by most in estimating The popular animal models for their proximity to
degree of tendon injury. human tendon anatomy are the canine, chicken, sheep,
Many patients with partial tendon laceration may and pig models. Majority of effort in understanding
present several weeks after the injury due to scheduling partial tendon injury has been associated with flexor
or persistence of symptoms, by which time the wound tendons specifically in zone 2.
may be healed and closed. Evidence of triggering or Gap formation in the context of partial tendon injury
entrapment is adequate indication for exploration of the is an important point of clinical interest because its
wound. If a moderate index of suspicion exists for explo increase is associated with higher gliding resistance, trig
ration, an imaging study such as ultrasound or magnetic gering, and delay in healing.14,15 Gapping beyond 2 mm
resonance imaging is beneficial. Partial tendon lacera is harmful to tendon healing.14
tion can also occur with other tendons lacerated com
pletely in a larger wound, which is easy to diagnose. Tensile Strength and Cross-Sectional Area
Feared sequelae of improperly treated partial tendon
PHYSIOLOGY OF TENDON HEALING
laceration include triggering, loss of entrapment, adhe
Through significant contribution early in the 20th sion formation, or late rupture. It is intuitive that partial
century by Mason, Allen, and Shearon8,9 an understand lacerated tendons would be weaker than intact tendons.
ing of various stages of tendon healing was developed. Additionally, some had suggested formation of a scar
Following injury, the tendons enter an exudative phase mass at the laceration sites if a partial injury were to go
of tendon healing (0 to 14 days) followed by a reparative nonrepaired, thus adversely affecting tendon function.4
phase (15 to 35 days). An understanding of the phases It is our presumption that many such tendons if they
in tendon healing is important in choosing appropriate were to be repaired would like be subjected to more
time point for biomechanical and biological studies. The rigorous immobilization postrepair than if they were
healing tendon is strongest at day 1 with this strength left alone. In the following sections, the evidence that
dropping by day 5. The lost strength is gradually restored has shaped our current approach to partial tendon
starting around day 15 and continues until the end of injury is reviewed. Of note, the great focus in study
the reparative phase. The exact length of time for the partial tendon lacerated has involved mainly flexor
tendon to reach maximum strength appears to extend tendons and attention specifically to zone 2 injuries in
beyond the 5th week. The above authors also demon part due to the historical poor outcome of injury in this
strated that the weakest sight on an undamaged tendon area. Many times, the clinicians inadvertently extrapo
corresponded to the musculotendinous junction and late this information to treatment of flexor tendon in
the tendon–bone insertion. This group was among the other zones and to extensor tendon injuries.
first to suggest that early motion resulted in increase in In the recent decades, several studies have pointed
strength and function of partially lacerated tendons. In toward early active finger motion to decrease adhesion
addition to tensile strength, the concepts of tendon formation and improve tendon gliding.16-18 While
gliding and resistance against motion were emphasized rupture of partially lacerated tendons has been dis
in the context of tendon repair. Many have shown the cussed as a complication of early motion and no repair,
deleterious effects of immobilization on tendons and many have shown this to be a more minimal concern
the subsequent change in substance constituents and than previously thought. In a series of 34 partial tendon
weakening of their insertion sites.10-12 lacerations ranging from 25% to 95% laceration of the
The degree of laceration has an effect on tendon cross-sectional area of the tendon, no rupture occurred
healing. In an in vivo canine model of partial flexor following non surgical management even in the 11 cases
tendon injury, Cooney and others13 noted that the with more than 75% laceration. All but one case had
greater lacerations had less evidence of healing. While good to excellent function.19 Several studies have
Chapter 14: Partial Tendon Lacerations 173
characterized the strength of partially lacerated tendon. Early Mobilization and Tendon Remodeling
While the tensile strength of the tendon decreases as the As hesitations to mobilize patients with partial tendon
cross-sectional area of laceration increase, these studies lacerations due to risk of rupture are lessened through
support that a partially lacerated tendon in most cases the mentioned studies, early mobilization was advo
retains sufficient tensile strength to withstand motion cated to increase tensile strength and to improve mor
and loading. In chickens, Reynolds and others3 showed phology of the nonrepaired partially lacerated tendons.
the mean tensile strength of unsutured tendons to be Wray and others26 showed that early motion accelerates
higher than the sutured repairs at both 2 and 4 weeks return of tensile strength to partially lacerated tendons.
of unrestricted motion after surgery. Dobyns and others20 Similarly, Reynolds and others3 showed that immobi
demonstrated that 30% of lacerated tendons retain 80% lized repaired tendons were weaker than nonrepaired
of their original strength, while 75% of lacerations partially lacerated tendon following unrestricted
maintain 40% and 90% of lacerations have 25% of the motion. This finding may be due to a more pronounced
strength. Hariharan and others7 looked at the tensile intrinsic healing with early motion.27 Using an in vivo
strength of 50% and 75% volarly lacerated flexor canine model, Bishop and others24 studied the relative
tendons in cadavers and compared the failure loads to effects of immobilization, early protected mobilization,
in vivo forces measured in human flexor tendons during tendon repair, and no repair by paired comparison to
unresisted active finger movement. Failure loads for contralateral side. Early motion improved stiffness and
50% lacerated tendon were almost twice as much as excursion significantly. Under scanning electron micros
the failure load for 75% lacerated ones. However, the copy, these tendons had more nearly normal morphol
failure values for both degrees of laceration far exceeded ogy compared with immobilized tendons. They also
the in vivo values required for unresisted active finger found a decrease in breaking strength and stiffness in
movement.21 tendons that had undergone repair compared with no
McCarthy and others7 noted a tendency for tendons repair. They concluded that tendon lacerations up to
to fail at the site of partial laceration when the cross- 60% of the cross-sectional area of the tendon should be
sectional area of laceration was equal or greater than treated with early protected mobilization with no
60% in an in vitro canine model. At this degree of lac attempt to repair.24 Kubota and others,28 in their in vivo
eration, they noted a 22.8% decrease in stiffness, 41.5% chicken model, documented that early motion and
decrease in failure loads, 15.6% decrease in percent tension on partial tendon injuries resulted in superior
elongation, and 56.2% decrease in energy absorbed biological remodeling. Grewal and others29 compared
compared with intact tendons. The structural properties canine tendon healing 3 weeks after passive to active
change adversely with increasing degree of laceration.7 rehabilitation following 60% tendon laceration. The
As inflicted lacerations through tendons are most tendons were repaired with modified Kessler suture in
commonly not transverse, the effect of the direction of one and were left nonrepaired in the other group. In
laceration and its impact on tensile strength becomes each group, a subgroup underwent immediate active
important. Tan and others22 have shown that obliquity mobilization while the other subgroup underwent
of tendon laceration affects the strength of partially lac passive motion. No difference was found in tendon
erated tendons. Using pig tendons lacerated to 90% of excursion, stiffness, or load to failure between passive
their diameter, they found that lacerations with 45° and versus active mobilization or repair versus nonrepair
60° had significantly less ultimate tensile strength com groups. However, gapping was significantly increased
pared with transverse, 15° or 30° oblique laceration.22 among the active rehabilitation group compared to the
passive rehabilitation group. The authors concluded
Tensile Strength and Repair that active rehabilitation is safe in lacerations up to
Several studies have investigated the effect of suture 60%, but gapping at 3 weeks raises the concern for
repair and subsequent immobilization on tensile future complication in tendon healing.29
strength of partially injured tendons. Suturing may
impair the vascularity of the tendon and damage tendon Tendon Gliding and Resistance
cells.23 Ollinger and others24 found that sutured tendons Unresisted gliding is important for normal tendon func
(Bunnell method) after partial laceration had less tensile tion. Proponents of surgical repair of partial tendon
strength than nonrepaired controls. Similar results were laceration have argued that presence of flaps at the non
replicated by Bishop and others.25 In a canine model, repaired site may result in triggering, entrapment in the
areas of tendon adjacent to the repair site had necrosis, pulley, and eventual rupture of the tendon.4-6 However,
which explains the diminished tensile strength.25 following surgical repair, the bulk of surgical repair and
Cooney and others12 showed in a similar model, that rough tendon surfaces can result in higher gliding resis
for 30%, 60%, and 90% lacerated canine flexor tendons, tance. This in turn may adversely affect the rehabilita
nonrepaired tendons had a greater mechanical strength tion process.30,31 In an in vivo chicken study, Ollinger
at 14 and 35 days compared with the repaired tendons. and others24 showed not only a decrease in tensile
strength but also a decrease in tendon gliding following results have resulted in a general consensus among clini
exposure and tenorrhaphy of partial tendon lacerations. cians to repair tendon laceration of 50% and greater
Early postoperative motion can restore smooth tendon based on a survey by McCarthy and others.1 Tendon
surface and improve gliding.32 Al-Qattan and others33 retains adequate tensile strength despite greater than
studied triggering and tendon flap formation over an 50% laceration of their cross section. Yet, structural
8-week period in an in vivo sheep model with 50% properties of the tendon are detrimentally affected with
lacerated flexor tendons without surgical repair. Trigger greater laceration. Tan and others39 have found benefi
ing occurred not due to bulbous scar formation but due cial effect to peripheral suture repair versus no repair of
to “bunching” of the tendon fibers proximal and distal 60% to 90% lacerated pig tendons. They noted a signifi
to the area of laceration. With time and mobilization, cant increase in load to failure and increase in gap for
these fibers became incorporated into the healing mation forces with this type of repair. On the other
process resulting in spontaneous resolution of trigger hand, Boardman and others40 found no significant dif
ing in majority of tendons.33 Various suturing tech ference in repair versus nonrepair of a 70% canine
niques result in different degree of friction and resistance tendon laceration. Stahl and others41 found no signifi
at tendon–pulley interface. Zhao and others34 character cant benefit to repair of the tendon lacerations up to
ized gliding resistance with several suture techniques on 75% in children versus no repair.
the 80% lacerated tendons using cadaveric tendons.
Modified Kessler repair had the least resistance com Peripheral Suture or Core Suture Repair
pared to Kessler, Savage, Tsuge, or Becker techniques. Using an in vitro sheep model, Haddad and others42
Yet, on average, there was an average increase of 1.08 N studied the effect of repair versus nonrepair on 75%
in gliding resistance of the tendon following repair, lacerated flexor tendons. Repairs included a group with
which is sufficient to limit tendon gliding during passive only peripheral sutures and a group with peripheral
motion (average 0.49 N).34 sutures plus a core sutures. After cyclic loading, the
Location as well as the degree of laceration of the nonrepaired group had 2mm or greater gap formation,
tendon also impacts the gliding resistance. Erhard and while either repair resulted in 1mm or smaller gap with
others35 compared volar and laterally transected tendons no significant difference between the two repair groups.
in an in vitro cadaver model. The degree of laceration Load to failure values between the two repair groups
in two different groups was 50% and 75%. Increase in were also not different. Using cadaveric tendons with
laceration resulted in greater gliding resistance. More 75% laceration, Zobitz and others43 compared different
interestingly, volar partial laceration resulted in greater core sutures combined with a peripheral suture to
gliding resistance in comparison to lateral transections peripheral sutures alone (Figure 14-1). With static
for both 50% and 75% lacerations.35 testing, they did not find any difference in gap forma
tion among the groups though an increase was recorded
Tendon Nutrition and Adhesion Formation in load to failure and stiffness among the repairs with
Formation of adhesion limits gliding ability of the core sutures.43 Neither of these two studies found a
tendon. Aside from potentially creating large physical mechanical disadvantage to having a core suture on the
mass that impedes proper excursion of the tendon at integrity of the tendon. This is in contrast to earlier
the pulley, the act of tendon repair may result in more studies looking at lesser laceration injuries where core
inflammation and adhesion formation. Suture repair suture weakened the tendon.24,25 Thus, it can be sug
and tendon immobilization contribute to adhesion gested that high degree lacerations (>70%) benefit from
formation.36 Chow and Yu37 observed more extensive repair. We recommend surgical repair with a large degree
adhesion and decrease in tendon gliding when unre of partial laceration.
paired incomplete tendon lacerations of greater than Another concern with repairing partial tendon lacera
50% were immediately moved, compared with those tion is its effect on gliding resistance. Presence of suture
repaired and immobilized. was shown to increase tendon gliding resistance by four
times that of intact tendons in zone 2.34 In high-degree
SURGICAL REPAIR OF PARTIAL laceration where a repair may be advocated, it is impor
TENDON INJURIES tant to use a suture technique that minimizes tendon
gliding resistance. As discussed previously, Zhao and
Surgical Repair or Nonrepair others34 had demonstrated in 80% lacerated tendons,
The exact extent of the lacerated tendon cross section repair with modified Kessler technique plus a peripheral
that warrants repair remains unknown. Schlenker and suture results in least resistance compared with other
others6 had recommended repairing laceration greater repairs in cadaveric tendons. Since adhesion formation
than 50% with modified Kessler and running peripheral is related to gliding resistance, it is intuitive that the
suture. Balk and others38 recommended similar repair suture techniques with lesser resistance will result in
for a slightly higher cutoff of 60% laceration. These fewer adhesions. In the same model, Zhao and others45
`V
Excursion
V
Kessler Modified Kessler
Augmented Becker Savage (modified)
Figure 14-2 Trimming of partial tendon injury. In an effort

to prevent bulky scar formation and provide smooth gliding,
the lacerated edges of the tendon are trimmed as shown.
This technique is as effective as suture repair in reducing
gliding resistance of laceration up to 75%.
Tsuge reported positive result from trimming partial lacera

Lee (modified)
tions of some greater than 50%,. Erhard and others35
Figure 14-1 Six popular core suture techniques for repair showed that in cadaveric tendons lacerated to 50%
of partially lacerated flexor tendons. Modified Kessler
and 75%, trimming tendon edges would result in less
technique was noted to have the lowest gliding resistance.
gliding resistance than circumferential running repair
(Figure 14-2). Interestingly, both trimming and running
have shown at 3 and 6 weeks, the adhesion breaking repair resulted in greater gliding resistance at 50% lac
strength was significantly lower in tendon repaired with eration compared to no repair. This relationship changed
modified Kessler core suture technique. in fair of trimming or running repair at 75% volar lac
Direction of tendon laceration is an important factor erations compared to no repair. Trimming is indicated
in consideration. Tan and others22 had shown that as for minor partial laceration as well, to reduce the chance
the direction of laceration becomes more oblique of triggering.
(≥45°), the tensile strength of the tendon is decreased
for the same cross-sectional area of laceration. They
found a peripheral tenorrhaphy to significantly increase Protected early mobilization was shown to benefit
gap formation forces and load to failure in such lacera outcome of tendon repair including repair of partial
tion. Therefore, this may lead one to consider surgical injuries. Zhao and others46 have pointed to the impor
repair for oblique laceration with smaller cross-sectional tance of the synergistic wrist motion in postoperative
area than a transverse laceration. The same group has rehabilitation following partial flexor tendon lacera
also shown that an oblique direction to the laceration tions. Following repair of 80% lacerated flexor tendons
can weaken the conventional modified Kessler or cruci in their in vivo canine model, gliding excursion of the
ate repair but their mechanical strength was strength group that underwent synergistic wrist and finger motion
ened by orientating the repair strands parallel to the therapy was significantly greater than the group in which
laceration.45 Thus, the orientation of the laceration the tendon were rehabilitated with wrist fixation (45°
needs particular attention when choosing a core suture. flexion) and finger motion at 1, 3, and 6 weeks. Addi
tionally, synergistic wrist motion has been shown to
Trimming of the Partially Lacerated Tendons result in significantly less severe adhesions and less
An alternative to surgical repair of partial tendon lacera adhesion breaking strength at weeks 3 and 6.47
tions (≤75%) is trimming. The approach has been advo
COMPLICATIONS
cated to be the more superior treatment even in light of
higher-degree laceration. Schlenker and others6 recom In management of partial tendon injuries, the incidence
mended trimming beveled edges of tendons with less of complications is related to the degree of laceration of
than 25% of lacerations, while Al-Qattan and others33 the cross-sectional area of the tendon. The prevalent
COMPLICATIONS
Tag or flap Tendon sheath
Entrapment
Rupture
Flapping
Figure 14-3 Complications of nonrepair of partial tendon A

laceration include entrapment, triggering or flapping, or
ultimately rupture of the tendon. This rate has been related
to the extent of laceration, direction, or location of the injury
on the tendon.
complications are triggering, entrapment, and rupture

(Figures 14-3 and 14-4). Interestingly, for lesser lacera
tion, complications are more significant when repaired,
while for greater laceration, complications are more fre
quent when no repair is performed. The exact cutoff in
the degree of the laceration between these groups again
is not exactly known. Cooney and others13 demon
strated a higher complication rate with repair of 30% B
and 60% lacerated flexor tendons but lower incidence Figure 14-4 Triggering in a patient sustained a laceration
of complications with repair of 90% laceration flexor over his left thumb metacarpophalangeal joint crease
tendons in a dog model at 35 days. 3 weeks after he was treated with skin closure and
discharged from emergency department. He subsequently
SUMMARY
had triggering and persistent pain at the A1 pulley site.
Partially lacerated tendon has been shown to be stron A, Intraoperatively, tendon laceration was found smaller
ger than previously assumed. The degree of laceration than 50%, with a reactive scar mass at the site of injury.
directly impacts tensile strength of the injured tendon. B, The mass along with lacerated edges of the tendon
Yet, with even large degrees of laceration (<75% lacera were trimmed. Patient was asked to flex the thumb
intraoperatively to assure resolution of triggering at the
tion), the tendon retains enough tensile strength to
pulley. The pulley was left intact.
withstand most active motion. The degree of obliquity
and the volar location of the laceration are features that
may lower a clinician’s threshold for surgical repair of a the method of tendon repair and the motion regimen.48
lesser degree laceration. With or without core suture technique, adding circum
Many have pointed out the benefits of surgical repair ferential sutures results in equivalent results when the
for large partial lacerations (>60% to 75%). Repair in laceration is less than 75%. We recommend core suture
these cases will improve tendon excursion, lower the repair of the greater degree of partial laceration. Trim
resistance during rehabilitation, and protect the integrity ming can be as effective as suture repair in reducing
of intact tendon portion. Improving postoperative gliding resistance of laceration up to 75%. Early passive
smoother tendon gliding surface and avoiding triggers or active motion is recommended after surgery.
are the major reasons for repair of the partially cut Over the past 50 years, the paradigm of management
tendon rather than restoring tensile strength, as the of partial tendon laceration has shifted thanks to the
tendon usually retains sufficient strength, but the cut active work, observations, and investigations of many
portion can be entrapped during tendon motion. The astute clinical scientists. We now have a wealth of infor
entrapped partially cut tendon may be torn entirely mation regarding the biomechanical properties tendons
or resist tendon motion. Early active motion and syner in the context of various degrees of laceration, different
gistic wrist motion are beneficial for proper healing modes of repair, and rehabilitation. Yet, many more
and remodeling of the tendon and lower the chance for years of research is necessary to create a consensus in
complications. Postoperative tendon gliding depends on different aspects of partial tendon injuries.
References
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12. Woo SL, Gelberman RH, Cobb HG, et al: The importance tendon healing and restoration of the gliding surface: An
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pp 148–155. fundus tendon in vitro, Clin Biomech (Bristol, Avon) 16:696–
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21. Hariharan JS, Diao E, Soejima O, et al: Partial lacerations ment of repair versus nonrepair of sheep flexor tendons
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43. Zobitz ME, Zhao C, Erhard L, et al: Tensile properties of 46. Zhao C, Amadio PC, Zobitz ME, et al: Effect of synergistic
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tendons in vitro, J Hand Surg (Am) 26:821–827, 2001. Clin Orthop Relat Res 396:223–230, 2002.
44. Zhao C, Amadio PC, Momose T, et al: The effect of suture 47. Zhao C, Amadio PC, Momose T, et al: Effect of synergistic
technique on adhesion formation after flexor tendon repair wrist motion on adhesion formation after repair of partial
for partial lacerations in a canine model, J Trauma 51:917– flexor digitorum profundus tendon lacerations in a canine
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45. Tan J, Wang B, Xu Y, et al: Effects of direction of tendon lac 48. Zhao C, Amadio PC, Momose T, et al: Remodeling of the
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28:237–242, 2003. in vivo, J Orthop Res 20:857–862, 2002.
CHAPTER
15
FLEXOR TENDON INJURIES
IN CHILDREN
Shian Chao Tay, PhD, and Steven L. Moran, MD
OUTLINE identification of these injuries include difficulties or

inadequacy of physical examination. Many flexor
Finger flexor tendon injury in the pediatric population tendons injuries in children are due to lacerations with
is less frequent than in adults and is often caused by broken glass, which may produce a small skin laceration
a sharp cut, requiring primary repair. Advances in or puncture but is often associated with a high rate of
tendon repair techniques and the postoperative reha- injury to underlying vital structure.2
bilitation protocols are not always applicable to chil- Advances in flexor tendon repair techniques and the
dren. The size of the tendon can be less than 4 mm in introduction of early postoperative rehabilitation pro-
young children, making the placement of multiple tocols have improved the results of flexor tendon surgery
core sutures difficult. Depending on the size of the in adults over the last two decades.3-7 Unfortunately,
tendon, core suture size of 4-0 can be used, and a four- these advances are not always applicable to children
strand repair should be attempted. Epitenon sutures with flexor tendon injuries due to the size of their
should be one size smaller than core sutures, and sizes tendons and their compliance with therapy. The size of
5-0 through to 7-0 can be used. In older children, the profundus tendon can be less than 4 mm in young
four-strand or even six-strand repairs can be per- children, making the placement of multiple core sutures
formed. The principle is to have as strong a repair as difficult, particularly if larger suture material is used.
possible without making the repair site too bulky. In Finally, early motion protocols can result in flexor
zone 2 injuries, both the flexor digitorum profundus tendon rupture if the child is noncompliant with splint-
(FDP) and flexor digitorum superficialis (FDS) tendons ing or therapy. The purpose of this chapter is to review
should be repaired. Repair of FDP alone and discard- the pertinent issues in the management of flexor tendon
ing the lacerated FDS is not recommended. We recom- injuries in children, including clinical pearls for identi-
mend that all children under 7 years of age or who are fication, repair, and rehabilitation of these injuries in an
not cooperative be immobilized in an above elbow effort to improve outcomes of flexor tendon injuries in
cast for 4 weeks after surgery. Children who are older this age group.
than 7 years and who are judged to be compliant can
INCIDENCE
be started on early mobilization regimens. Unre-
stricted exercises are started after 4 weeks. In delayed Finger flexor tendon injury in the pediatric population
cases with extensive scarring, tendon grafting will be is less frequent than in adults. In a report from Helsinki,
necessary. If the pulley system is excessively damaged, the annual incidence is 3.6 per 100,000 children (<16
a two-stage tendon grafting procedure is indicated. years). Peak incidence is at 7 years of age. The ratio of
boys to girls was 3:1.8 Broken glass is the most common
Pediatric flexor tendon injuries remain a complicated mechanism of injury with some authors reporting
problem for the hand surgeon. The factors that contrib- nearly 80% of such injuries being caused by it.9-12 As in
ute to the difficulties in treating these injuries in chil- adults, zone 2 injuries are the most common injuries in
dren include difficulties in diagnosis, the technical children with the little finger being the most commonly
demands of the repair, and the child’s compliance with injured.10,13,14 The rate of concurrent digital nerve injury
postoperative therapy. Five decades ago, more than 90% range from 36% to 58%.8,11,12,14-16
of flexor tendon injuries in children were missed at the
DIAGNOSIS
time of the initial injury and thus were treated late with
flexor tendon grafting.1 Unfortunately, within the The assessment of flexor tendon injuries in the pediatric
present day, a significant percentage of flexor tendon population is difficult (Figure 15-1). Young children,
injuries in children still present late making primary particularly those under 6 years of age, cannot be
repair more difficult. Reasons for continued delays in expected to cooperate well with the examiner during the
179
A B
C D
Figure 15-1 A 2-year-old child suffered a laceration to
the small finger while playing on a slide. The laceration was
initially closed by the local emergency room physician 2
weeks prior to presentation to the hand surgeon for noted
lack of motion of the small finger. A, Note the lack of normal
cascade in repose. B, The lack of flexion of the small finger
with wrist extension tenodesis. C, Additional maneuvers to
identify flexor tendon injury include forearm compression
which should result in some flexion of the fingers, but none
is seen within the small finger of this child. D, The finger
was explored through a Bruner incision where a complete
laceration of the FDP and FDS tendons was noted in zone 2.
E, Tendon repair was performed with a four-strand core
repair using a modified Kessler technique followed by a
E
locked running epitendinous suture.
Chapter 15: Flexor Tendon Injuries in Children 181
hand exam.1 Observation and additional techniques

must be used to determine the status of the flexor
tendon in children. Previous reports by Bell and Mason
have also noted the importance of observation of the
child’s hand at rest and during play to look for signs of
active flexion or a loss of the normal cascade within the
hand.1,9 Children with older injuries will learn to adapt
to their injury and can gasp the injured finger with a
normal adjacent finger during flexion, thereby giving
the impression that active motion is being performed.1
This trick maneuver, called “trapping,” may initially
mislead both parents and examiners into thinking that
there is no disability.13
Missed diagnosis resulting in a delayed diagnosis
still accounts for 15% to 30% of pediatric patients
with flexor tendon injuries.8,11,14 The risk of delayed diag- Figure 15-2 Loss of tenodesis of the long finger with wrist
nosis and treatment is particularly high in children who extension.
are less than 6 years of age8 and, paradoxically, in chil-
dren who sustain injuries with small surface wounds
that bleed little.1 Wounds that bleed profusely often
compel parents to seek medical attention and the likeli- Radiographs of the injured finger or hand may be
hood of a missed flexor tendon injury is thus lower. useful in excluding a retained foreign body or underly-
Regardless, a high index of suspicion should always be ing fracture. Ultrasound has limited diagnostic accuracy
adopted when faced with a child with a hand or finger in an uncooperative child. Magnetic resonance imaging
laceration. (MRI) is expensive and requires a general anesthetic for
Examination begins with simple observation of the young children.13 Both modalities can be considered if
resting posture of the hand. In the normal situation, the the child is sedated.
fingers of the hand lie in a cascade with some flexion Concurrent injury to neurovascular structures should
being present in all the finger joints. A finger that is always be assessed. Vascularity of the finger is assessed
observed to be out of alignment from the normal finger in the usual manner by observation of color and contour
cascade may have a flexor tendon injury. If the joints in of the finger pulp. Capillary refill can be checked by
that finger are carefully observed, it may be possible to indenting the finger pulp and observing for the speed
even determine which flexor tendon is injured. In com- of refill. In dark-skinned individuals, finger pulp color
plete lacerations of both the flexor digitorum profundus may be difficult to assess. In such cases, the nail bed
(FDP) and flexor digitorum superficialis (FDS) tendons, is blanched by distal pressure on the nail and the
both the proximal interphalangeal (PIP) joint and distal speed of refill of the nail bed is observed when the
interphalangeal (DIP) joint will be extended. In isolated pressure is released. Hand-held Doppler exam may be
lacerations of the FDP tendon, only the DIP joint will used to aid in identification of unilateral digital arterial
be in extension with residual flexion present in the PIP injuries.
joint. In isolated FDS injury, the finger will lie out of the Examining for digital nerve injury in the child can be
normal finger cascade but there will be residual flexion virtually impossible if they are not able to understand
present in both the PIP and DIP joints. If the child or cooperate with the examination. As such, the usual
permits, the tenodesis effect can be elicited by perform- methods employed in the adults such as comparative
ing passive wrist flexion and extension to check for light touch and two-point discrimination tests may not
integrity of the flexor tendons (Figure 15-2). In a normal work. Thus, in children, nerve injury should always
situation, one should observe increasing flexion of all be suspected based on the location of the surface
finger and thumb joints with passive wrist extension. wound. The loss of resistance to glide using a plastic pen
Assuming that the child is cooperative and is able to can help in diagnosing the loss of sweating in a nerve
relax, flexor tendon injury should be suspected if there injury. Alternatively, the hand may be immersed in
is either absence of flexion or decreased amount of water at room temperature until skin wrinkling occurs.
flexion in a finger joint. Passive flexor tendon excursion As only innervated skin wrinkles, an area of unwrinkled
can also be performed by compression of the flexor skin indicates a likely nerve injury.13 In older injuries,
tendons in the distal forearm. Again, if there is absent dryness or trophic changes are clues to sensory nerve
flexion or decreased amount of flexion, this would disturbances.1 Surgical exploration under anesthesia
suggest a complete flexor tendon laceration (see Figure may be the only way to verify the condition of the
15-1C). nerves.9,13
tendon injury, up to 46% of flexor tendon injuries in

TREATMENT
children are still treated with plaster immobilization.8,14
In 1963, Entin stated that flexor tendon surgery in Most authors now agree that no benefit can be found in
children is more difficult and demanding than in instituting early mobilization protocols in children.11,14-16
adults and requires meticulous attention to handling of The Mayo Clinic group found that children started on
tissues as the structures are so delicate.9 Many authors early mobilization had a TAM of 78%, whereas those in
have also advocated that only surgeons trained in hand the immobilized group, 82%, using the Strickland and
surgery should perform such operations.3,4,9,10 Absorb- Glogovac formula.14 Fitoussi et al reported a mean TAM
able sutures should always be used for wound closure of 87% for the group with early mobilization versus 86%
so as to avoid another anesthetic exposure for suture in the immobilized group.16 Berndtsson and Ejeskär
removal.13 reported 79% mean TAM in the group with Kleinert
The options for tendon repair in children are as protocol versus 74% in the immobilized group.11 None
varied as they are in the adult patient. The literature is of these differences were statistically significant.
scant with regard to comparative studies, but most series It is well known that flexor tendon healing is more
favor some type of four-strand repair with an epitendi- rapid in children.9,10 In children, the distances between
nous suture. Navali and Rouhani reported one rupture the vinculi are shorter so that the relative blood supply
in a group of children less than 4 years of age with a per square centimeter of tendon substance is consider-
two-strand repair while there were no ruptures in the ably better than in the adult. The better vascularity of
group with four-strand repairs.17 Nietosvaara et al the flexor tendon encourages healing and resultant
reported no ruptures in their group of children less adhesions are less extensive and more pliable.9,19 As
than 16 years of age who had multistrand repairs, but such, prolonged immobilization beyond 4 weeks is
three postoperative ruptures occurred in their group unnecessary in children. It is also documented that
with two-strand repairs.8 In both reports, other than the immobilization for longer than 4 weeks significantly
ruptures, no difference in functional outcomes was deteriorates functional outcome.15,16
found between the two-strand and multistrand repair Fitoussi et al recommend that an above elbow cast
groups. It appears that in children, multistrand repair be routinely used for postoperative immobilization to
may protect against postrepair rupture but not have any avoid tendon ruptures.16 In their study, five ruptures
significant effect on functional outcomes. occurred in 58 fingers reviewed. Of these, two of the
ruptures were attributed to noncompliance to splint.
ADJUNCTS TO SURGERY
The remaining three ruptures occurred in the group of
Tuzuner et al20 reported on the adjunctive use of botu- patients immobilized in a below elbow plaster cast. No
linum toxin type A for children less than 6 years with ruptures were found in the group immobilized in an
zone 2 flexor tendon repairs. The principle was to tem- above elbow cast. Incidentally, four of the five ruptures
porarily paralyze the muscle unit of the repaired flexor above occurred in children who were 5 years or younger.
tendon to avoid ruptures due to poor compliance. All The benefit of above elbow casting for postoperative
the patients received intramuscular injections into the immobilization is corroborated by Kato et al’s report.
specific muscles of the repaired tendons. Postopera- They looked at the long-term outcome of 12 children
tively, all patients were started on Duran’s passive less than 6 years of age with zone 2 flexor tendon lac
motion program for 4 weeks, after which active motion erations repaired with a modified Kessler technique
was allowed. The average duration of the botulinum and immobilized with an above elbow cast for 4 weeks.
effect was 6 weeks and all seven patients achieved satis- They reported a mean TAM of 89% evaluated with the
factory results with an average total active motion (TAM) Strickland formula, which was a very favorable result.12
of 84%. There were no tendon ruptures. However, a few
OUTCOMES
concerns were noted. Forearm atrophy was noted in
three of the seven patients. Rehabilitation was pro- As stated earlier, there are many factors that can affect
longed when otherwise it would have taken only 4 the outcome of flexor tendon repairs in children includ-
weeks. Other potential concerns of this experimental ing type of repair and zone of injury. Other variables are
adjunctive therapy include allergic reactions. At this more controversial; the effect of age on functional
point in time, the use of botulinum toxin A is experi- outcome continues to be an area of debate. The Mayo
mental and should be performed within the confines of Clinic group reported that age was not a determinant of
a clinical trial. outcome.14 On the other hand, Berndtsson et al reported
that older children tended to have better results.11
REHABILITATION
Fitoussi et al compared the outcomes between those
Young children cannot always be expected to cooperate aged 0 to 5 years, 5 to 10 years, and 10 to 15 years.16
with a rehabilitation program. In this day and age when Although they did find that the youngest age group was
early mobilization is the norm in adults with flexor associated with higher rupture rates, they did not find
any significant difference in functional outcome among required tenolysis. Both achieved satisfactory outcomes
the three age groups. after secondary repairs and tenolysis, respectively.14 Kato
Concomitant injuries within the affected fingers may et al reported that only one of their 12 patients required
also influence outcomes. The Mayo Clinic group a tenolysis, which achieved excellent outcome at final
reported lower TAM in zone 2 for combined FDP/FDS follow-up.12 Fitoussi et al reported a 9% rupture rate.16
injuries compared with isolated FDP injuries. They also They report that risk factors for rupture were a noncom-
reported that in patients with concomitant digital nerve pliant patient, age group less than 5 years, and immo-
injury, the outcome was poorer.14 O’Connell et al also bilization in a below elbow cast compared to an above
reported poorer TAM in patients with concomitant elbow cast.16 Two of the ruptures were treated by direct
palmar plate or digital nerve injury.15 The one exception secondary repair after lengthening at the musculotendi-
to these findings was reported by Berndtsson and nous junction. Both achieved satisfactory outcomes at
Ejeskär, who evaluated their outcomes in zone 2 flexor final follow-up. The other 3 underwent two-stage flexor
tendon repairs and found that concurrent superficialis tendon grafting with one achieving good outcome and
tendon injury did not appear to impact negatively on the other 2 fair outcomes. Navali and Rouhani had one
functional outcome.11 rupture in one child with a two-strand repair. In this
Injuries within zone 2 are still presumed to produce case, no further treatment was given as the parents
the poorest outcomes. Fitoussi et al reported that all declined.17
flexor tendon repairs in zones 1, 4, and 5 in children Digital growth disturbances may occur after flexor
achieved good or excellent outcomes.16 Outcomes in tendon injury during childhood. Kato et al reported that
zones 2 and 3 were good or excellent in 77% and 71% there is a small risk of the finger being shorter at the
of the digits in terms of TAM, respectively.16 The Mayo middle and distal phalanx as a result of previous flexor
Clinic group also reported better outcomes in zone 1 tendon injury. The range of shortening was 2 to 4 mm
injuries compared to zone 2.14 for each digit.12 A mean shortening of 3% of digit length
Surprisingly, delayed repairs have not been shown to was also reported by Tuzuner et al.20
consistently result in a poorer outcome in children. Ber-
FLEXOR TENDON GRAFTING IN CHILDREN
ndtsson and Ejeskär found no significant difference in
outcome between children who had primary repair Primary tendon repair has been shown to be superior
versus those with delayed repairs (mean of 58 days after to tendon grafting and staged reconstruction.21-24 As
injury, range 10 days to 1 year). In addition, none of such, flexor tendon grafting should be done only when
their patients with delayed treatment required tendon direct repairs are not possible. Courvoisier et al recom-
grafting.11 mend that one-stage flexor tendon grafting can be per-
Functional outcome in children following flexor formed in a digit with moderate scarring with intact A2
tendon repair appears to improve with time. This has and A4 pulleys and full passive mobility of the PIP and
been attributed to better remodeling and continuing DIP joints.25 Two-stage flexor tendon grafting should be
digital growth, which contributes to the rupture of ten- reserved for cases where scarring within the flexor sheath
dinous adhesions.12,14,18 O’Connell et al reported con- is associated with extensive pulley damage with PIP or
tinuing improvements in TAM beyond 18 months of DIP joint contractures. In his series, Courvoisier et al
follow-up.15 In their report, a further 17% improvement reported 38% (3 of 8 children) satisfactory outcomes
of TAM was noted in a subgroup of patients who were for one-stage flexor tendon grafting and 42% (5 of 12
available for extended reevaluation 18 to 120 months children) satisfactory outcomes for two-stage flexor
later. tendon grafting.25 Darlis et al painted a better picture in
a group of children who underwent two-stage flexor
COMPLICATIONS
tendon reconstruction with the modified Paneva-
Grobbelaar and Hudson reported that complications Holevich technique.26 Eight of their 9 children achieved
after flexor tendon repair in children were rare.10 In their satisfactory outcomes with a mean TAM of 75%.
series of 38 patients, there were three cases of tendon However, they had one child who had a complication
ruptures that they attributed to technical factors. All of deep infection that required removal of the silicone
underwent direct secondary repair and eventually rod. They were able to reinsert the rod 3 months later
achieved excellent to good outcomes. None of their 38 when the infection cleared.
cases required flexor tenolysis. However, they com- Valenti and Gilbert reported satisfactory outcomes in
mented that if tenolysis were required, they would prefer 73% of the 27 children they treated with two-stage
to wait at least 18 months before contemplating it, as flexor tendon grafting.27 They noted that they achieved
adhesions in children are more pliable.10 better outcomes in older children. The mean TAM for
In the Mayo Clinic group of 35 patients, complica- children aged 10 to 15 years was 81.5%, whereas chil-
tions were noted in only two patients.14 One had a dren aged 1 to 3 years had a mean TAM of 53%. They
tendon rupture and the other had a stiff finger that had a complication rate of 27%: there were 4 distal
ruptures occurring at the distal implant–tendon inter-

face, 2 silicone synovitis requiring synovectomy, and
one deep infection requiring removal of the silicone
rod. Four of these 7 cases with complications ended up
with unsatisfactory outcomes.27
CURRENT TREATMENT RECOMMENDATIONS
A high index of suspicion should always be adopted
when evaluating children for flexor tendon injury. If
there is any doubt, exploration under general anesthesia
should be performed to confirm the status of the flexor
tendon and digital neurovascular bundles.
Surgery should always be performed under general A
anesthesia, in a bloodless field using pneumatic tourni-
quet control, fine instruments, and magnification. If the
injury is more than 1 week old, the parents and the
patient should be informed of the possibility for graft-
ing of the flexor tendon. Direct tendon repairs should
be attempted even in delayed cases. Flexor tendon graft-
ing procedures should be reserved for salvage situations
where there is extensive injury to the flexor tendon
sheath or irreparable damage to the pulleys. Tenodesis
and arthrodesis should be avoided in children as they
may further affect finger growth adversely.
The flexor tendons should be approached through
a Bruner extension of skin laceration (Figure 15-3).
Windows in the flexor tendon sheath can be created B
using L-shaped incisions to expose the tendons. As far Figure 15-3 A, A Bruner incision is used to expose the
as possible, A2 and A4 pulleys should be preserved. If profundus and superfiicalis tendon injury of the middle
necessary not more than half the length of the A2 and finger in a 5-year-old child. B, Flexion cascade is restored
A4 pulleys can be released to aid in exposure of the following tendon repair.
flexor tendon for repair.
Depending on the size of the tendon, core suture size
of 4-0 can be used, and a four-strand repair should be For zone 1 repairs without sufficient distal tendon
attempted. Epitenon sutures should be one size smaller stump, the FDP tendon may be repaired directly to bone
than core sutures, and sizes 5-0 through to 7-0 can be using a nonabsorbable suture13 or a Bunnell pull-out
used. Cutting needles are preferred as they allow the repair using 4-0 monofilament suture.14 Care should be
needle to pass through the tendon with less trauma than taken not to damage the epiphysis if drill holes are
with round needles. made in the distal phalanx.
Whether a two-strand or multistrand repair is per- In zone 2 injuries, both the FDP and FDS tendons
formed will depend on the size of the tendon. In very should be repaired. Presently, repair of FDP alone and
small caliber tendons, a four-strand repair may not be discarding the lacerated FDS is not a recommended
possible. In older children, four-strand or even six- option. The tendons are repaired with nonabsorbable
strand repairs can be performed. The principle here is sutures. All skin wounds should be closed with absorb-
to have as strong a repair as possible without making able sutures so as to avoid suture removal, which may
the repair site too bulky. Tendon repair techniques be distressing for the child.
reported in children include Tajima,17 modified Kessler,14 Postoperatively, we recommend that all children
and Lim.8,28 under 7 years of age or children who are not cooperative
Once the repairs are complete, the finger should be be immobilized in an above elbow cast with the elbow
passively flexed and extended to make sure that the in flexion for 4 weeks. Children who are older than 7
repair can glide smoothly through the pulleys and the years and who are judged to be compliant and coopera-
flexor sheath. Occasionally, partial release of the unyield- tive can be started on early mobilization regimens. In
ing ends of the A4 or the A2 pulleys29 may be needed to both cases, unrestricted motion exercises are started
prevent the repair site from snagging on the pulley edges. after 4 weeks.
We prefer leaving the L-shaped windows of the flexor In delayed flexor tendon injuries with significant
sheath unrepaired to avoid constriction to the tendon. scarring making direct repair impossible, flexor tendon
grafting will be necessary. If the pulley system is intact will be necessary, which has been detailed by Valenti
and there are no joint contractures, one-stage flexor and Gilbert.27 After stage 1 surgery, passive motion exer-
tendon graft using the palmaris longus or the plantaris cises are started and continued for at least 3 months
tendon should be performed with the proximal tendon before proceeding to stage 2 surgery. After stage 2, the
juncture sited in the palm.27 If the pulley system is exces- wrist and elbow are immobilized for 4 weeks before
sively damaged, a two-stage tendon grafting procedure beginning active motion exercises.27
References
1. Bell JL, Mason ML, Koch SL, et al: Injuries to flexor tendons 16. Fitoussi F, Lebellec Y, Frajman JM, et al: Flexor tendon injuries
of the hand in children, J Bone Joint Surg (Am) 40:1220–1230, in children: factors influencing prognosis, J Pediatr Orthop
1958. 19:818–821, 1999.
2. Provencher MT, Allen LR, Gladden MJ, et al: The underestima- 17. Navali AM, Rouhani A: Zone 2 flexor tendon repair in young
tion of a glass injury to the hand, Am J Orthop (Belle Mead children: a comparative study of four-strand versus two-
NJ) 35:91–94, 2006. strand repair, J Hand Surg (Eur) 33:424–429, 2008.
3. Kleinert HE, Kutz JE, Atasoy E, et al: Primary repair of flexor 18. Friedrich H, Baumel D: The treatment of flexor tendon injuries
tendons, Orthop Clin North Am 4:865–876, 1973. in children, Handchir Mikrochir Plast Chir 35:347–352, 2003.
4. Creekmore H, Bellinghausen H, Young VL, et al: Comparison 19. Arons MS: Purposeful delay of the primary repair of cut flexor
of early passive motion and immobilization after flexor tendons in “some-man’s-land” in children, Plast Reconstr Surg
tendon repairs, Plast Reconstr Surg 75:75–79, 1985. 53:638–642, 1974.
5. Savage R: In vitro studies of a new method of flexor tendon 20. Tüzüner S, Balci N, Ozkaynak S: Results of zone II flexor
repair, J Hand Surg (Br) 10:135–141, 1985. tendon repair in children younger than age 6 years: botuli-
6. Savage R, Risitano G: Flexor tendon repair using a “six strand” num toxin type A administration eased cooperation during
method of repair and early active mobilisation, J Hand Surg the rehabilitation and improved outcome, J Pediatr Orthop
(Br) 14:396–399, 1989. 24:629–633, 2004.
7. Small JO, Brennen MD, Colville J: Early active mobilisation 21. Boyes JH, Stark HH: Flexor-tendon grafts in the fingers and
following flexor tendon repair in zone 2, J Hand Surg (Br) thumb. A study of factors influencing results in 1000 cases,
14:383–391, 1989. J Bone Joint Surg (Am) 53:1332–1342, 1971.
8. Nietosvaara Y, Lindfors NC, Palmu S, et al: Flexor tendon 22. Ejeskar A: Flexor tendon repair in no man’s land. II: Early
injuries in pediatric patients, J Hand Surg (Am) 32:1549– versus late secondary tendon repair ad modum Kleinert,
1557, 2007. Scand J Plast Reconstr Surg 14:279–283, 1980.
9. Entin MA: Flexor tendon repair and grafting in children, Am 23. Vahvanen V, Gripenberg L, Nuutinen P: Flexor tendon injury
J Surg 109:287–293, 1965. of the hand in children. A long-term follow-up study of 84
10. Grobbelaar AO, Hudson DA: Flexor tendon injuries in chil- patients, Scand J Plast Reconstr Surg 15:43–48, 1981.
dren, J Hand Surg (Br) 19:696–698, 1994. 24. Amadio PC, Wood MB, Cooney WP 3rd, et al: Staged flexor
11. Berndtsson L, Ejeskär A: Zone II flexor tendon repair in chil- tendon reconstruction in the fingers and hand, J Hand Surg
dren. A retrospective long term study, Scand J Plast Reconstr (Am) 13:559–562, 1988.
Surg Hand Surg 29:59–64, 1995. 25. Courvoisier A, Pradel P, Dautel G: Surgical outcome of
12. Kato H, Minami A, Suenaga N, et al: Long-term results after one-stage and two-stage flexor tendon grafting in children,
primary repairs of zone 2 flexor tendon lacerations in chil- J Pediatr Orthop 29:792–796, 2009.
dren younger than age 6 years, J Pediatr Orthop 22:732–735, 26. Darlis NA, Beris AE, Korompilias AV, et al: Two-stage flexor
2002. tendon reconstruction in zone 2 of the hand in children,
13. Havenhill TG, Birnie R: Pediatric flexor tendon injuries, Hand J Pediatr Orthop 25:382–386, 2005.
Clin 21:253–256, 2005. 27. Valenti P, Gilbert A: Two-stage flexor tendon grafting in chil-
14. Elhassan B, Moran SL, Bravo C, et al: Factors that influence dren, Hand Clin 16:573–578, 2000.
the outcome of zone I and zone II flexor tendon repairs in 28. Lim BH, Tsai TM: The six-strand technique for flexor tendon
children, J Hand Surg (Am) 31:1661–1666, 2006. repair, Atlas Hand Clin 1:65–76, 1996.
15. O’Connell SJ, Moore MM, Strickland JW, et al: Results of zone 29. Amis AA, Jones MM: The interior of the flexor tendon sheath
I and zone II flexor tendon repairs in children, J Hand Surg of the finger. The functional significance of its structure, J Bone
(Am) 19:48–52, 1994. Joint Surg (Br) 70:583–587, 1988.
CHAPTER
16
PRIMARY REPAIR OF
THE FLEXOR POLLICIS
LONGUS TENDON
OUTLINE tension as a result of the greater retraction of the FPL

muscle remains unknown. Murphy believed this
A series of changes of primary treatment of divisions problem to be due to the fact that the FPL tendon is
of the flexor pollicis longus tendon were carried out completely separated from the other flexor tendons,
in the St. Andrew’s unit in a total of 216 thumbs over making retraction easier than where a tendon is
18 years in an attempt to reduce the rupture rate restrained by others. An alternative explanation may lie
from the initial high level of 17%. It was possible, in the difference of muscle configuration between the
eventually, by strengthening the sutures and including FPL muscle and those of the finger flexors.
the fingers in the splint, to reduce the rupture rate to
THE AVASCULAR ZONE 2 SITE OF THE FPL
zero. A simplification was then made and others dis-
cussed, whereby elimination of mechanical ruptures Recently, we re-examined data from our earlier studies
of the repairs could be achieved using simpler suture and found that the rate of rupture after repair in zone
methods that are more appropriate for use by the 2 is twice as common as after zone 1 FPL repairs.3
training surgeons who normally perform these repairs Zone 1 FPL repairs had a rate of rupture similar to that
worldwide. of primary finger flexor repairs.4 The increased rate of
rupture of zone 2 repairs largely explains the higher
More difficulty is encountered in approximation of the rupture rate of the FPL tendon when compared with
severed ends than in any other tendon of the hand. finger flexor repairs in zones 1 and 2. A lack of extrin-
Murphy, 1937 sic vascular supply of the FPL tendon immediately
palmar to the metacarpophalangeal joint was identi-
THE PROBLEM OF FLEXOR POLLICIS
fied by Lundborg.5 Hergenroeder et al6 also found that
LONGUS RETRACTION
there is a zone of relative avascularity of the tendon at
It has been known that the flexor pollicis longus (FPL) the same point, and this was illustrated by Tubiana
tendon is more difficult to repair than the finger flexors et  al.7 This avascular point coincides with the zone
for over 60 years. In 1937, Murphy identified this 2 site of FPL repair and may explain the particular
problem and highlighted the fact that retraction of the susceptibility of zone 2 repairs to rupture, contributing
proximal end of the cut FPL tendon was almost always to the higher rupture rate of FPL tendon primary
greater than that of the proximal ends of cut finger flexor repairs.
tendons.1 Our clinical experience, and that of others
TREATMENT OF FPL DIVISION BEFORE 1989
more recently, would agree that the greater retraction of
the cut FPL tendon is due to shortening of the FPL Reports published in the 20 years after Murphy’s report,
muscle as there is often considerable difficulty pulling when many repairs would now be classified as delayed
the proximal tendon end out to length if FPL repair is primary, or even secondary surgery, repeatedly high-
attempted after even a short delay beyond 48 hours. It lighted the difficulty of direct repair of the FPL after any
would seem likely that this increased tension is also the delay and many recommended that primary repair be
cause of the higher rupture rate in the repaired FPL avoided in most instances.8 To overcome this problem,
tendon compared to that of finger flexor tendon repairs. most authors favored tendon reconnection by interposi-
More recently, the presence of a retracted proximal end tion grafting,1,9-19 although some reported direct repairs
of the FPL tendon at surgery has been shown to be det- of the tendon, usually in cases seen within a few
rimental to the outcome of the tendon repair.2 Whether hours.1,11,14-18,20-29 Tendon lengthening, either in the
all FPL repairs, or only those with visible retraction of muscle or in the tendon at the wrist, was also used
the proximal tendon at surgery, are exposed to increased by several authors as an alternative to interposition
186
Chapter 16: Primary Repair of the Flexor Pollicis Longus Tendon 187
grafting.12,15,26,30,31 During this era, all cases were immo- included an assessment of 30 primary FPL repairs
bilized postoperatively. Mobilization started at varying repaired with a two-strand modified Kessler suture and
intervals from surgery, in one instance as early as 12 a simple running circumferential suture.45 These cases
days after operation but usually after a longer delay of were mobilized in the manner used to mobilize finger
between 3 and 5 weeks. The results reported were often flexor tendons but with the thumb only prevented from
impressive. Unfortunately, direct comparison with today free movement and had a rupture rate of 17%. We rec-
is difficult, if not impossible, as the methods of assess- ommended that early active mobilization using the
ment differ, not only between different reports but also technique we were using at that time was not appropri-
from all of the methods of assessment in current use. ate to FPL tendon primary repair. Subsequently, we
Although a few very large studies were reported, many examined two additional groups of 39 and 49 patients
contained very small numbers of cases, many being part with divided FPL tendons.8 In the first of these, the FPL
of much larger studies of treatment of finger flexor tendons were repaired by the original method but
tendon divisions. Rupture rates were rarely mentioned. mobilization was carried out in a modified splint, which
In 1973, Urbaniak and Goldner reported their own included slight ulnar deviation of the wrist (intended to
experience32 and Urbaniak subsequently reviewed the allow the FPL tendon a straighter “run” into the thumb)
options of treatment.33 Like others before him, Urba- and inclusion of the fingers in the splint (Figure 16-1).
niak favored direct repair when possible and used the The second group underwent a modified repair that
other techniques when the tendon gap was too wide. included one of the more recent techniques of strength-
The results of tendon lengthening in his unit were better ening the circumferential repair46 (Figure 16-2) as well
than those of interposition grafting in those cases in as mobilization in the modified splint. The changes in
which direct repair was not possible. the splint alone made little difference to the rate of
ruptures, only reducing the rupture rate to 15%. We
TREATMENT OF FPL DIVISION 1989–1999
retained the splint mainly because it included the
Between the advent of primary direct repair and early fingers: power gripping with the fingers is almost auto-
postoperative mobilization of flexor tendons in the late matically followed by movement of the thumb around
1950s and the end of the 20th century, there were sur- the dorsum of the index and middle fingers, which
prisingly few reports published on the effectiveness of brings the FPL into play and risks any primary FPL
primary repair of the FPL tendon in zones 1 and 2, this repair. Preventing normal finger activities remains part
being the common site of division of this tendon.34-37 of our rehabilitation regimen. Despite achieving excel-
These studies tended to confirm the high rupture rate lent and good results and a rupture rate equal to those
after primary repair compared to primary repair of in the Percival and Sykes study after addition of the
finger flexors. Various other studies of primary repair stronger circumferential suture technique, the 8% rate
and early mobilization of finger flexor tendons included of rupture in our study remained higher than the 4% to
repairs of the FPL but usually in such small numbers 5% reported from our unit for finger zone 1 and 2
and/or with inclusion of divisions of the FPL in other primary flexor tendon repairs4 and was still a matter for
zones, as to make useful interpretation of the data concern. Although the drop of rupture rate from 17%
difficult.38-43 Few of the units that reported large series to 8% was a definite improvement, the figures were not
of primary direct repairs of finger flexor tendons in zone statistically significant; it would have required a study
2 followed by early mobilization by any method have with 98 patients in each of the two groups for a reduc-
published equivalent results for the FPL tendon. Three tion of this amount to attain a statistical significance of
studies of primary repair of the FPL tendon34,35,37 mobi- p <.05. This would have required a study period of 15
lized the repairs postoperatively in variations of the years, or longer. This presents a dilemma to clinicians
Kleinert technique of active extension-passive flexion reporting personal experiences in this field, even from
mobilization.44 The fourth compared this regimen with busy units.
immobilization of the repair for 4 weeks after surgery.36
FPL REPAIR WITH NO RUPTURES:
Although Percival and Sykes reported an 8% rupture
ST. ANDREW’S 1999–2004
rate of 50 repairs,36 we used the work of these authors
as a gold standard against which we compared our The addition of a stronger core suture to the stronger
results at that time because a variety of problems with epitendinous suture was the most obvious way of trying
data presentation in the few other reports made direct to further reduce the rupture rate of the FPL repair. In
comparison with our work difficult. 2004, we reported another study in which a four-strand
Kessler suture with a Silfverskiöld circumferential suture
FPL REPAIR WITH 8% RUPTURES:
was used in the primary repair of 48 FPL tendons fol-
ST. ANDREW’S 1994–1999
lowed by early active mobilization.3 Two Kessler two-
In an earlier report on primary repair of finger flexor strand repairs in planes at 90° to each other were used
tendons followed by early active mobilization, we (Figure 16-3),47 which is, perhaps, the simplest means
A B C
Figure 16-1 The modified splint with inclusion of the fingers used for early active mobilization in St Andrew’s of FPL repairs
since 1994. A, Mobilization of the fingers with the thumb resting. B, Early mobilization of the thumb using Kapandji’s
method. C, Later mobilization of the thumb to near-full flexion.
have been the cause of the slight drop in the excellent

and good results in this group of patients compared
with our previous results.8 Possibly of more significance
is the fact that this technique is difficult to use in clinical
practice and may be too complicated for those routinely
doing these repairs worldwide.
FPL REPAIR WITH NO
RUPTURES: ELSEWHERE
In the early 2000s, an additional three studies of primary
repair of the FPL tendon were published,2,49,50 two of
which reported no mechanical ruptures of FPL repairs
Figure 16-2 Diagram showing the technique of stronger
using various conventional two-strand core sutures and
circumferential suturing described by Silfverskiöld and
Anderson (1993) and used in St. Andrew’s for FPL repair,
simple circumferential repair,2,49 albeit in small numbers
1996–2004. of patients (Table 16-1). These studies may identify a
factor that is currently given little attention because of
concentration on stronger sutures, namely the quality
of the rehabilitative service. At a time when stringent
financial pressures are being forced on clinicians
worldwide, this may be of political importance to the
well-being of this group of patients. Unfortunately,
strengthening of suture techniques is considerably easier
Double Kessler core suture
for most surgeons than achieving any increase in hand
therapy availability and expertise.
Figure 16-3 Diagram showing the technique of four strand
repair using two Kessler core sutures described by Smith SIMPLER FPL REPAIR WITH NO RUPTURES:
and Evans (2001) and used in St Andrew’s for FPL repair, ST. ANDREW’S 2004–2009
1999–2004.
Our most recent study51 reported the results of an addi-
tional 50 FPL primary tendon repairs performed since
of achieving a four-strand core suture. This combination January 2004 using Tang’s technique of three Tsuge
of sutures achieved a 0% rupture rate. However, the bulk sutures as the “core” suture,52,53 with no circumferential
of a combination of a multistrand core suture and a suture (Figure 16-4). The Tsuge system of suturing
complex circumferential suture may increase the resis- flexor tendon repairs54,55 is as strong as the more con-
tance to movement of the repaired tendon.48 This may ventional core and circumferential suture combinations,
Table 16-1 Summary of Major Studies of Primary Repair of the FPL Tendon, 1989–2009
Study
Rehabilitation Number of Period Excellent and Good Mechanical
Authors Techniques Tendons Zones (Years) Results Rupture Rate (%)
Percival and Immobilized 25 1, 2, 3 4 44% (White76) 8
Sykes (1989) Kleinert 26 1, 2, 3 60% (White76) 8
mobilization
Noonan and Kleinert 30 1, 2, 3, 4, 5 6 71% Interphalangeal —
Blair (1991) mobilization joints normal
82% Metacarpophalangeal
joints normal
Nunley et al Kleinert 38 1, 2 2 Average IP 35% 3
(1992) mobilization
Thomazeau Immobilization 10 1, 2, 3, 4, 5
et al (1996)
Kleinert 3 1, 2, 3, 4, 5 5 85% (Tubiana7) 5
mobilization
Passive 7 1, 2, 3, 4, 5
mobilization
Sirotakova and Early Active 30 1, 2 8.5 70% (White76) 73% 17
Elliot (1999) Mobn (Group 1) (Buck-Gramcko77)
Early Active 39 1, 2 67% (White76) 72% 15
Mobn (Group 2) (Buck-Gramcko77)
(3) Early Active 49 1, 2 76% (White76) 80% 8
Mobn (Group 3) (Buck-Gramcko77)
Kasashima Immobilization 16 1, 2, 3 12 50% (JSSH 1994)* 0
et al (2002)
Kleinert 13 1, 2, 3 77% (JSSH 1994)* 0
mobilization
Peck et al Kleinert 23 1, 2 1.5 Not reported 4
(2003) mobilization
Baer et al Mantero Early 22 1, 2 6 91% (Buck-Gramcko)† 0
(2003) Active Mobn
Sirotakova and Early Active 48 1, 2 3.5 73% (White76) 77% 0
Elliot (2004) Mobn (Buck-Gramcko77)
Giessen et al Early Active 50 1, 2 2.75 78% (White76) 82% 0
(2009) Mobn (Buck-Gramcko77)
*JSSH, assessment of the Japanese Society for Surgery of the Hand (similar to the White Assessment, uses IP range of motion only).
†
This figure includes results of both finger and thumb flexor repairs. Although the authors indicate that the results were poorer in the
thumbs, they only give an overall result of excellent and good results for all cases.
which are commonly used in Europe and may be more suture,3 this difference was not statistically significant.
simple to insert.56 This group, again, had a 0% rupture More recently, Tang modified his technique of inserting
rate and showed that the three Tsuge suture technique the three Tsuge sutures58 and, then, further modified
described by Tang and his colleagues is of adequate the technique to a four-strand Tsuge-type of repair to
strength to prevent rupture of primary repairs of the FPL make the repair easier and faster59 (Table 16-2). We
tendon during early active mobilization using the have no experience of these newer techniques and
“Belfast” regimen.57 It is also considerably easier to carry cannot comment on them in a clinical setting, but
out a repair by this technique. Although the results of the results reported by these authors in their animal
this latest cohort of repairs were better than those fol- studies would suggest that these variations are similar
lowing repair with a combination of a four-strand in effectiveness to the original technique that was used
Kessler core suture and a Silfverskiöld circumferential in our study.
beyond a 3-0 suture size. The Mantero technique,62

FPL REPAIR WITH NO RUPTURES: OTHER
probably based on a distal technique of flexor tendon
SIMPLE ALTERNATIVES
suture fixation first described by Brunelli 20 years
Another method of simplifying the flexor repair while earlier,63 avoids the problem of suture knotting within
adding to its strength is to use a larger caliber of core the flexor tendon sheath. It leaves less knotted suture
suture.60,61 However, sutures become cumbersome to tie material in the repaired part of the tendon than do
and the knot is bulky at the flexor tendon junction Kessler repairs, so it is particularly suitable for use with
larger core sutures. This technique was, perhaps, the very
earliest attempt at early active mobilization without
rubber bands. It comprises a two-strand core suture with
suture fixation to the proximal part of the tendon using
half of a Kessler suture and distal fixation over a button
at the tip of the digit. Although the Mantero technique
has been used more recently with 3-0 sutures,49 the
original Mantero technique used a 2-0 suture.62 Both the
technique and this suture size are still used routinely in
many parts of southern Europe, including Mantero’s
unit.43,64-70 This technique is applicable to primary repair
of zone 1 and 2 divisions of the FPL, so it provides an
A alternative means of adding strength while simplifying
the FPL suture.
MANAGEMENT OF THE RETRACTED FPL
When retraction is obvious at surgery, proximal tendon
lengthening within the muscle31,71 or by “Z” lengthening
of the tendon at the musculotendinous junction30,72
may improve the results. It has certainly been our own
B experience that, even after short delays, apposition of
Figure 16-4 A, Illustration of the 1977 modification by the FPL tendon ends is sometimes only possible by
Tsuge of his own suture, which is used in B, the triple Tang considerable flexion of the interphalangeal (IP) joint of
technique used in St. Andrew’s for FPL repair, 2004–2007. the thumb. These repairs have then proved liable to
Table 16-2 Summary of the Five Groups of Primary FPL Tendon Repairs Carried Out in the St. Andrew’s Hand
Unit (1989–2007)
Number of Zones of Excellent and Rupture
Tendons Injuries Good Results (%)* Rate (%)
Group 1: Two-strand Kessler core suture, simple 30 1 and 2 70/73 17
circumferential suture, thumb only splint and early
active mobilization
Group 2: Two-strand Kessler core suture, simple 39 1 and 2 67/72 15
circumferential suture, thumb and finger splint and
early active mobilization
Group 3: Two-strand Kessler core suture, Silfverskiöld 49 1 and 2 76/80 8
Group 4: Four-strand Kessler core suture, Silfverskiöld 48 1 and 2 73/77 0
Group 5: Tang technique of triple Tsuge suture, no 50 1 and 2 78/82 0
*The first figures shown are the excellent or good results according to the White (1956) method and the second figures are the excellent or
good results according to the Buck-Gramcko et al (1976) method of assessment.
rupture during early postoperative mobilization, unless

one limited the speed and extent of rehabilitation and
accepted the possibility of an unsatisfactory result with
a very flexed IP joint. In these cases, we have used FPL
tendon lengthening within the muscle by simple trans-
verse division of the tendon in its intramuscular part at
one or two places as a tension relieving maneuver
(Figure 16-5), as described by Le Viet.71 Routine tendon
lengthening of all FPL repairs is another possible way of
reducing the FPL rupture rate. Rouhier described this in
1950 as an alternative to tendon grafting.31 The Rouhier
technique is well recognized and, occasionally, still used A
in France73 but is not commonly considered, or used,
elsewhere. The FPL tendon is detached from its muscle
along its intramuscular course and a tendon slide is
carried out within the muscle, allowing the FPL to act
as its own graft to close any gap without tension at the
site of tendon division. Once the repair has been com-
pleted, the tendon is sutured back to the muscle belly
more distally than its original attachment. Although we
have no experience of this technique, one would expect
it to allow considerable lengthening of the proximal FPL
tendon. It may be a useful means of tendon lengthening
B
for difficult cases when repair is delayed but it is pos-
sibly too elaborate for use in reducing the tension on Figure 16-5 Use of the technique of intramuscular division
an immediate repair. The Le Viet technique71 of making of the tendon described by Le Viet (1986) to overcome a
a complete transverse division of the tendon one or retracted FPL at primary repair. A, A single intramuscular cut
more times within the muscle belly is technically easier of the tendon. B, A double cut.
to carry out than intratendinous slide lengthening,
whether in the muscle or at the wrist. It only increases
the tendon length by 1 cm or so, but this can be suffi-
cient to reduce the active tension on the repair more additional 24 hours. Eleven achieved good results and
distally in the thumb during early mobilization. four achieved fair results using both methods of assess-
ment, suggesting that immediate re-repair, although not
THE SUCCESS OF FPL RUPTURE RE-REPAIR
easy, is the treatment of choice for most patients who
All 15 ruptures of the FPL in these studies presented present quickly after rupture of an FPL repair, as it is for
within 48 hours and were re-repaired within an finger flexor tendon repairs that rupture.4,57,74,75
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206, 1992.
CHAPTER
17
TREATMENT OF FLEXOR
TENDON INJURIES AT OR
PROXIMAL TO THE WRIST
A Zone 5 Flexor Tendon Repairs
OUTLINE the ulnar nerves, division of which is almost inevitable

if the main longitudinal structures are divided. These
Recent reports concerning management of zone 5 can, occasionally, cause significant problems of end-
flexor tendon injuries have identified this injury as neuroma pain if ignored at primary surgery.3-5
more significant in terms of digital motor dysfunction The wounds are generally transverse, or nearly so,
than previously thought. Recent research has shown across the wrist. Access is easiest by converting the
that, despite a small risk of losing differential tendon wound to an “H” or “Z.” Whatever is done with the skin,
gliding when the superficialis tendons are repaired, it is unusual to have healing problems with the skin as
repair of both sets of tendons is beneficial and to be whatever extension incisions of the primary laceration
recommended. are made surgically to aid access, the flaps so designed
(without thought) will be broad-based, short fasciocu-
Arguably, flexor tendons are more commonly injured in taneous flaps with the radial and ulnar arteries feeding
the flexor aspect of the distal forearm (zone 5) than in directly into their bases. It is rare to be unable to achieve
any other zone, yet less is written about the manage- safe primary wound closure for this reason.
ment after tendon divisions in this zone than in any The tendon repairs are carried out largely using the
other. This may relate directly to a comment by Kleinert techniques used in zone 2, so this will not be discussed
and his colleagues over 30 years ago that “tendon gliding further, except to say that the anatomy mostly allows for
in this area should not be a problem.”1 larger core and circumferential sutures than in zones 1
and 2. The tendon repairs are, theoretically, easier than
CLINICAL FEATURES
in the fingers because the tendons are not confined
These cases are an everyday feature of upper limb trauma within a tendon sheath. However, the multitude of
units. The mechanisms of injury include laceration by structures and the associated nerve and, sometimes,
broken glass (alcohol-related in many instances), sharp arterial injuries make flexor wrist injuries daunting and
machinery at work, knives, and self-inflicted injuries. long operations for junior training surgeons and these
The flexor aspect of the distal forearm transmits eigh- injuries should not be dismissed by seniors as “good
teen longitudinal structures superficial to the wrist and training cases,” to be left without help to junior sur-
carpal joints, with the pronator quadratus lying trans- geons. The many structures to be repaired can turn these
versely across the wrist area between the skeleton and operations into marathons in inexperienced hands! It
these longitudinal structures. Any, or all, of these struc- is, also, often the case that the individual tendons are
tures can be injured. Most emergency surgery is con- not cut transversely but obliquely, with different tendons
cerned with the (longitudinal) running flexor tendons, cut at different levels relative to the carpal canal or, even,
radial and ulnar arteries, and the median and ulnar within the carpal tunnel by shards of glass. The tendons
nerves. A “spaghetti” wrist is defined as one with a flexor may be “shredded” longitudinally, making textbook
laceration in which at least 10 of the 15 longitudinal repairs difficult. Where multiple structures are divided
structures (11 tendons, 2 arteries, and 2 nerves, exclud- or surgery is lengthy and, particularly, when the tendon
ing the palmaris longus) have been transected.2 Often repairs approximate to the proximal edge of the carpal
forgotten are the palmar branches of the median and ligament on full digital extension, the carpal tunnel
194
Chapter 17A: Zone 5 Flexor Tendon Repairs 195
should be decompressed to avoid both the development following failure to repair the FDS tendon in zone 5,
of secondary carpal tunnel syndrome6 and loss of exten- although of less significance, is suggested by a single
sion as a result of the tendon repairs impinging on the case report.13 The possibility of adhesions causing limi-
carpal ligament on full extension of the wrist and digital tation of finger excursion and/or loss of independent
joints. FDS action, despite early mobilization, was not
Following surgery, these injuries are mobilized using researched at that time.
the same regimes as zone 2 injuries and these are not The literature on injuries to the flexor aspect of the
discussed further. When the carpal ligament has been distal forearm immediately prior to 2000 is scant.11,13-16
divided, the fingers are mobilized with the wrist splinted Two of these reports were small and concentrated their
in the neutral position or slight extension. In other cir- reviews mainly on the injuries to the median and ulnar
cumstances, a straight wrist or only slightly flexed wrist nerves and not on the outcome of the finger flexor
position may be preferred, but it should be remembered tendon injuries.11,16 In 1985, Puckett and Meyer reviewed
that the 30° flexed wrist position originally advocated 37 patients who suffered a minimum of three and an
for rehabilitation is little different from the Phalen test average of eight completely transected longitudinal
we use to irritate the median nerve when diagnosing structures at the wrist.15 One-third of their patients had
carpal tunnel syndrome and may precipitate this “spaghetti” wrists. The hands were mobilized postop-
problem postoperatively if the carpal ligament remains eratively using a Kleinert regimen. Tendon function was
intact. considered to be excellent when digital range of motion
One point about rehabilitation of zone 5 flexor was 85% to 100% of normal or finger flexion brought
tendon repairs that is unique to this zone is that there the fingertip within 1.0 cm of the distal palmar crease;
will be no intrinsic proximal interphalangeal (PIP) joint good with 70% to 84% of normal digital range of
extensors of the ulnar fingers if the ulnar nerve has also motion or the fingertip within 2.0 cm of the distal
been divided. This requires that the metacarpophalan- palmar crease; fair with 50% to 60% of normal digital
geal (MCP) joints of these fingers be held in flexion range of motion; or poor with fixed contractures or
during the 4-week postoperative splinting period to acti- adhesions. Thirty-three (97%) of 34 wrists available for
vate PIP extension by the long extensor tendons, if PIP assessment were reported to have good or excellent
joint contractures are to be avoided.7 ranges of digital motion and one patient to have a fair
It is also frequently forgotten by surgeons what may range of motion. The method by which the overall
be being asked of a patient with a spaghetti, or near- results were derived from the assessment of the indi-
spaghetti, wrist. At 1 to 3 days after surgery, the patient vidual fingers was not given. No tendon ruptures
is being expected to move a large number of swollen occurred in their series.
tendons, possibly bristling with unabsorbable suture In 1992, Stefanich et al13 reported independent FDS
ends and tightly bound down by swollen fasciocutane- action in only 30% of a retrospective series of 23 patients
ous flaps across repaired median and/or ulnar nerves. who underwent zone 5 flexor tendon repairs that were
This is painful! Mobilization may be hindered by lack mobilized using Kleinert’s early mobilization (active
of adequate analgesia, making the therapist’s job impos- extension-passive flexion) regimen. In this series, five
sible and the ultimate result less than perfect. patients had transection of a single digital (finger or
thumb) flexor tendon and 18 patients had transections
THE FLEXOR DIGITORUM SUPERFICIALIS
of multiple digital flexor tendons. The total active
TENDONS: TO REPAIR OR NOT
motion (TAM) of the associated digits as well as for the
Until the introduction of early mobilization of flexor corresponding unaffected digits was calculated, as sug-
tendon repairs in the latter half of the twentieth century, gested by the American Society for Surgery of the Hand,
it was believed that repair of divided flexor digitorum but, unfortunately, the associated scoring system of
superficialis (FDS) tendons following wrist lacerations excellent/good/fair/poor was not recorded. Instead the
in which both the superficial and deep digital flexor average TAM (as a percentage of the uninjured contra-
tendons had been divided caused adhesions with limi- lateral digit) was given for the whole group of 23 patients
tation of excursion of the associated fingers.8,9 However, for each of the five digits. Sixteen of the 23 patients
the superficial digital flexors increase the grip of the regained full digital flexion of all digits but the number
hand and make pinch and flexion of the PIP joint more of digits in these patients that had not suffered flexor
stable, in addition to providing superior individual tendon injury was not stated. There was an average PIP
finger flexion.10 For these reasons and, possibly, reas- extension deficit of 8° and distal interphalangeal exten-
sured by the comment that “tendon gliding in this area sion deficit of 4°. Two patients (9%) had extremely
should not be a problem,”1 repair of the superficial limited motion. Rupture of one flexor pollicis longus in
digital flexors became routine with the advent of early one patient and rupture of one ring finger flexor digito-
mobilization.1,10-12 The possibility of PIP hyperextension rum profundus (FDP) in an additional patient occurred
in their series. This report reintroduced the question of action after repair of the FDS at the wrist in this study
adhesion of the flexor tendons after repair of both may include fewer failures of mobilization than is sug-
tendon groups in zone 5 and the possibility that loss of gested by our figures as it has been shown that the
digital excursion and/or independent FDS action is superficialis tendon of the little finger, although present
more common than had been assumed. at the wrist, cannot achieve flexion of this finger in one-
Subsequent to this small study,13 we carried out a third of normal individuals.18,19
larger prospective study17 over a 2-year period to examine For the first time, an analysis was presented to math-
the results of routine repair of both finger flexor tendons ematically to analyze these injuries in terms of the effect
in zone 5 followed by early postoperative mobilization on overall hand function rather than by consideration
using the variant of the controlled active mobilization of the individual fingers that had sustained division of
(active extension-active flexion) regimen described pre- flexor tendons at the wrist. This showed that there was
viously and used routinely in our unit.14 In this study, a statistically significant interdependence of the flexor
after mobilizing the injured hands using an early active systems of the different fingers in those wrists with inju-
motion regimen, good or excellent results were achieved ries to the flexors of all four fingers. This indicates that
in 90% of fingers that had repair of completely divided the consequences of this injury in respect of hand func-
flexor tendons in zone 5 and independent FDS action tion are more complex than the mere sum of its con-
was achieved in 66% of the fingers. No tendon ruptures stituent tendon injuries and future attempts to assess
occurred in this series. The group of patients with “FDS the zone 5 injury need to change to reflect this
injuries only” fared better than those with ‘“FDS and complexity.
FDP” injuries in terms of independent FDS action, the Since our study, few reports on zone 5 have been
difference being statistically significant. This most prob- written.20-24 Two of these studies lend support to the
ably reflects the difference in magnitude of the total benefit of active, as opposed to passive, mobilization of
injury to the wrist between those with more superficial zone 5 flexor repairs.22,23 In 2005, Wilhelmi et al reviewed
injuries and deeper injuries, rather than simply a differ- 168 zone 5 tendon flexor divisions24 repaired using their
ence between division of one or two tendon groups. own core suture technique and mobilized early using a
Multivariate analysis showed that the presence of a “spa- technique of protected active motion similar to that
ghetti” wrist injury had a significant adverse effect on reported by Silfverskiöld and his colleagues from Göte-
the overall hand recovery in terms of independent FDS borg in Sweden25 in 29 patients treated over 4 years.
action but had no significant adverse effect on the Despite the emphasis of the authors on the strength and
overall hand recovery in terms of digital range of motion. benefits of their particular suture technique, three rup-
While the extensive scar tissue likely to follow a “spa- tured tendons occurred in one patient. Of more interest
ghetti” wrist injury might be expected to eliminate dif- was the use of a technique of mobilization that opti-
ferential gliding of the tendons, the resultant tendon mized differential gliding between the FDS and FDP
mass appeared to be capable of moving the fingers tendons. This allowed these authors to achieve good or
through a full, or near full, range of motion in most excellent results in 97 (99%) of 103 fingers and inde-
cases. Age was not a significant factor in determining pendent FDS action in 88 (91%) of 103 fingers. These
recovery of either independent FDS action or range of authors stressed loss of extension in patients with con-
digital motion. A statistically significant association comitant ulnar nerve injuries as responsible for their
between recovery of independent FDS action and recov- few less than perfect results.
ery of the digital range of motion appears to confirm The benefits of FDS function favor repair of the FDS
that wrists that do well with respect to one modality will tendons in zone 5 flexor tendon injuries. There would
do well with respect to the other. Those fingers with FDS appear to be no logical basis for not repairing the FDS
tendons lying close to the FDP tendons at the wrist— tendons at the wrist as the use of a supervised active
namely, the index and little—are more likely to lose mobilization regimen in the early postoperative period
independent FDS action after division and repair of is likely to achieve a high proportion of good and excel-
their tendons at the wrist. The little finger had the lowest lent results in terms of finger movement and a good
incidence of independent FDS action in this study. chance of retaining independent action of the superfi-
However, those little fingers without independent FDS cial finger flexors.
References
1. Kleinert HE, Kutz JE, Atasoy E, et al: Primary repair of flexor 3. Atherton DD, Leong JCS, Anand P, et al: Relocation of painful
tendons, Orthop Clin North Am 4:865–876, 1973. end neuromas and scarred nerves from the zone II territory
2. Katz RG: Discussion. Results of treatment of extensive volar of the hand, J Hand Surg (Eur) 32:38–44, 2007.
wrist lacerations; the spaghetti wrist, Plast Reconstr Surg 4. Evans GRD, Dellon AL: Implantation of the palmar cutane-
75:720–721, 1985. ous branch the median nerve into the pronator quadratus for
Chapter 17A: Zone 5 Flexor Tendon Repairs 197
treatment of painful neuroma, J Hand Surg (Am) 19:203–206, 16. Rogers GD, Henshall AL, Sach RP, et al: Simultaneous lacera-
1994. tion of the median and ulnar nerves with flexor tendons at
5. Sood MK, Elliot D: Treatment of painful neuromas of the the wrist, J Hand Surg (Am) 15:990–995, 1990.
hand and wrist by relocation into the pronator quadratus 17. Yii NW, Urban M, Elliot D: A prospective study of flexor
muscle, J Hand Surg (Br) 23:214–219, 1998. tendon repair in zone 5, J Hand Surg (Br) 23:642–648, 1998.
6. Figus A, Iwuagwu FC, Elliot D: Subacute nerve compressions 18. Austin GJ, Leslie BM, Ruby LK: Variations of the flexor digi-
after trauma and surgery of the hand, Plast Reconstr Surg torum superficialis of the small finger, J Hand Surg (Am)
120:705–712, 2007. 14:262–267, 1989.
7. Elliot D: Primary flexor tendon repair: operative repair, pulley 19. Baker DS, Gaul JS, Williams VK, et al: The little finger
management and rehabilitation, J Hand Surg (Br) 27:507– superficialis–clinical investigation of its anatomic and func-
513, 2002. tional shortcomings, J Hand Surg (Am) 6:374–378, 1981.
8. Carroll RE, Match RM: Common errors in the management 20. Bircan C, El O, Akalin E, et al: Functional outcome in patients
of wrist lacerations, J Trauma 14:553–562, 1974. with zone V flexor tendon injuries, Arch Orthop Trauma Surg
9. Verdan C: Practical considerations for primary and secondary 125:405–409, 2005.
repair in flexor tendon injuries, Surg Clin North Am 44:951– 21. Gibson TW, Schnall SB, Ashley EM, et al: Accuracy of the
970, 1964. preoperative examination in zone 5 wrist lacerations, Clin
10. Kleinert HE, Meares A: In quest of the solution to severed Orthop Relat Res 365:104–110, 1999.
flexor tendons, Clin Orthop Relat Res 104:23–29, 1974. 22. Korstanje JW, Schreuders TR, van der Sijde J, et al: Ultrasono-
11. Hudson DA, de Jager LT: The spaghetti wrist. Simultaneous graphic assessment of long finger tendon excursion in zone
laceration of the median and ulnar nerves with flexor tendons V during passive and active tendon gliding exercises, J Hand
at the wrist, J Hand Surg (Br) 18:171–173, 1993. Surg (Am) 35:559–565, 2010.
12. Strickland JW: Flexor tendon repair, Hand Clin 1:55–68, 23. Panchal J, Mehdi S, Donoghue JO, et al: The range of excur-
1985. sion of flexor tendons in zone V; a comparison of active and
13. Stefanich RJ, Putnam MD, Peimer CA, et al: Flexor tendon passive flexion mobilisation regimes, Br J Plast Surg 50:517–
lacerations in zone V, J Hand Surg (Am) 17:284–291, 522, 1997.
1992. 24. Wilhelmi BJ, Kang RH, Wages DJ, et al: Optimizing indepen-
14. Elliot D, Moiemen NS, Flemming AFS, et al: The rupture dent finger flexion with zone V flexor repairs using the Mas-
rate of acute flexor tendon repairs mobilised by the con- sachusetts General Hospital flexor tenorraphy and early
trolled active motion regimen, J Hand Surg (Br) 198:607– protected motion, J Hand Surg (Am) 30:230–236, 2005.
612, 1994. 25. Silverskiöld K, May E: Flexor tendon repair in zone II with a
15. Puckett CL, Meyer VH: Results of treatment of extensive volar new suture technique and an early mobilization program
wrist lacerations; the spaghetti wrist, Plast Reconstr Surg 75: combining passive and active flexion, J Hand Surg (Am)
714–721, 1985. 19:53–60, 1994.
B Methods and Outcomes of Zone 5
Flexor Tendon Repairs
Jun Tan, MD, and Jin Bo Tang, MD
OUTLINE longitudinal incision suffices. The distal tendon ends

are easily brought into the operative field after wrist
Flexor tendons in zone 5 are located in the distal and flexion and the wrist is held in flexion by an assistant
middle parts of the forearm. A severe injury can during surgery. Because of frequent lacerations in nerve
produce “spaghetti wrist,” namely, lacerations of 10 or trunks, particular care must be taken to identify the
more structures, including tendons, nerves, and vessels. tendons and nerves and to suture the corresponding
In this chapter, we present our current methods for ends correctly. Careful attention to their locations in the
repair of zone 5 flexor tendon injuries and follow-up wound, diameters and the shape of the lacerated struc-
of 52 patients. Recovery of active digital motion and tures, and the oblique angle of their cross sections help
grip strength are generally good, but functional loss produce a proper match of the tendon ends.
caused by accompanying nerve injuries is a concern. Adhesion formations between tendon injuries and
Repairs by experienced surgeons produce better recov- overlying skin and fascia are frequent, but subsequent
ery. Outcomes of “spaghetti” injury are worse than limitations to active finger motion vary. In a majority of
those of less severe injuries. cases, adhesions between the tendons and loose
paratenon are not problematic, because the adhesions
The region of the distal and middle forearm, which are not as restrictive as those between the tendon and
extends from the proximal border of the transverse fibroosseous sheath or the firm flexor retinaculum.
carpal ligament to the musculotendinous junctions of Severe adhesions can arise between multiple tendons
the forearm flexors, contains zone 5 flexor tendons. In and affect the motion of multiple digits, subsequently
the forearm, the flexor digitorum profundus (FDP) has requiring secondary tenolysis.
a single muscle belly and travels distally to separate into The median and ulnar nerves and the radial and ulnar
a radial bundle and an ulnar bundle. The radial bundle arteries are frequently involved. The median nerve is
forms the FDP tendon to the index finger, and the ulnar more frequently cut than the ulnar nerve, and the lacera-
bundle forms the FDP tendons of the middle, ring, and tions to the ulnar artery are more frequent than those
small fingers. The flexor digitorum superficialis (FDS) to the radial artery. Because the ulnar nerve and artery
separates into individual tendon units and muscle are located so close together in the distal forearm, injury
bellies. No synovial sheath covers the tendons in this to the artery is almost always accompanied by injury to
region. the nerve. In the presence of intact radial artery and
Tendon lacerations in this zone are easy to diagnose; positive Allen’s test, the severed ulnar artery may not
with rare exceptions, all the injuries are repaired primar- require anastomosis, but the ulnar nerve should always
ily. Secondary surgeries are reserved for tenolysis or be repaired primarily if no lengthy defect presents.
nerve grafting. Wound contamination can be a serious We reviewed the records of 52 patients (52 wrists)
concern if the patients are injured by dirty tools or oily treated in our clinic and found that 43 wrists (83%) had
machines. Thorough irrigation of the wounds and complete lacerations to median or ulnar nerves, with
débridement of wounds are particularly necessary, median nerve cut in 31 (59%) and ulnar nerve cut in 21
together with intravenous administration of antibiotics (40%). Both median and ulnar nerves were lacerated in
to prevent wound infection. nine wrists (17%). Twenty-nine (56%) had complete
We perform primary, rather than “delayed” primary or major severance of ulnar (40%) artery, radial (26%)
repairs, for tendons injured in zone 5, because these artery, or both (10%). Lacerations in anterior cutaneous
wounds are open and in many cases are extensive. The branches of median or ulnar nerves (which need no
tendon ends are easily found during surgery. The repair) were seen in almost all cases. We repaired all
proximal tendon ends may retract, but not over a severed median and ulnar nerves primarily with direct
long distance. Additional incisions are in most cases end-to-end suture along with tendon repairs.
not required to locate the retracted tendon ends. If We should emphasize that cases necessitating second-
proximal tendon ends retract too proximally, a single ary tenolysis and secondary surgery are not rare. We
198
Chapter 17B: Methods and Outcomes of Zone 5 Flexor Tendon Repairs 199
perform 10 to 15 cases of secondary surgeries for zone 5

flexor tendons (and their accompanying nerve repairs)
annually. Around three-fourths of the patients are
referred from local hospitals where primary repair is
done. The secondary surgeries are indicated in one of
the following situations: (1) adhesions form between
multiple tendons, (2) tendon adhesion with skin
wounds, (3) nerves are not sutured during primary
surgery, or (4) infrequently, loss of proper finger flexion,
due to improper match of the tendon ends (e.g., wrong
tendon-to-tendon match, or tendon is sutured to a
nerve). Among the zone 5 injures that are treated primar-
ily in our unit, 7% of the wrists need secondary tenolysis
due to formation of adhesions among multiple tendons.
In our unit, we routinely repair lacerated nerve trunks Figure 17(B)-1 The distal part of the left forearm of a
primarily, and tendons are carefully identified to ensure 36-year-old patient was cut with a knife, presenting a
proper match, but this is not always the case in the “spaghetti” injury involving complete cut of 11 tendons, two
nerves (median and ulnar), and ulnar artery.
hospitals when injuries are handled by surgeons with
inadequate training. In such cases, the complications
rate of zone 5 tendon repairs can be higher, including
(1) improper primary treatment of the tendons, such as
mismatching of the tendon ends or suturing nerves to
tendons, (2) failure to repair the lacerated nerves, and
(3) extensive adhesion formations involving multiple
tendons.
PATIENTS AND OUTCOMES

Patients
In 2010, we reviewed the medical charts of the patients
admitted after surgery for primary repairs of zone 5 Figure 17(B)-2 A thermoplastic splint is applied with the
tendon injuries over the previous 6 years. We were wrist in flexion of 20° to 30° and the fingers in slightly
unable to include a small number of patients who had flexed position after surgery.
lacerations to a single tendon in forearms because they
were discharged immediately after surgery. Cases of
massive soft tissue loss, extensor tendon injuries, hand department, including the current authors. We repaired
fractures, or replantation surgery were excluded, as were flexor tendons using one of three methods: a two-strand
patients younger than 12 years. A total of 69 patients modified Kessler method (with either 4-0 or 3-0 sutures),
with intact medical records were reviewed. Follow-up a four-strand cruciate method (with either 4-0 or 3-0
was available for 52 patients. The average follow-up sutures), or a six-strand Tang (or M-Tang) method1,2
period was 2 years 8 months (range, 11 to 78 months). (with 4-0 looped nylon sutures), supplemented with a
There were 41 males and 11 females, with a mean age simple running or locking circumferential suture (with
of 35 years (range, 15 to 57 years). a 5-0 or 6-0 nylon suture). Choice of repair methods
The flexor tendons to 163 digits (14 thumbs, 35 index, remains a personal preference; over the last a few years,
44 middle, 42 ring, and 28 small fingers) were involved. we have tended to use four- or six-strand repairs, and
There were 14 flexor pollicis longus (FPL) tendon cuts, two-strand Kessler repairs were used only sometimes.
82 FDP tendon cuts, and 147 FDS tendon cuts. When multiple tendons were repaired in a single patient,
Of the 52 patients, 16 (30.7%) had “spaghetti” a mixture of simple or more complicated methods were
wrists (i.e., at least 10 structures lacerated, involving used, which reduces the total operation time.
tendons, nerves, and arteries, not including cutaneous
nerve branches and palmaris longus tendon) (Figure Postoperative Care
17[B]-1). After surgery, a cast or a thermoplastic splint with the
wrist in flexion of 20° to 30° and the fingers in slightly
Surgical Methods flexed position is used to protect the hand (Figure
All patients were treated with primary surgery within 12 17[B]-2). We used a motion protocol similar to that
hours after trauma by staff hand surgeons in our used for zone 2 tendon repair1 but under less stringent
supervision. Typically, patients begin the early passive-

active motion on postsurgical day 3 or 4 under the IV 31 3
supervision of surgeons and therapists while they are
Level of expertise
still hospitalized. During the first 3 weeks, in each exer-
cise session, passively placing the fingers into flexion III 66 11 5
and extension position is initiated first, followed by
active motion over the amplitude at which the motion II 22 10 7 2 *
does not encounter marked resistance.
Within the first 3 weeks, when multiple tendons are
I 2 1 3 **
lacerated or the tendon repairs are accompanied by
direct nerve approximation, we do not encourage
patients to move actively through the full range of finger 0 10 20 30 40 50 60 70 80 90 100
motion. Instead, we encourage them to move in a rela- % Functional recovery
tively small range, just enough to move the tendons in
Excellent Good Fair Poor
the forearm, avoiding pain, potential bunching of the
repaired tendons, or disturbance to the nerves by Figure 17(B)-3 The graph showing correlation between
tendons. The patients move to the extent they feel com- expertise levels of surgeons and functional outcomes. The
fortable. Flexion of the wrist is a component of the outcomes in terms of active range of digital motion treated
motion protocol. by more experienced surgeons (Levels 3 and 4) are better
At the end of week 3, a dorsal extension block splint than junior surgeons (Level 2)* or residents (Level 1).** The
is applied to keep the wrist at 30° extension. From the numbers shown in the bars are number of fingers evaluated.
third to fifth weeks, the dorsal splint is discontinued
gradually and further active and passive finger flexion is
emphasized. After 5 weeks, the splint is discarded. After Patients under 35 years of age were more likely to
6 to 7 weeks, the patients return to normal activities. have satisfactory outcomes than were patients over 35
Differential FDS and FDP motion exercise can be started years of age (p < 0.01). Outcomes in the nondominant
from the second or third weeks, and continue for 3 to hand were significantly worse than when the dominant
4 weeks. hand was involved (p < 0.01). Outcomes in the fingers
Exercise can be controlled more loosely than zone 2 with a mixture of FDS and FDP injuries were worse than
repairs. The number of exercise sessions each day varies those of only FDS injuries (p < 0.01). Gender and
among patients. Generally, at least four or five sessions follow-up time (from 11 months to 6.5 years) were not
are encouraged daily, but it is not necessary to perform associated with any significant differences in the out-
exercise hourly. Each session consists of about 20 to 30 comes of digital range of motion and independent FDS
repetitions of motion; active motion precedes passive action.
motion. Worse outcomes were significantly associated with
repairs performed by surgeons with lower levels of
Outcomes expertise4 (Figure 17[B]-3).
Consistent with the results reported previously, we Sixteen cases had “spaghetti” wrists. Grip and pinch
found that tendon repairs in zone 5 generally yield quite strength, DASH, active range of digital motion, and
satisfactory results, but we also noted that patients with independent FDS motion of the spaghetti wrists were
severe injuries or whose repairs were carried out by significantly worse as compared with non-spaghetti
junior surgeons had a higher percentage of digits func- wrists (p < 0.01). Grip and pinch strength of spaghetti
tionally ranked as “fair” or “poor.” wrists recovered to only about one-third of the unin-
Graded using Strickland and Glogovac criteria3 for volved side (Table 17[B]-1).
the range of active digital motion among 163 digits of
SUMMARY
52 patients, excellent results were achieved in 123 digits
(75.5%), good in 23 (14.1%), fair in 12 (7.4%), and We were able to perform primary tendon repairs in all
poor in 5 (3%). The good and excellent rate was 89.6%. the cases brought to us. Over the past 6 years, no cases
No repairs ruptured. Independent FDS action was dem- were unsuitable for primary repair, which would have
onstrated in 103 (70.1%) of the 147 fingers with FDS necessitated delayed or secondary tendon repairs. None
injuries. Grip strength recovered to an average of 68% of the cases developed serious wound infection. Patients
and tip pinch strength to 65% of the uninjured hand, with an extensive wound were given intravenous anti
respectively. Mean DASH (Disabilities of the Arm, biotics, and particular care was taken to irrigate the
Shoulder and Hand) score was 11.9 (SD 11.0, range 1.7 wound. We consider that thorough wound irrigation
to 40). and débridement are an important part of treatment.
Chapter 17B: Methods and Outcomes of Zone 5 Flexor Tendon Repairs 201
Table 17(B)-1 Comparison of Outcomes Between the Wrists With “Spaghetti” and “Non-Spaghetti” Zone 5
Tendon Injuries
Digital Range of Motion*
Independent Grip Pinch
No. of Total FDS Action Strength Strength DASH
Injuries Patients Excellent Good Fair Poor Digits (Digits)* (%)* (%)* Scores
Spaghetti 16 42 15 8 2 67 36 (59.0) 50 ± 26 47 ± 25 21 ± 12
(62.7) (22.4) (11.9) (3.0)
Non- 36 81 8 4 3 96 67 (77.9) 75 ± 18 75 ± 20 8±8
spaghetti (84.4) (8.3) (4.2) (3.1)
Grip and pinch strengths of the injured side were recorded as percentage of the contralateral side. Numbers in parentheses are percentages.
Digital range of motion was examined by the nonparametric Mann-Whitney U test; other comparisons were done with student t test.
*Of significant difference between two types of injuries.
Proper identification of nerves and tendons during tendon ends are crushed. We consider repairs to the FDS
surgery is important to ensure correct surgical repair. tendon a positive option, favoring gain in grip strength.
Particularly, junior surgeons can confuse two different Nevertheless, no clinical data indicate whether lacerated
structures. FDS tendon repairs are absolutely necessary or whether
Our follow-up findings indicate that it is not abso- only a part of the lacerated FDS tendons need to be
lutely necessary to use four- or six-strand repairs for repaired. If the FDS tendons are to be selectively repaired
zone 5 tendon injuries, but this has become a preference to reduce operation time or reduce the chance of adhe-
in our unit in recent years. We suggest that stronger sions, we usually repair the FDS to the index and middle
repair methods be used, rather than the weaker conven- fingers.
tional Kessler repairs. Alternatively, it is also proper to One of us (the senior author) proposed classification
use 3-0 suture rather than 4-0 suture to enhance repair and documentation of the level of expertise of sur-
strength. We do not have recommendations about the geons4; we considered zone 5 injuries a perfect test
particular one or two methods that should be used in ground in which to apply such criteria to analyze pos-
zone 5; methods vary. In our unit, we use a cruciate sible associations between expertise levels and treat-
repair or a six-strand M-Tang repair. At a hand surgery ment outcomes. In fact, outcomes were correlated
center in a neighboring city, surgeons use a four-strand positively with expertise levels. While the results of zone
U-shaped method (another method developed by the 5 tendon repairs are generally considered favorable, we
senior author5) with 4-0 looped suture together with a found that this injury is more likely to have a better
running peripheral suture. The surgeons achieved gener- outcome in more experienced hands within our unit.
ally good and excellent results in more than 25 cases When treated by experienced surgeons, patient out-
without repair ruptures over the past 3 years (Zun Shan comes were rated as good or excellent in nearly all cases;
Ke, MD, personal communication, 2011). We have not the few cases with poor results were all treated by junior
used the U-shaped method in zone 5 repairs; a six- staff members.
strand M-Tang method has been adopted. Accompanying nerve injuries in this area present a
In our cases, 89% of the digits have good or excellent greater concern than tendon lacerations. Loss of hand
active range of digital motion, and 70% fingers exhib- function is mostly due to incomplete recovery of associ-
ited independent FDS action. An overall good and excel- ated nerve injuries (Figure 17[B]-4). Inadequate active
lent rate of 90% was reported by Yii et al,6 though they finger extension is not infrequently, caused by incom-
used American Society for Surgery of the Hand (ASSH) plete functioning of the intrinsic muscles.
criteria; those are in fact different from the criteria in The “spaghetti” wrist consists of severe trauma to
our follow-up. The thumb was not included into the the soft tissues of the wrist.8 Previous studies indicated
grading by Yii et al. Our cases appeared to have more that a spaghetti wrist was associated with poor indepen-
severe vascular injuries. In the past reports, the propor- dent FDS action.1,3-6 Our results are consistent with pre-
tion of independent FDS action varied from 30% to vious findings. Spaghetti wrist trauma produces a severe
85% of the fingers after zone 5 tendon repairs.7-14 adverse effect on overall hand function. Grip and pinch
Regarding the number of tendons to repair, all the strength of such wrists recovered to only about one-
wrist flexors except the palmaris longus tendon should third that of the contralateral side. After median or ulnar
be repaired. While FDP and FPL tendon repairs are nec- nerve injuries, intrinsic muscles do not function nor-
essary, it may not be necessary to repair all the FDS mally, which contributes to decreased grip strength and
tendons, particularly if the wounds are untidy and the inability to perform fine hand actions.
A B
Figure 17(B)-4 Findings of a patient with spaghetti wrist injury 2 years 8 months after primary tendon and ulnar nerve
repair. The patient recovered full digital extension (A), and full flexion (B). Note the patient was unable to abduct the little
finger (A [arrow]) due to incomplete recovery of ulnar nerve function. There were mild hypotrophy of intrinsic muscles and
flattened hypothenar area (A). Incomplete function of intrinsic muscles presented as a prominent problem. Recovery of grip
strength was also incomplete.
References
1. Tang JB: Indications, methods, postoperative motion and 9. Noaman HH: Management and functional outcomes of com-
outcome evaluation of primary flexor tendon repairs in Zone bined injuries of flexor tendons, nerves, and vessels at the
2, J Hand Surg (Eur) 32:118–129, 2007. wrist, Microsurg 27:536–543, 2007.
2. Tang JB: Clinical outcomes associated with flexor tendon 10. Weinzweig N, Chin G, Mead M, et al: “Spaghetti wrist”:
repair, Hand Clin 21:199–210, 2005. management and results, Plast Reconstr Surg 102:96–102,
3. Strickland JW, Glogovac SV: Digital function following flexor 1998.
tendon repair in Zone II: A comparison of immobilization 11. Jaquet JB, van der Jagt I, Kuypers PD, et al: Spaghetti wrist
and controlled passive motion techniques, J Hand Surg (Am) trauma: functional recovery, return to work, and psychologi-
5:537–543, 1980. cal effects, Plast Reconstr Surg 115:1609–1617, 2005.
4. Tang JB: Re: Levels of experience of surgeons in clinical 12. Stefanich RJ, Putnam MD, Premier CA, et al: Flexor tendon
studies, J Hand Surg (Eur) 34:137–138, 2009. lacerations in zone V, J Hand Surg (Am) 17:284–291, 1992.
5. Cao Y, Tang JB: Biomechanical evaluation of a four-strand 13. Wilhelmi BJ, Kang RH, Wages DJ, et al: Optimizing indepen-
modification of the Tang method of tendon repair, J Hand dent finger flexion with zone V flexor repairs using the
Surg (Br) 30:374–378, 2005. Massachusetts General Hospital flexor tenorrhaphy and early
6. Yii NW, Urban M, Elliot D: A prospective study of flexor protected active motion, J Hand Surg (Am) 30:230–236,
tendon repair in zone 5, J Hand Surg (Br) 23:642–648, 1998. 2005.
7. Bircan C, EI O, Akalin E, et al: Functional outcome in patients 14. Katz RG: Discussion. Results of treatment of extensive volar
with zone V flexor tendon injuries, Arch Orthop Trauma Surg wrist lacerations: the spaghetti wrist, Plast Reconstr Surgt 75:
125:405–409, 2005. 720–721, 1985.
8. Puckett CL, Meyer VH: Results of treatment of extensive volar
wrist lacerations: the spaghetti wrist, Plast Reconstr Surg
75:714–721, 1985.
CHAPTER
18
FLEXOR TENDON REPAIRS
WITH NOVEL SUTURES
AND DEVICES
A Mantero’s Technique for
Tendon Repair
Ombretta Spingardi, MD, Mario Igor Rossello, MD,
and Renzo Mantero, MD
OUTLINE with consequent acquired and permanent deformity

and stiffness of the joints was remarkably decreased.
We present our experience with pull-out repairs of
INDICATIONS
flexor digitorum profundus (FDP) tendon injuries in
zone 2. Since 1973, we have repaired zone 1 and 2 Any clean-cut injury of the flexor digitorum profundus
tendon injuries with the Bunnell technique of pull-out (FDP) tendon in zone 2 or the flexor pollicis longus
suture through the fingertip, together with immediate (FPL) tendon in zone 2 can be repaired with this tech-
active digital mobilization of patients. We followed a nique. This method is also indicated for FDP tendon
sample of patients with zone 2 FDP tendon lacerations injuries in proximal zone 1, where direct end-to-end
treated between 2005 and 2008, and no patients had tendon repair is necessary.1,4-6 However, we do not use
rupture of the repairs. We assessed the outcomes of this method in the case of complex trauma (e.g., ampu-
one group of 46 patients (46 digits) by evaluating tation or tendon injury associated with exposed frac-
subjective and objective function; 33 digits (72%) had ture), because early motion is not possible, and the
good or excellent results. We also compared the results button on the top of the finger carries a risk of causing
in 22 digits treated with the pull-out method to those ischemia in situations in which digital circulation is
in 22 digits after two-strand surgical repairs. We noted already poor.
faster recovery of active finger flexion and grip strength When both the FDS and FDP tendons are injured,
after the pull-out method. Poor results were seen only the FDS tendon can be repaired with any end-to-end
when tendon mobilization was begun too late or was repair method in association with FDP repair by our
insufficient. method.
SURGICAL TECHNIQUES
Flexor tendon surgery has made much progress since
the 1970s due to accrued knowledge of the biology of Under regional anaesthesia, two cut tendon ends are
tendon tissue repair and great improvement in suture exposed through a Bruner’s skin incision. A needle (size:
techniques and postoperative mobilization concepts. 20G) used for spinal anesthesia is inserted from the
However, tendon repair in zone 2 still is a problem due fingertip and passed through the distal FDP tendon
to the high risk of adherence and consequent limitation stump, from distal to proximal. Then, a 2-0 nylon thread
of range of active motion, even when early postopera- is passed in the proximal tendon stump for 1 to 1.5 cm
tive protected motion is adopted. from the cut creating an Ω-shaped loop. The needle is
The pull-out technique was described by Bunnell in then cut and the two ends of the suture are passed in
the beginning of the 20th century for tendon repair. the distal tendon stump by the previously inserted
Mantero and colleagues1-3 started using the technique needle. The thread is pulled out from the tip of the
in 1973 in association with immediate postoperative finger and its two ends are secured over a mother-of-
active motion. With this regimen, the occurrence of pearl button with multiple knots (Figures 18[A]-1 to
tendon adherence and an hypertrophic cutaneous scar 18[A]-6). For all repairs, ensuring correct coaptation of
203
Distal
tendon
stump
Proximal
tendon Figure 18(A)-3 A case of zone 2B flexor tendon injury in a
stump child and skin incisions to expose the tendons.
Figure 18(A)-1 Illustration of the pull-out technique. The

needle is passed through the distal part of the tendon after
an Ω-shaped loop is made in the proximal tendon stump.
Distal
tendon
Figure 18(A)-4 The retracted proximal tendon stump was
stump exposed and pulled distally under the A2 pulley.
Proximal
tendon
stump
Figure 18(A)-2 Passing the thread through the distal Figure 18(A)-5 The Ω-shaped suture was placed in the
tendon stump. proximal stump of the tendon.
Chapter 18A: Mantero’s Technique for Tendon Repair 205
Figure 18(A)-6 The thread was passed through the distal

stump of the tendon and tired over a mother-of-pearl button
on the fingertip.
the two tendon ends with good tension is very impor-

tant and depends on the surgeon’s experience. A running
suture with 4-0 suture is added to tighten the tendon
edges. Previously, we used a 4-0 Prolene suture and
noted some foreign body reactions caused by sutures
during long-term follow-up, and suture remnants had
to be removed. We prefer to use absorbable (such as
PDS) sutures presently. B
Tendons cut distal to the A2 pulley (in zones 2A
and 2B) can be more easily repaired with this method, Figure 18(A)-7 Seventeen days after pull-out suture repair
because the distal tendon is shorter and has fewer con- of the FDP tendons in the ring and little fingers. Active
strictive pulleys. Therefore, it is easier to insert the needle flexion and extension exercise are shown.
from the fingertip through the entire distal tendon
stump. For tendons cut at or proximal to the A2 pulley,
POSTOPERATIVE CARE
the needle will pierce a greater length of the distal tendon
stump with both DIP and PIP joints slightly flexed. After Immediate active motion is the keystone to success with
piercing, the internal guide of a spinal needle is retracted this technique and it has to start as soon as possible.1-4
so that the passage of the 2-0 nylon thread is allowed. We In particular, full extension of the proximal interphalan-
prefer to use two different passages through the tendon geal (PIP) joint must be achieved in the first few days
stump for the thread; it ensures greater tightness of the after surgery. On the first day, the dressing is reduced
system as the suture tension is more evenly spread along and the patient can start active digital motion with the
all parts of the tendon during motion. wrist in a protected position (wrist in flexion). Daily
Whenever possible, the pulley system is respected. homework is given to the patient, so that he or she can
When the A2 or A3 pulley is partially or totally damaged be autonomous, not only in moving but also in clean-
or when the pulleys must be partially incised to avoid ing and renewing the dressings if necessary. One week
any impingement of the tendon repair site on the edge later, the wound is checked and any remaining swelling
of the pulley, these pulleys are not repaired. When more is controlled. If possible, a smaller dressing is placed to
pulleys are injured, reconstruction is strongly recom- allow a wider range of motion. The range of active
mended, especially for A2 and A4 pulleys, to avoid digital flexion is increased gradually (Figure 18[A]-7).
tendon bowstringing. We prefer to use a flap of extensor At about 21 days, it is important to observe whether
retinaculum (Lister technique) or one of the FDS tendon there are any early clinical signs of block of tendon
slips (when the FDS tendon is not repaired), sutured to gliding or joint motion. If nothing abnormal is found,
the pulley remnants. A suction drain is placed and the more vigorous and full active digital flexion exercises are
skin is sutured with absorbable sutures. The drain is performed.
removed 1 day later, and a thinner dressing is made so The patient returns every 6 to 8 days to have the dress-
that a wider range of active digital motion is allowed. ing changed and for a wound check. In more recent
years, we have preferred to use absorbable sutures for

skin closure to avoid the need for removal of suture
stitches, which can be painful or quite unpleasant, espe-
cially for young patients. From 30 to 35 days after surgery,
the pull-out suture is cut and the button is removed. The
scab on the tip of the finger, where the button has created
a small bedsore, will fall off within 2 to 3 days with daily
antiseptic cleaning. A rehabilitation program is started
after pull-out removal, with progressive strengthening
active digital flexion from 8 weeks. The average time to
return to work is 10 weeks after injury.
OUTCOMES
We conducted two studies on patients who were treated
with the pull-out technique. Both studies contained
only a portion of the patients who were treated in this
period. The patients included in the two studies were
those living in close proximity to our city, so they could
come to our department for regular follow-up. In the
first study, we followed 46 patients with injuries to 46
FDP or FPL tendons in zone 2 treated with this method Figure 18(A)-8 Complete recovery of active finger flexion
between 2005 and 2008. At postoperative weeks 3, 6, after surgical repair of FDP tendon of the little finger with
and 12, we evaluated the total active range of motion the pull-out method.
of the distal interphalangeal (DIP), PIP, and metacarpo-
phalangeal (MCP) joints; visual analog scale;7 DASH
(Disabilities of the Arm, Shoulder, and Hand) score; sessions, (3) less pain and disability, and (4) earlier
grip strength; and Kapandji test8 (for thumb motion recovery in grip strength. The ultimate total range of
evaluation during opposition to long fingers). Being active digital motion was not significantly different, and
impossible to equally compare all these data, as all the repair ruptures were not recorded in either group.
tests have different numerical ranges, we decided to We had no case of deep infection or tendon rupture.
make them homogeneous by calibrating their minimum A few patients had superficial infection on the fingertip,
and maximum values from 0 to 30. According to all the due to prolonged contact of the button on the skin.
data provided from the different evaluation systems, we The wound healed within a few days after use of local
could obtain poor, fair, good, and excellent results— and oral antibiotics and daily careful disinfection. An
“poor” for mean values between 0 and 7, “fair” for infrequent but serious complication is a permanent
values between 7 and 15, “good” for values between 16 residual loss of extension of the PIP joint, due to late
and 21, and “excellent” for values between 22 and 30. start of active mobilization. This often occurred in low-
We recorded poor results in 13 patients (28%), fair compliant patients. However, they seldom requested
results in none, good results in 28 patients (61%), and surgical treatment (tenolysis) because the extension
excellent results in 5 patients (11%) (Figure 18[A]-8). deficits were often only mild and were not bothersome,
Similar to literature data,5 tendon injuries in the ring creating no serious limitation of function.
and little fingers led to the worst recovery of range of
DISCUSSION
motion of the hand. No repairs ruptured.
The second study that we carried out between 2005 Because the pull-out technique is not popular outside
and 2008 compared two different treatments: (1) 22 of southern Europe, it is difficult to compare our results
patients (22 FDP tendons injured in zone 2) treated by with reports in the literature. However, we agree with
pull-out technique followed by active digital flexion and Wulle5 that the best results of the pull-out repair method
extension exercise and (2) 22 patients (22 FDP tendons are achieved in young patients with early tendon motion
in zone 2) treated with two-strand repair methods exercise, even when injuries of the arteries and/or nerves
(Tsuge, Kleinert, Kessler, or Kessler-Tajima) followed by coexist. Elder patients have a worse prognosis.
either Kleinert or Duran early motion programs. Our Except for cases involving bone injuries, to which
referring hand therapist evaluated all the patients at 4, early motion cannot be applied, all zone 2 tendon cuts
6, 8, and 12 weeks after surgery. We recorded impres- deserve to be treated with this easy, reliable, and fast
sively superior results for the patients treated with the method. This pull-out repair method can be used for
pull-out method: (1) faster recovery of the active range FDP tendon injuries in zones 1 and for FPL tendon
of digital motion, (2) lower number of rehabilitative injuries in the thumb.1-6,9,10 Owing to reliable strength,
Chapter 18A: Mantero’s Technique for Tendon Repair 207
this method also allows use of early motion of the The advantages of this technique are easy technical
repaired finger in children. Nevertheless, this method execution, cheap (and easy to find) surgical materials,
has not been used popularly so far, possibly because reliability of repair strength, and no need to wear a
putting a button on the top of a finger is not considered splint. The pull-out system is of particular merit in the
“smart” or, more simply, because it is an old technique case of tendon injuries in multiple fingers because it
and hence “out of fashion.” We believe that these allows active motion of these fingers. Rupture of the
ideas are prejudicial. Although this method is rarely suture or infection of the tip of the finger is rare, even
included in descriptions of currently prioritized surgical if the patient is not quite compliant. Postoperatively few
techniques of repair of flexor tendons, it should be dressings are needed; at 30 to 35 days, the thread passing
considered. though the fingertip is cut and the button is removed.
References
1. Mantero R, Bertolotti P, Badoino C: Il pull-out in “no man’s 6. Guinard D, Montanier F, Thomas D, et al: The Mantero
land” e al canale digitale nelle lesioni dei flessori (metodo flexor tendon repair in zone 1, J Hand Surg (Br) 24:148–151,
personale), Riv Chir Mano 11:119–130, 1973–1974. 1999.
2. Mantero R, Bertolotti P: La mobilizzazione precoce nel trat- 7. Ohnhaus EE, Adler R: Methodological problems in the mea-
tamento dei tendini flessori al canale digitale, Revista Esp Chir surement of pain: a comparison between verbal rating scale
Mano 5:35–43, 1975. and the visual analogue scale, Pain 1:379–384, 1975.
3. Mantero R, Bertolotti P: La mobilisation précoce dans le trait- 8. Kapandji A: Clinical test of apposition and counter-apposition
ement del lesions des tendons fléchisseurs au canal digital, of the thumb, Ann Chir Main 5:67–73, 1986.
Ann Chir Main 30:889–896, 1976. 9. Elliot D, Southgate CM: New concepts in managing the long
4. Grandis C, Rossello MI: Dieci anni di esperienza con il pull- tendons of the thumb after primary repair, J Hand Ther 18:
out intertendineo nella chirurgia dei tendini flessori al canale 141–156, 2005.
digitale (zona 1–2), Riv Chir Mano 25:43–49, 1988. 10. Schaller P: Repair of the flexor pollicis longus tendon with
5. Wulle C: Flexor tendon suture in zone 1 and distal zone 2 by the motion-stable Mantero technique, Scand J Plast Reconstr
the Mantero technique, Ann Hand Upper Limb Surg 11:200– Surg Hand Surg 44:163–166, 2010.
206, 1992.
B Teno Fix for Tendon Repair
Antonio Merolli, MD, FBSE, Lorenzo Rocchi, MD, and
Francesco Catalano, MD
OUTLINE We present clinical findings on our early patients

treated with Teno Fix, including detailed follow-up. We
We present our experience with the Teno Fix Tendon also performed mechanical tests of two devices from our
Repair System (Ortheon Medical, Winter Park, Florida) hospital inventory.
device for primary flexor tendon repair in digits. We
A BIOMECHANICAL STUDY
treated 22 patients presenting with laceration of a
single flexor digitorum profundus or superficialis The Teno Fix is a stainless steel device (ASTM F138-00)
tendon or flexor pollicis longus tendon within the composed of two intratendinous spindle–coil com-
digital sheath in zone 2; the mean follow-up was 16 plexes (the “anchor”) joined by a multifilament 2-0
(range, 6 to 26) months. Of the 22 patients, the results stainless steel suture (the “wire”). The anchor is
according to the Strickland’s total active motion crite- composed of a spiralling cork-screw-like coil around
ria were excellent in 12, good in 6, and fair in 4. a hollow spindle core (Figure 18[B]-1A). The early
Radiography revealed rather smooth gliding of the anchor that we used was 2.0 mm in diameter and
repaired tendon after surgical implantation of the 4.0 mm in length; a smaller anchor is now available.
device. However, in our series, the results of four Two stop-beads are used for tensioning the wire. One is
patients were not satisfactory, and the device was secured by the manufacturer, while the other must be
removed from three of them. The other patients did crimped intraoperatively by the surgeon (with the help
not complain of discomfort, nor have they required of a dedicated instrument). This latter step seemed to
secondary surgery for removal of the device after us to be the weak point of the device, since in clinical
tendon healing, with the longest follow-up being 7 practice the strength of the stop grain is crucial for the
years. This device is practical clinically and can produce mechanical performance of the device. For this reason,
strong tendon repairs that withstand early active finger we tested two devices randomly chosen from the stan-
motion. Use of this device may ensure a quicker recov- dard inventory of the hand clinic.
ery and return to work after surgery. However, we also To evaluate the load needed to pull out the lower and
present possible reasons for unsatisfactory recovery in upper stop grains from the wire and the load at which
four cases in our series. the wire itself starts rupturing, a metal plate with a suit-
able hole was used to constrain each grain, allowing us
Our main motivation for testing the Teno Fix Tendon to test the effective strength of the grain-wire assembly.
Repair System device (Ortheon Medical, Winter Park, A wire length of 15 mm (common in clinical practice)
Florida) in the clinic is the way it interfaces with the was chosen. Two grips were used to hold the plate con-
fibers of the tendon. Specifically, Teno Fix does not straining the grain and the end of the wire. The tests
apply tractional force to a small number of fibers con- were performed in a tensile mode at 1 mm/min, using
stricted inside a knot; instead, it distributes traction a material testing machine (Model 5566; Instron Corp,
more evenly along a greater number of fibers. Despite Norwood, Massachusetts) with a load cell of 100 N
being compressed into the small volume of the anchor- (Figure 18[B]-1B).
ing system, those fibers maintain their physiological axis Results showed a typical load-displacement curve
of elongation. that was linear until a maximum load value was reached
The Teno Fix device has been marketed as a practical (Figure 18[B]-1C). Maximum load values of 56.7 and
clinical tool, able to produce strong tendon repairs that 58.9 N were recorded (greater than the mean stated by
withstand early active finger motion.1-6 It is advisable to the manufacturer). Although the wires became damaged
mobilize the tendon with either passive or active flexion in tests, it was notable that the stop grains were not
as soon as possible, to prevent adhesions. Late initiation pulled out (Figure 18[B]-1D).
of finger mobilization would increase the risk of an We believe these data support the conclusion that the
incomplete functional recovery.7-10 device withstands loads in excess of those likely to be
encountered in clinical practice. They also support the
*Conflict of interest: The authors have no financial relation- conclusion that crimping the grain intraoperatively is a
ship with the manufacturer or the distributors of the device. suitable procedure.
208
Chapter 18B: Teno Fix for Tendon Repair 209
CLINICAL TECHNIQUES AND OUTCOMES

We report on treating 22 patients presenting primary
flexor tendon injuries within the digital sheath in zone
2. Results were assessed after a mean of 16 (6 to 26)
months of follow-up.
Clinical end points assessed included a comparison
in range of active motion according to the Strickland
and Glogovac method9,10 of the distal and proximal
A interphalangeal (DIP and PIP, respectively) joints of the
finger as well as a recording of the linear measurement
of pulp–to–distal palmar crease distance.11 We adopted
the Strickland criteria in the documentation of out-
comes of flexor tendon repair in zones 1 and 2, because
we find these criteria more practical than the total active
motion (TAM) method advocated by the American
Society for Surgery of the Hand (ASSH). In fact, some
degree of joint stiffness is always present after tendon
repair, making patients with normal TAM rare. With the
Strickland method, excellent functional status requires
a sufficiently large total range of active digital motion
but not necessarily the same range as on the contralat-
eral side.12
Patients
There were 14 men and 8 women, with a mean age of
32 (range, 18-46) years, presenting with a complete
B tendon transsection caused by a sharp blade injury, in
flexor digital sheath zone 2 (the subdivision zones
60
defined by Tang12-14 were followed). Lesions were treated
50 on the thumb (3 patients) and index (12 patients),
middle (3 patients), ring (1 patient), and little (3
40 patients) fingers. The study reports the complete experi-
Load (N)
ence of the authors, and no patient was lost to follow-up

30 before end results were determined.
20 Inclusion Criteria
10 All patients were treated within 12 hours of injury, and
the injured flexor tendons were treated primarily. Four
0 kinds of lesions were included in this case series: (1)
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 complete transsection of the flexor digitorum profundus
C Displacement (mm) (FDP) tendon without or with only minor negligible
lesion of the flexor digitorum superficialis (FDS) tendon
at zones 2B or 2C; (2) complete transsection of the FDP
tendon without concomitant lesion of the FDS tendon,
at zone 2A; (3) complete transsection of the FDS alone,
at zone 2D (the authors propose surgical intervention
in young and active patients; the reason is that even if
D
finger motion remains normal when only the FDP is
Figure 18(B)-1 A, The spindle–coil complex (the “anchor”) present, cumulative grip strength is reduced); and (4)
positioned on the needle of its delivery tube. B, The second complete transsection of the flexor pollicis longus (FPL)
stop-bead, with the multifilament wire already in place, tendon at zone 2.
held by the dedicated crimping instrument. C, A load-
displacement curve shows a linear trend, with a sawtooth Exclusion Criteria
denoting the partial breaking of wire filaments. D, At the In the interest of simplification, patients with injuries
time of failure under load, the wires were broken, but stop
of both flexor tendons or accompanying injuries (of the
grains were not pulled away from the wire.
vessels or joints) or fractures were excluded. Because of hole in the core, until the bead comes into contact with
the diameter of the anchors, children were excluded the complex. After the wire has passed through the
from the study as well as some adult patients presenting second anchor and the second stop-bead (allocated into
lesions in comparably small fingers (most often, the the preloaded crimping instrument), the stumps are
little finger). gently redirected into the tendon sheath and under the
pulleys, to be held together under proper tension. The
Operative Techniques second stop-bead is crimped and the excess wire is cut
Under brachial plexus block anesthesia, after the skin away. A continuous epitendinous 6-0 nylon suture com-
has been incised according to Bruner, the injured tendon pletes the repair, while the longitudinal tenotomies are
stumps are exposed. A longitudinal palmar split is made sutured by buried knots. We never found it necessary to
about 10 mm from the cut edge, to accommodate the close the sheath, although we repaired the pulleys
obturator and the delivery tube, which contains the whenever necessary.
anchor–coil complex. The tendon sheath at this level is
often disrupted by the trauma; however, a limited lon- Postoperative Care
gitudinal incision can be made if necessary. Either proxi- The most attainable active digital flexion to the palm
mal or distal stumps can be chosen as the first point of was allowed beginning on the first postoperative day.
entry, according to clinical need (Figure 18[B]-2A). Extension was limited by placing the hand in a plaster
Once the complex has been gently twisted into place, cast with both the wrist and metacarpophalangeal
the straight needle with the stainless steel suture and the (MCP) joints flexed at 30° until the 14th postoperative
built-in stop-bead (the “wire”) is passed through the day. Afterward, the plaster cast and the skin suture were
A B
D
Figure 18(B)-2 A, FDP tendon cut in the index finger in a patient. We chose the proximal stump as the first point of entry.
B and C, Despite an initial effort at early active and passive motion, after 20 days, rehabilitation was discontinued and rigidity
of the index finger ensued. D, We removed the device after 5 months and performed a cruciate repair.
removed. A dorsal splint in neutral wrist position was DISCUSSION

applied until the 28th day for limiting wrist extension.
Complete active motion of all the fingers was allowed Advantages
(apart from flexion against resistance and forced passive An ideal tendon repair should be simple and reproduc-
extension). ible in execution, of immediately high strength, take up
The patients were monitored on outpatient visits only a small amount of space within the sheath, produce
weekly during the first month and then at 2, 6, 12, and negligible gaps, allow vascularization, and tolerate early
24 months. Anterior and lateral x-ray films in flexion active tendon mobilization. Many proposed techniques
and extension were taken on the 14th and 60th postop- are adequate in tensile strength but are technically
erative days. demanding, requiring excessive tendon manipulation
and possibly increasing the tendon bulk.14-17 Teno Fix
Outcomes respects the vascular perfusion provided by the vincula
Of the 22 patients, function was excellent in 12, good vessels. Tendon repairs with this device do not directly
in 6, and fair in 4 by the Strickland criteria 12 months involve the surfaces of the tendon cut and do not require
after surgery. The four patients who scored a “fair” had knots to be placed between tendon cut surfaces. This
an unsatisfactory outcome, and in three of them the characteristic facilitates the closure of the epitenon,
device was removed; the details are given below. The first favoring reestablishment of tendon continuity.19,20
patient fell accidentally after surgery, provoking a forced We noted that this device has a unique feature: the
hyperextension and the eventual tendon rupture around intratendinous complex inserted in the tendon belly
the anchors; the device did not rupture but was removed. allows the tendon collagen fibers, caught between the
The second patient required the removal of the device coil and the core, to maintain their physiological elon-
because of a low-grade sepsis that gave persistent pain; gation. This happens without excessive twisting and/or
the use of Teno Fix was probably a poor choice for this constriction of the tendon fibers, which is more likely
patient, who presented with a torn and poorly vascular- in repairs using ordinary surgical sutures. Surgical suture
ized wound at the time of surgery. The third patient was repairs may interfere with vasculature of the tendon
extremely noncompliant and did not follow any reha- and produce a well-demarcated acellular zone in tied
bilitation instructions. The fourth patient, despite an knots.21
initial effort at early active motion (Figure 18[B]-2B We compared results in the literature from clinical
and C), failed to continue a rehabilitation program, and series of traditional treatment of flexor tendon injuries
ended up with a rigidly extended finger. The device was in zone 2 with our results with Teno Fix. They are in the
removed (Figure 18[B]-2D). As with all other removals same range when the Strickland criteria and percentage
of the device, we performed a traditional cruciate repair of rupture are considered.22 However, Teno Fix appears
for the tendon. However, failure to comply with a reha- to have faster functional recovery and return to work. In
bilitation regimen resulted in novel rigidity. our series, the average time needed to return to work
In the remaining 18 patients (i.e., six FDP cuts at was only 34 days.
zones 2B or 2C, 5 FDP cuts at the border of zone We did not receive any complaints or requests for
2A, 4 FDS cuts at zone 2D, and 3 FPL cuts), we found removal of the device in the long term, and our oldest
notable that patients returned to work after a mean case now dates back 7 years. We believe it is not neces-
of 34 (±12) days, a comparatively short period. We sary to remove the device after successful healing because
extended use of this device in treating disruption of the of the possible damage to healed tendons, presenting a
FPL tendon of the thumb and outcomes were excellent risk that far outweighs the benefits of not having an
(Figure 18[B]-3A and B). artificial device in place.
Dynamic x-ray films in full flexion and full extension
showed that the device did not interfere with the Disadvantages
pulleys, since no blockage of the repaired tendon Because of the diameter of the anchors, use of the Teno
occurred under them. This proved true with a critical Fix is not indicated in children or some adult patients
pulley like the A4 in distal zone 2A lesions (Figure presenting with lesions in comparably small fingers, like
18[B]-3C) and with another critical pulley like the A2 the little finger. Regarding possible risk of infection due
(Figure 18[B]-3D). to the presence of a metallic device, in our opinion the
In 14 cases of the series, radiographs taken 2 months Teno Fix is not indicated in treatment of dirty lesions or
after surgery showed that the anchors had slid closer to generally in complex multiple lesions. Because it requires
the junction site (see Figure 18[B]-3C). This has been good-quality tissue in the stumps receiving the anchors,
interpreted as a sign of effective tendon scarring, which the device is not indicated in case of fraying cut tendons.
involves a physiological contracture of the stump tissue. Finally, the need for full patient compliance with the
However, in the other cases anchors were not displaced, rehabilitation program suggests that the device should
even in the long term (see Figure 18[B]-3D). not be used with uncooperative patients. All these are
A B
AP LL
sb
a
sb
D
Figure 18(B)-3 A and B, Good results were obtained in the thumb, as shown in this patient 22 months after surgery.
C, Dynamic x-ray films taken after 2 months showed that the anchors (a, anchor; sb, stop-beads) had slid toward the junction
site in the majority of patients. This is interpreted as a sign of effective tendon healing and scarring, which involves a
physiological contracture of the stump tissue. D, In the other cases, anchors were not displaced, even after 2 years.
clear disadvantages that argue against the use of Teno with a rehabilitation regimen, a requirement in recovery
Fix in these clinical settings. In our series, this treatment from tendon surgery. In the other two patients with
was not the right choice for four patients, giving us fair unsatisfactory outcomes, we stress that the reasons for
results and a reoperation rate no lower than in recent removal (forced hyperextension and low-grade sepsis)
reports of primary flexor tendon repairs in zone 2. were not directly associated with the device itself. The
We should acknowledge that in our case series, only drawbacks and limitations revealed in our case series
a single flexor tendon was injured, which calls for a should be taken into consideration when this device is
relatively simple clinical response. We do not know used in future cases.
whether this device would work well for patients with
Acknowledgments
simultaneous injuries of both FDS and FDP tendons. In
addition, four of our cases did not recover satisfactory We would like to thank Professor Luigi Ambrosio and
function. Three of those four required removal of the Dr. Antonio Gloria from the Institute of Biomedical
device, and we then performed a traditional four-strand Composite Materials (Naples, Italy) for their coopera-
cruciate repair to provide some kind of treatment. tion in performing mechanical tests. Figures 18-1A and
However, we must also note that two of the four patients 18-3, A–D, are used with permission from Springer
with unsatisfactory outcomes were unable to comply Verlag, Heidelberg-New York.
References
1. Lewis N, Quitkin HM: Strength analysis and comparison of 11. Boyes JH: Flexor tendon grafts in the fingers and thumb: an
the Teno Fix Tendon Repair System with the two-strand modi- evaluation of end results, J Bone Joint Surg (Am) 32:489–499,
fied Kessler repair in the Achilles tendon, Foot Ankle Int 1950.
24:857–860, 2003. 12. Tang JB: Clinical outcomes associated with flexor tendon
2. Su BW, Protopsaltis TS, Koff MF, et al: The biomechanical repair, Hand Clin 21:199–210, 2005.
analysis of a tendon fixation device for flexor tendon repair, 13. Tang JB, Shi D: Subdivision of flexor tendon “no man’s land”
J Hand Surg (Am) 30:237–245, 2005. and different treatment methods in each sub-zone. A prelimi-
3. Su BW, Solomons M, Barrow A, et al: Device for zone-II flexor nary report, Chin Med J 105:60–68, 1992.
tendon repair. A multicenter, randomized, blinded, clinical 14. Tang JB, Shi D, Gu YQ, et al: Double and multiple looped
trial, J Bone Joint Surg (Am) 87:923–935, 2005. suture tendon repair, J Hand Surg (Br) 19:699–703, 1994.
4. Su BW, Raia FJ, Quitkin HM, et al: Gross and histological 15. Wade PJ, Wetherell RG, Amis AA: Flexor tendon repair: sig-
analysis of healing after dog flexor tendon repair with the nificant gain in strength from the Halsted peripheral suture
Teno Fix device, J Hand Surg (Br) 31:524–529, 2006. technique, J Hand Surg (Br) 14:232–235, 1989.
5. Su BW, Solomons M, Barrow A, et al: A device for zone-II 16. Trail IA, Powell ES, Noble J: The mechanical strength of
flexor tendon repair. Surgical technique, J Bone Joint Surg various suture techniques, J Hand Surg (Br) 17:89–91,
(Am) 88(Suppl 1 Pt 1):37–49, 2006. 1992.
6. Wolfe SW, Willis AA, Campbell D, et al: Biomechanic com- 17. Barrie KA, Tomak SL, Cholewicki J: Effect of suture locking
parison of the Teno Fix tendon repair device with the cruciate and suture calibre on fatigue strength of flexor tendon repairs,
and modified Kessler techniques, J Hand Surg (Am) 32:356– J Hand Surg (Am) 26:340–346, 2001.
366, 2007. 18. Strickland JW: Flexor tendon repair, Hand Clin 1:55–68,
7. Kitsis CK, Wade PJ, Krikler SJ: Controlled active motion fol- 1985.
lowing primary flexor tendon repair: a prospective study over 19. Strickland JW: Development of flexor tendon surgery:
9 years, J Hand Surg (Br) 23:344–349, 1998. twenty-five years of progress, J Hand Surg (Am) 25:214–235,
8. Peck FH, Bucher CA, Watson JS: A comparative study of two 2000.
methods of controlled mobilization of flexor tendon repairs 20. Ketchum LD: Suture materials and suture techniques used in
in zone 2, J Hand Surg (Br) 23:41–45, 1998. tendon repair, Hand Clin 1:43–53, 1985.
9. Strickland JW, Glogovac SV: Digital function following flexor 21. Wong JKF, Cerovac S, Ferguson MWJ, et al: The cellular effect
tendon repair in Zone II: A comparison of immobilization of a single interrupted suture on tendon, J Hand Surg (Br)
and controlled passive motion techniques, J Hand Surg (Am) 31:358–367, 2006.
5:537–543, 1980. 22. Rocchi L, Merolli A, Genzini A, et al: Flexor tendon injuries
10. Strickland JW: Flexor tendon surgery. Part 1: primary flexor of the hand treated with Teno FixTM: mid-term results,
tendon repair, J Hand Surg (Br) 14:261–272, 1989. J Orthop Traumatol 9:201–208, 2008.
CHAPTER
19
TREATMENT OF RUPTURE
OF PRIMARY FLEXOR
TENDON REPAIRS
strength. Two curious facts should make us wary of

OUTLINE
this search for the perfect suture configuration. Savage
reported one rupture in 20 fingers and 3 thumbs with
Clinical series of primary flexor tendon repairs world-
zone 2 complete flexor divisions repaired with a six-
wide, using a variety of suture materials and suture
strand suture, a rupture rate in the fingers of 5% or
configurations, all include a small, but ever present,
a rupture rate of 3% overall.2 Harris et al,4 reporting
rupture rate. That the assumption that stronger sutures
results from my own unit from June 1989 to December
will “cure” the problem may be false is discussed and
1996, recorded 17 ruptures in a series of 397 fingers
the role of the sheath and of the patient considered.
(4%) with zone 2 complete flexor divisions using a two
Immediate re-repair of ruptures has been carried out
strand modified Kessler core suture. So simply putting
for many years without analysis of the success of this
in more complex sutures is possibly not the answer, or
procedure. This chapter discusses a study of the effec-
not the only answer.
tiveness of immediate re-repair of ruptures of the
A very interesting laboratory study from Professor
primary repair. It identifies that this works adequately
McGrouther’s laboratory in Manchester5 showed that
for all digits but the little finger. Possible modifica-
even a single suture passed through a tendon signifi-
tions of the method of re-repair used in this study
cantly affects the cell population of the tendon around
which might improve the results are discussed and an
it: the suture foreign body causes the tenocytes to move
alternative management plan for the little finger is
away. So, perhaps, we are, unwittingly, making tendon
considered.
repair breakdown more likely as we put more foreign
suture material into the tendon.
Rupture of the tendon repair, or detachment of the rein-
serted tendon, if recognised immediately, should be treated THE PATIENT
with prompt re-exploration and repair.
This may be the reason why we cannot get past an inevi-
Leddy, 19821
table rupture rate, although it is probably more likely
With a few exceptions, most studies published during that it is simply human nature that is defeating us. In
the past 25 years discussing acute flexor tendon repair 1999, we highlighted the role of patient irresponsibility
and early mobilization report a rupture rate of between in the etiology of rupture of primary flexor tendon
3% and 9%. In studies of less than 100 patients, which repairs.4 This study included 526 fingers in 440 patients
are the norm for this field, these figures indicate negli- with primary flexor tendon repairs in zones 1 and 2 who
gible differences in the number of patients with rup- underwent surgery and postoperative mobilization in a
tured tendon repairs in different units using a multitude controlled or early active motion. Twenty-three patients
of core and circumferential suture techniques and many ruptured 28 tendon repair(s) in 23 fingers, an overall
variations of the three basic regimes of early postopera- rupture rate of 4%. Eleven of these, just less than half,
tive mobilization. occurred as a result of patients using the hand, in or out
of their splint, against therapy advice. It is likely than
THE SUTURE
this figure is an underestimate of this problem of patient
Survey of the many new suture techniques used through- noncompliance in this population worldwide.
out the past 20 years confirms that the Savage six-strand
THE SHEATH
suture2,3 is still the strongest suture, although it is diffi-
cult to use. One could argue that 20 years have been In a laboratory study, Tang et al6 identified a further
spent trying to achieve a simpler suture with equal possible factor in the etiology of these ruptures. These
214
Chapter 19: Treatment of Rupture of Primary Flexor Tendon Repairs 215
Table 19-1 Timing of Ruptures of Primary Finger rehabilitation of the initial tendon division, were rela-
Flexor Tendon Repair in a Total of 62 Fingers tively small and the studies were not focused on the
Mechanical Infective results of re-repair.
Time After Primary Ruptures Ruptures THE RESULTS OF RUPTURE RE-REPAIR
Repair (Wk) (n = 57) (n = 5)
In view of the paucity of data on the results of immedi-
<1 6 2
ate re-repair, we carried out a study to examine the cir-
1-2 23 0 cumstances of the 62 fingers in 61 patients who ruptured
2-3 9 2 primary zone 1 and 2 finger flexor tendon repairs in
our unit over a 14-year period, from 1989 to 2003, and
3-4 7 1
reported the outcome of immediate re-repair of the rup-
4-5 6 0 tured tendons in those fingers in which re-repair was
5-6 2 0 undertaken.7 This study remains the major work on this
subject to date.
6-7 2 0 There are some absolute contraindications to attempt-
7-8 1 0 ing re-repair after rupture, such as poor general health
precluding either regional or general anesthesia, infec-
8-9 1 0
tion of the involved finger, and a mental status of the
patient incompatible with cooperation with therapy.
Most other contraindications are relative but may
constitute logical reasons not to attempt to re-repair a
authors suggested that repair rupture is most likely to rupture of a primary finger flexor tendon repair in a
occur at sites where tendons glide over a rim of a major particular individual or in a particular finger. These
pulley or over gliding curves of a small diameter, char- include advanced or very young age, the general medical
acteristics found typically in zone 2B repairs and repairs status of the patient, the suitability and compliance of
of tendons in little fingers. In our study, described later, the patient, other pathologies or injuries of the affected
32 of a total of 42 fingers (77%) requiring re-repair of hand or digit, rupture of the flexor digitorum profundus
the flexor tendons occurred in zone 2B and/or in little (FDP) tendon in the presence of a functioning flexor
fingers.7 digitorum superficialis (FDS) tendon with a good range
of motion of the proximal interphalangeal joint, palmar
TIMING OF OCCURENCE OF THE RUPTURE
skin loss of the affected digit or excessive stiffness, and/
The times after primary repair at which the ruptures or swelling of the digit. It is commonly thought that
occurred are shown in Table 19-1, which contains infor- re-repair should be performed no more than 48 to 72
mation from our unit in 62 fingers in 61 patients who hours from rupture, although there are no data to
ruptured primary zone 1 and 2 finger flexor tendon support this cut-off time. After 5 weeks from the primary
repairs. The average time to rupture of the primary repair, the digit is often at that stage of the healing
repairs was 18 days (range, 3 to 61 days). The highest process when it is hard and “wooden” and re-repair is
incidence of rupture of primary finger flexor tendon difficult and may endanger other structures in the opera-
repairs was seen in the second week after surgery. The tive field. The re-repair is also very likely to stick post-
incidence of rupture was higher in the first 5 weeks after operatively. In our study, the average time to rupture of
surgery than in the later 4 weeks (weeks 6 to 9). the primary repairs was 18 days (range, 3 to 61 days),
so most ruptures fall within the time when this factor
IMMEDIATE RE-REPAIR OF RUPTURES
does not prevent re-repair. Patients may also decline
Little has been published specifically about the manage- further surgery for various reasons. In our study, two
ment of ruptured primary flexor tendon repairs. For 20 patients in whom only the FDP repair had ruptured,
years, the quotation at the beginning of this chapter has leaving an “FDS-only” finger with full proximal inter-
been the teaching on the management of rupture of phalangeal (PIP) joint flexion, declined to undergo
primary flexor tendon repairs of the fingers in zones 1 re-repair. A third patient, who ruptured both tendon
and 2 during the early part of the rehabilitation program. repairs, declined re-repair for business reasons. He, sub-
While most experienced clinicians would agree with this sequently, underwent a two-stage tendon graft proce-
opinion, this statement was made without published dure at a more convenient time with a good result.
evidence to support it. The available literature in the Although it is usually possible to re-repair the rup-
period immediately following Leddy’s statement sug- tured tendon(s) if correct decisions have been made
gested that he was correct.4,8-11 However, the numbers of preoperatively, it can become obvious at surgery that
ruptures and re-repairs in these studies, which were pri- this will be difficult, impossible or unwise. It is impor-
marily concerned with the surgical management and tant that the patient be informed of this possibility
preoperatively. The tendons may be too swollen, cases, general medical problems in two cases, dense
although this can often be overcome by single tendon scarring in the flexor sheath and frayed tendon ends in
repair and excision of the whole, or half, of the FDS two cases, a large gap between the tendon ends preclud-
tendon. The proximal end of the tendon may have ing direct suture of the tendon without undue tension
retracted too far. This is most commonly a problem of in one case, and an overly long delay of 9 days between
the long flexor tendon of the thumb but can occur with tendon rupture and presentation in one case. This list
finger flexor tendons. It can often be overcome by emphasizes some of the more common considerations
lengthening the proximal tendon, using either the Le of management.
Viet technique12 or conventional tendon lengthening at Immediate re-repair of the flexor tendons was per-
the wrist, although this was not necessary in our series. formed in 44 fingers (71%) in 43 (70%) patients. All
The alternatives to immediate re-repair should be were carried out within 48 hours from the rupture. Two
discussed carefully with the patient preoperatively both fingers in two patients were excluded from analysis of
to allow informed consent and in case re-repair proves the effectiveness of immediate re-repair because the sub-
impossible. Making a discussion intraoperatively will be sequent poor results were considered an unfair repre-
impossible if general anesthesia has been used initially sentation of the result of the immediate re-repair
or after failure of regional anesthesia. Where immediate procedure. One patient developed chronic regional pain
re-repair is clearly impossible preoperatively, or it syndrome (CRPS) type 1 postoperatively and one had
becomes apparent during surgery that re-repair is impos- severe osteoarthritis of multiple joints in all of his
sible, the options include (1) doing nothing further; (2) fingers. Five patients re-ruptured their re-repairs in five
single-stage tendon grafting; (3) the first stage of two- fingers and so were excluded from analysis of the effec-
stage tendon grafting, i.e., insertion of a silicone rod; tiveness of immediate re-repair.
and (4) tendon transfer. Doing one of these may convert In the remaining 37 fingers in 36 patients, the results
the failure of the primary intention to re-repair the were assessed using the original Strickland method13
flexor tendon(s) into a useful operation. (Table 19-2). This group of patients included 31 men
In our series, it was not possible to carry out immedi- (average age, 36 years; range, 30 to 58 years) and five
ate re-repair in 18 fingers (29%) in 18 (30%) patients, women (average age, 23 years; range, 16 to 32 years).
approximately one-third of cases. The reasons for not Eighteen fingers had primary repair of both the profun-
re-repairing the ruptured tendon repairs in these cases dus and superficialis flexor tendons (FDP, FDS). In nine
included infection in five cases, poor previous compli- of these fingers, both tendon repairs had ruptured. In
ance with therapy in four cases, patient choice in three eight of these, both tendons were re-repaired, while only
Table 19-2 Results of Immediate Re-Repair of Ruptures of Primary Flexor Tendon Repairs and Distribution of
Ruptures of Primarily Repaired Tendons Among Different Fingers at the St Andrew’s Centre for Plastic Surgery,
Chelmsford, UK
Locations Excellent Good Fair Poor Second Rupture Total
Results by fingers
All fingers 9 (24%)* 10 (27%) 5 (14%) 13 (35%) 5 42
Index 2 4 1 1 0 8
Middle 4 3 0 4 1 12
Ring 1 0 0 1 0 2
Little 2 3 4 7 4 20
Results by locations in fingers
Zone 1 1 (20%) 2 (40%) 0 (0%) 2 (40%) — 5
Zone 2 8 (25%) 8 (25%) 5 (16%) 11 (34%) — 32
Zone 2A 0 1 0 0 — 1
Zone 2B 5 5 4 7 — 21
Zone 2C 2 2 1 3 — 8
Zone 2D 1 0 0 1 — 2
*The percentages shown are only for the 37 fingers which were rehabilitated successfully.
Chapter 19: Treatment of Rupture of Primary Flexor Tendon Repairs 217
FDP was re-repaired in one finger, with no reason being and/or additional unadvised use of the hand after
given by the operating surgeon as to why FDS was not re-repair, provided the resulting repair is not so thick as
re-repaired. In the other nine of these fingers, rupture of to preclude free gliding within the sheath. However, the
the FDP repair only occurred and immediate re-repair of size of the re-repair is more likely to be a problem in
the FDP was performed. Nineteen fingers, including five this respect than at the time of primary repair as the
zone 1 injuries, had primary repair of FDP only, so only fingers involved are already edematous from the primary
this tendon repair ruptured. All nineteen underwent injury and repair. This limitation was initially identified
re-repair of this tendon alone. Of the 37 re-repairs, nine in primary repair when increasingly complicated cir-
(24%) had excellent, 10 (27%) had good, 5 (14%) had cumferential repairs were used,16 and our clinical experi-
fair, and 13 (35%) had poor results (see Table 19-2). ence supports this finding. For reasons discussed
Earlier studies mentioning the results of immediate previously, simply putting in more complex sutures may
re-repair of zone 1 and 2 finger flexor tendon injuries not be the answer, or not the only answer.
after rupture of primary repairs during rehabilitation Given the above, single tendon re-repair may also be
suggest that immediate re-repair can achieve an excel- more appropriate after double tendon rupture. In this
lent or good result in just over 60% of cases. This study, study, both previously repaired tendons ruptured in
specifically examining this option of treatment in a nine fingers. Both were re- repaired in eight fingers. This
larger number of fingers, does confirm that immediate policy may be one of perfection that should be modi-
re-repair is feasible in cases which present within 48 fied. However, five (62.5%) of these eight fingers had
hours of rupture but only achieved excellent or good excellent or good results. It is certainly easier to repair
results in just over 50% of the fingers. While flexor one tendon only as the tendons are swollen and the
tendon grafting may achieve better results in the hands tendon ends are more frayed and less easily handled at
of some surgeons and in some patients, it should be re-repair than primary repair. Removing the FDS tendon
remembered that these patients include many who are from the finger to reduce the likelihood of the tendons
unlikely to achieve excellent or good results by any sticking under the A2 pulley is a further step to reducing
method of treatment.4 the possibility of tendon adhesion. This is unlikely to
result in PIP swan-necking as these fingers mostly have
RUPTURE OF THE RE-REPAIR
shortened PIP palmar plate ligaments as a result of their
In this study, second rupture was also associated with a postinjury/operative state. The extensibility of this joint
high incidence of noncompliance. That only 50% of the can easily be tested intraoperatively and appropriate
patients in this series achieved excellent or good results tenodesis of the distal part of the superficialis tendon
after immediate re-repair of ruptures of previous tendon across the proximal interphalangeal joint carried out, if
repairs may be a realistic expectation for this subgroup necessary.
of patients. Nevertheless, this, and the fact that 5 of the
THE LITTLE FINGER
41 patients in this study ruptured the re-repairs again
(see Table 19-2), is a poor result that brings into ques- In previous studies, we have found difficulty achieving
tion a universal policy of immediate re-repair of all good results in the little finger after primary repair.17
ruptured primary finger flexor tendon repairs and alter- This experience is repeated in this series of re-repair of
natives should be considered. ruptures of the primary repairs. The percentage of rup-
tures of primary repairs was very much greater in the
POSSIBLE MODIFICATIONS OF THE RE-REPAIR
little finger (46%) than in the other fingers and second
In our study, all of the tendons were re-repaired using rupture was almost exclusively a problem of the little
the same technique, which had been used in the primary finger, with four of the five re-ruptures occurring in the
repair, namely the modification of the two-strand little finger (see Table 19-2). The number of excellent
Kirchmayr/Kessler core suture14,15 in which the suture is or good results after immediate re-repair of ruptured
tied with a single intratendinous knot, and a continuous primary repairs in the index and middle fingers was
circumferential suture. Core sutures of 3-0 or 4-0 poly- higher than in the ring and little fingers and only 5 of
propylene (Prolene) and a continuous circumferential 20 re-repairs in the little finger achieved excellent or
suture of 5-0 or 6-0 nylon (Ethilon) or polypropylene good results. Certainly, there are technical difficulties to
were used in all tendons, with the suture sizes being repairing the small tendons and to rehabilitation of this
chosen according to tendon size. The repairs were mobi- finger and, possibly, higher risks to the repair in the
lized postoperatively using the same technique as used border digit.
after the primary repair, namely a variation of the As mentioned earlier, Tang et al6 suggested that repair
controlled, or early, active motion regimen previously rupture is most likely to occur at sites where tendons
described in 1989 in Belfast,9,11 for a minimum of 8 glide over gliding curves of a small diameter, a charac-
weeks. Use of stronger suturing techniques might seem teristic found typically in repairs of tendons in little
appropriate to withstanding the forces of rehabilitation fingers. These figures support a policy of no re-repair in
patients who rupture primary flexor tendon repairs of the finger. Review at 6 months will identify functional
the little finger. Unfortunately, even when only the FDP problems requiring tendon grafting in individual cases
tendon of the little finger has ruptured, doing nothing but these are likely to be rare. Where the little finger has
may not be an option as the FDS tendon may be absent, no means of flexing after rupture of a primary repair, we
or too weak, to provide sufficient PIP joint flexion for would advise that a rod be inserted into the finger and
useful function. In this difficult finger, particularly in a secondary grafting scheduled when the finger is soft and
less than ideal patient, we would not contemplate single supple, as the alternative of re-repair has a 4 : 20 (20%)
stage tendon grafting. In making a decision to insert chance of a second rupture, necessitating further treat-
a rod when the patient presents with a rupture of a ment within a few weeks, and a 7 : 20 (35%) chance of
primary repair in a little finger, it is often possible to creating a little finger that is a hindrance because of loss
identify those patients who are most likely to do badly of sufficient extension and hooking and/or insufficient
if they are known to the therapy department, having flexion ability to provide good grip function and prevent
spent time—or not—mobilizing the primary repair. objects dropping out of the ulnar side of the hand.
Although these conclusions are empirical, they are no
CONCLUSION
less worthwhile and useful in formulating a treatment
Most ruptures outside of the little finger should be strategy for the management of primary flexor tendon
re-repaired if possible. Little finger ruptures with a strong repairs which rupture. When evidence that stronger
intact FDS tendon can provide adequate little finger re-repairs give better results in the little finger is avail-
flexion and usually do not have significant hooking of able, this policy may require modification.
References
1. Leddy JP: Flexor tendons: acute Injuries. In Green DP, trolled active motion regimen, J Hand Surg (Br) 19:607–612,
editor: Operative Hand Surgery, New York, 1982, Churchill 1994.
Livingstone, p 1359. 10. Moiemen NS, Elliot D: Primary flexor tendon repair in zone
2. Savage R: In vitro studies of a new method of flexor tendon 1, J Hand Surg (Br) 25:78–84, 2000.
repair, J Hand Surg (Br) 10:135–141, 1985. 11. Small JO, Brennen MD, Colville J: Early active mobilisation
3. Savage R, Risitano G: Flexor tendon repair using a “six strand” following flexor tendon repair in zone 2, J Hand Surg (Br)
method of repair and early active mobilisation, J Hand Surg 14:383–391, 1989.
(Br) 14:396–399, 1989. 12. Le Viet D: Flexor tendon lengthening by tenotomy at the
4. Harris SB, Harris D, Foster AJ, et al: The aetiology of acute musculotendinous junction, Ann Plast Surg 17:239–246,
rupture of flexor tendon repairs in zones 1 and 2 of the fingers 1986.
during early mobilization, J Hand Surg (Br) 24:275–280, 13. Strickland JW, Glogovac SV: Digital function following flexor
1999. tendon repair in Zone II: a comparison of immobilization
5. Wong JK, Cerovac S, Ferguson MW, et al: The cellular effect and controlled passive motion techniques, J Hand Surg (Am)
of a single interrupted suture on tendon, J Hand Surg (Br) 5:537–543, 1980.
31:358–367, 2006. 14. Kessler I, Nissim, F: Primary repair without immobilization
6. Tang JB, Xu Y, Wang B: Repair strength of tendons of varying of flexor tendon division within the digital sheath, Acta
gliding curvature: a study in a curvilinear model, J Hand Surg Orthop Scand 40:587–601, 1969.
(Am) 28:243–249, 2003. 15. Kirchmayr L: Zur Technik der Sehnennaht, Z Chir 40:906–
7. Dowd MB, Figus A, Harris SB, et al: The results of immediate 907, 1917.
re-repair of zone 1 and 2 primary flexor tendon repairs which 16. Kubota H, Aoki M, Pruitt DL, et al: Mechanical properties of
rupture, J Hand Surg (Br) 31:507–513, 2006. various circumferential tendon suture techniques, J Hand Surg
8. Allen BN, Frykman GK, Unsell RS, et al: Ruptured flexor (Br) 21:474–480, 1996.
tendon tenorrhaphies in zone 2: repair and rehabilitation, 17. Elliot D: Invited personal view. Primary flexor tendon repair:
J Hand Surg (Am) 12:18–21, 1987. operative repair, pulley management and rehabilitation,
9. Elliot D, Moiemen NS, Flemming AFS, et al: The rupture J Hand Surg (Br) 27:507–513, 2002.
rate of acute flexor tendon repairs mobilized by the con-
CHAPTER
20
CLOSED AVULSION OR
RUPTURE OF FLEXOR TENDONS
A Traumatic Avulsion of
Flexor Tendons
Pierre Mansat, MD, PhD, and Michel Mansat, MD
OUTLINE involved in more than 75% of cases.1,2,4 Satisfactory

results of surgical repair are usually obtained in most
Traumatic avulsion of flexor tendons is not uncom- cases if the diagnosis is made quickly. However, impair-
mon. Often observed in athletes, this lesion concerns ment of the function of the finger can result from a late
mainly an avulsion of the flexor digitorum profundus diagnosis. In these chronic cases, the results of surgical
tendon on the distal phalanx of the ring finger. treatments are often unpredictable.
Although clinically typical, diagnosis is often missed.
BACKGROUND
Prognosis factors identified are the level of retraction
of the tendon, the status of the vinculae, the delay In 1960, Gunter11 reported avulsion of the FDP tendon
between injury and treatment, and the presence occurring in eight rugby players. In 1970, Carroll and
and size of a phalangeal bony fragment. Acutely, March12 reviewed 35 cases and emphasized the particu-
direct reinsertion of the profundus tendon on the lar involvement of the ring finger and the irreversibility
distal phalanx gives satisfactory results. Long-standing of the injury once the tendon had retracted into the
lesions with tendon retraction and impaired tendon palm. The “grasping jersey” mechanism of this trauma
vascular supply should not be treated by reinsertion was specified by Folmar et al13 and Chang et al.14 A clas-
to avoid finger stiffness. No surgery is recommended sification into three types according to the amount of
when impairment of function is slight, the proximal tendon retraction has been proposed initially by Leddy
interphalangeal (PIP) joint perfectly mobile, and the and Packer in 19771 and then in France by Mansat and
distal interphalangeal (DIP) joint stable. If the PIP Bonnevialle in 19852 after review of a series of 19 cases.
joint is stiff, the retracted flexor digitorum profundus In 1981, Smith15 described a fourth type, with avulsion
tendon is resected, followed by tenodesis or capsu- of the profundus tendon in association with a bone frac-
lodesis of the DIP joint. One-stage tendon graft is ture of the distal phalanx. Al-Qattan, in 2001,16 added a
reserved for cases in which the loss of strength and type V with tendon and bony avulsion and transverse
range of active finger flexion are not acceptable, but fracture of the distal phalanx. Only case reports have
the PIP and DIP joints have normal passive motion. been published of traumatic rupture of the FDS.5,6,13,17
MECHANISM OF INJURY
Closed traumatic avulsion of the insertion of flexor
tendons is a relatively common injury, particularly in Many of these injuries occur in rugby or American
athletes. The majority of injuries involve the profundus football, when the finger is forcibly extended during a
tendon at its insertion1-4 and, less frequently, the super- maximum contraction of the profundus flexor muscle.
ficialis5,6 or both tendons.7-10 Avulsion of the flexor digi- The injury occurs when a player is attempting to make
torum superficialis (FDS) tendon can be directly from a tackle and the little finger slips off the opposite player’s
the middle phalanx5 or can be associated with a middle pants or jersey (Figure 20[A]-1). As this occurs, the ring
phalangeal cortical bone avulsion.6 Avulsion of the finger is caught in the pants or jersey. Because of the
flexor digitorum profundus (FDP) tendon occurs most mechanism of injury, the lesion has been termed “jersey
commonly at the bony insertion on the distal phalanx, finger” or “rugby finger.”2,18-20 Other etiologies have
with or without bone fracture.1,2 The injury has been been reported, including blast injury21 and closed blunt
reported to occur in all fingers, but the ring finger is trauma.22
219
Figure 20(A)-1 Mechanism of injury of a “rugby finger.”
The ring finger is most susceptible to avulsion of the

FDP tendon.1 Several studies have shown that the inser-
tion of the profundus tendon is anatomically weaker in
Type I Type II Type III
the ring finger than in the middle finger.19,23 The FDP of
the ring finger is tethered in the palm by a bipennate Figure 20(A)-2 Leddy and Packer’s classification.1
lumbrical muscle,19 and the anatomic arrangement of
the extensor tendons in the ring finger may also relate
disrupted, resulting in loss of blood supply to the
to the susceptibility of the ring finger to rupture.1
tendon.
When the four long fingers are grasping an object with  Type II, the tendon retracts back to the level of the
force, they bear strong traction, which causes acute hyper-
proximal interphalangeal (PIP) joint, being held
extension of the distal interphalangeal (DIP) joints. The
there by the intact long vinculum.
index, whose muscular belly is independent, can release  Type III, there is usually a large bony fragment that
its grip before the others. Because the muscular part of
is avulsed from distal phalanx and holds the
the profundus is united to the surrounding structures
tendon from proximal retraction by catching on
and because of the existence of tendinous connections,
the A4 pulley. The tendon and vinculae remain
the ring finger is submitted to the constraint along with
intact.
the middle and little fingers. Because of the shorter size
of the little finger, it closes up before the others. This Mansat and Bonnevialle2 have found it more logical
leaves the middle and ring fingers to oppose this strong to classify this injury according to the extent of retrac-
hyperextension force. The distal insertion of the ring tion of the avulsed FDP tendon from a more benign
finger, being weaker than that of the middle finger, gives form to a more severe form:
away first.2
 Type I, proximal retraction of the avulsed FDP
CLASSIFICATION
tendon to the level of the bifurcation of the FDS
The amount of injury to the extrinsic vascular supply of tendon, but the long vinculum remains intact.
the distal flexor tendon is proportional to the degree of  Type II, marked retraction of the avulsed FDP
retraction of the avulsed tendon. The short vinculum, tendon into the palm, with avulsion of the vincu-
located at the neck of the middle phalanx and at the lae and loss of the tendon vascular support.
DIP joint, is injured when the FDP tendon is avulsed  Type III, Intraarticular fracture of the distal phalanx
from the distal phalanx. However, the tendon may be and dorsal subluxation of the DIP joint; the
still supplied by the long vinculum located on the FDS tendon still attaches to the bony fragment and
tendon closed to its chiasma, which extends to the FDP proximal retraction of the FDP tendon is very
tendon. The intactness of this long vinculum determines limited. The bony fragment is entrapped in the
the severity of the injury.24-26 distal part the digital sheath tunnel.
Leddy and Packer classified the FDP tendon avulsion  Type IV, the tendon is avulsed from the fractured
injury in the finger into three types1 (Figure 20[A]-2): fragment of the distal phalanx and retracts; the frac
ture is intraarticular, involving articular surface.15
 Type I, the avulsed FDP tendon is retracted into the  Type V, avulsion of an osseous fragment connect-
palm. The vincular system has been completely ing to the insertion of the FDP tendon. There is a
Chapter 20A: Traumatic Avulsion of Flexor Tendons 221
concomitant fracture of the distal phalanx beside tendon.27 The only differential diagnosis is a torn volar
the avulsion.16 plate of the DIP joint as described by Bowers and
Fatjgenbaum.28
In some rare cases, both flexor tendons can be avulsed Isolated, closed avulsion of the FDS tendon at its
on the same finger.7-10 insertion can present diagnostic and therapeutic chal-
lenges. The injury is often associated with flexion defor-
DIAGNOSIS
mity and diminished extension of the involved digit.
The problem of this injury is that it is often missed This presentation is readily explained by the anatomy
initially. In the Mansat and Bonnevialle series, only 50% of the digital flexor tendon and annular pulley system.
of the cases had been diagnosed within the first 3 weeks.2 Once torn from its insertion on the middle phalanx, the
The history of the mechanism of injury is typical. While superficialis tendon retracts proximally. It stops at the
playing rugby, American football, or other sports, the level of the A1 pulley where Camper’s chiasma acts as
patient feels a searing pain in the ring finger when grasp- noose to ensnare the FDP tendon. If diagnosis is delayed,
ing the opposite player’s jersey, sometimes with ecchy-
mosis (Figure 20[A]-3). The patient may notice loss of
active DIP joint flexion (or PIP joint flexion for an FDS
tendon avulsion) (Figure 20[A]-4). Pain localization
may give an indication of the amount of retraction of
the avulsed tendon. According to Mansat and Bonnevi-
alle’s classification,2 in type I, patients have pain, swell-
ing, and loss of motion of the PIP joint as well as no
active flexion of the DIP joint. In type II, the patient may
have tenderness over the insertion area of the FDP
tendon on the distal phalanx, and there also may be
tenderness and swelling in the palm where the tendon
has retracted. In type III, the patient has marked swell-
ing, ecchymosis, and pain over the distal aspect of the
middle phalanx just proximal to the DIP joint, as well
as no active flexion at the DIP joint. Radiographs are
often negative in type I and II lesions. However, in types Figure 20(A)-4 Loss of active flexion of the DIP joint after
rupture of the FDP tendon in a ring finger.
III, IV, and V, a lateral radiograph shows a large bony
fragment just proximal to the DIP joint with or without
distal phalanx fracture (Figure 20[A]-5). The use of
ultrasound has been proposed to localize the avulsed
Figure 20(A)-5 A lateral x-ray film showing a bony

Figure 20(A)-3 Ecchymosis along the finger. fragment avulsed from the base of the distal phalanx.
inflammation and adhesion formation further entrap rupture.4 Transosseous suture repair is preferred, using
the profundus tendon.5 Lateral radiograph can show a a standard pull-out wire and button technique,1,2 a
bony fragment at the middle phalanx.6 double-arm reinsertion technique,29 or micro-anchors4,30
(Figure 20[A]-7). In the Brustein et al study,31 the
TREATMENT
micro-bone suture anchor provided a stronger tendon-
Several factors have been identified which influence the to-bone repair compared to pull-out wire and button
prognosis and treatment of injury of the FDP tendon: or a mini-anchor. However, McCallister et al32 have
(1) the level of retraction of the tendon, (2) the status shown no difference between pull-out wire and button
of the vinculae, (3) the delay between injury and treat- technique and mini-anchors for zone 1 flexor tendon
ment, and (4) the presence and size of a phalangeal repair in respect of clinical outcome, although signifi-
bony fragment.2,18 cant improvement was found in the time to return to
The definition of “acute” cases varies from one sur work following repairs using suture anchor technique.
geon to another. For Mansat and Bonnevialle,2 a delay There was less potential morbidity associated with the
of 3 weeks is the limit, whereas for Tropet et al,3 10 days anchor technique compared to the pull-out wire and
is the maximum. For Leddy and Packer,1 the delay is not button technique. The main problems reported with the
the major factor but more the level of tendon retraction pull-out technique were discomfort, pain, suture wire
at diagnosis. If the tendon is not retracted, a direct repair rupture, difficulty in daily care of the bolster, infection,
can be performed up to 3 months after injury; on the skin necrosis, and nail bed injury.33 The use of a braided
other hand, if the tendon is retracted into the palm, polyester suture instead of a monofilament suture is
direct repair may not be possible after 10 days have recommended, as it is more resistant to cyclic testing.34
elapsed. Usually, final decision is made during surgery. Care should be taken not to injure the volar plate of the
The treatment of an acute injury, according to Mansat DIP joint when reinserting the tendon.
and Bonnevialle’s classification,2 is described below. The In type II, the exposure is identical to that for a type
decision to repair or reattach the tendon to the distal I injury. If the tendon is not identified just distal to the
phalanx depends on the degree of retraction. A2 pulley, it must have retracted into the palm. Then, a
In type I, the optimal treatment for this injury is early slightly curved incision is made just proximal to the
reinsertion of the tendon to the distal phalanx. The distal palmar crease; this allows exposure of the flexor
exposure is through a zigzag incision on the finger, sheath proximal to the A1 pulley. A small incision is
exposing the flexor sheath from the area of the insertion made in the sheath, and the distal end of the profundus
to just proximal to the PIP joint. An opening is created tendon is identified. Next, a small catheter is inserted
in the sheath just distal to the A2 pulley to identify the into the sheath through the incision in the distal finger
retracted tendon (Figure 20[A]-6). The tendon is found and passed to the level of the A1 pulley. The profundus
and threaded beneath the flexor tendon sheath to the
level of the distal phalanx in a nontraumatic manner.
A raised osteoperiosteal flap is then created at the
insertion site on the distal phalanx, and the profundus
tendon is reinserted. If some tendon materials remain
on the distal phalanx direct tendon-to-tendon suture
must be avoided because of a high risk of secondary
B
Figure 20(A)-7 Repair of the FDP tendon by means of
Figure 20(A)-6 Surgical exposure for a type I lesion. pull-out or barb-wire suture (A), or micro-anchors (B).
tendon is then sutured to the catheter, which is pulled

distally, threading the profundus tendon back beneath
the pulleys and through the superficialis chiasma to the
level of the PIP joint. The tendon is then passed in a
similar fashion beneath the C1, A3, C2, A4, and C3
pulleys to the level of the distal phalanx. The tendon is
reattached to the phalanx with the methods for a type I
injury. However, if reinsertion on the phalanx is difficult
and under tension, resection of the tendon with stabi-
lization of the DIP joint in slight flexion is preferred. A
Using the distal remnant of the profundus tendon may
help to create a simple tenodesis protected by a tempo-
rary K-wire. Fusion is an alternative to tenodesis.2
In type III, treatment consists of open reduction and
internal fixation of the bone fragment. Correct reduc-
tion of the joint line is necessary to obtain good motion
without pain. Internal fixation can be performed with
K-wires,2,4,15,35,36 micro-screws,20,37,38 or a micro-plate39,40
(Figure 20[A]-8).
In types IV and V, the bony fragment is openly
reduced and fixed followed by repair of the avulsed B
profundus tendon, as described for type I and II injuries,
depending on the level of retraction.15,16
For old injuries, management is variable and indi-
vidualized for each case. Decision-making is based on
functional impairment (PIP joint stiffness, loss of
strength), patient’s needs and expectation, and total
ranges of active and passive motion of the PIP and DIP
joints. Those patients who are asymptomatic should be C
left alone. Rarely do patients have limitation of motion
at the PIP joint 6 months after injury; however, if there
is instability of the DIP joint with weakness of pinch
or recurrent dorsal dislocation, arthrodesis or tenodesis
of the joint should be considered18 (Figure 20[A]-9).
Fusion provides joint stability and does not interfere
with the function of the superficialis tendon. If there is
a tender lump in the palm, the retracted tendon end can
be excised at the time of fusion. Generally, Mansat and
Bonnevialle2 advocated (1) no surgery when impair-
ment is slight (non-manual workers), the PIP joint is
perfectly mobile, and the DIP joint is stable; and (2) D
simple resection of the retracted FDP tendon if the PIP
joint is stiff, in association with tenodesis of the DIP
joint. There is a risk of PIP and DIP joint stiffness if
reinsertion is performed, even in type I injury. One-stage
tendon graft with palmaris longus tendon should be
reserved for patients for whom strength and function
impairment of the ring finger are not acceptable but who
have normal passive motion of PIP and DIP joints
(Table 20[A]-1).
FDS tendon avulsion can be reinserted or sutured
totally or partially with repair of one slip through a
palmar zigzag incision centered on the PIP joint if diag-
nosed early. However, for long-standing cases, the inci- E
sion must be extended into the palm. The retracted end Figure 20(A)-8 Treatment of a type III lesion. A, Osteosyn-
of the tendon is found at the level of the A1 pulley. thesis of the fracture with a screw. B and C, Tendon repair
with a micro-anchor. D and E, Clinical results at follow-up.
Table 20(A)-1 Operative Methods for Avulsion of the

FDP Tendon
Operative Treatment: Operative Treatment:
Type* Acute (<3 Wk) Late (>3 Wk)
I Direct repair FDP resection + DIP
(+micro-anchors) joint capsulodesis or
tenodesis
FDP resection + DIP FDP resection + DIP
joint capsulodesis or joint arthrodesis
tenodesis
A FDP resection + DIP Tendon graft

joint arthrodesis
II Direct repair Direct repair
(+micro-anchors) (+micro-anchors)
FDP resection + DIP
joint capsulodesis or
tenodesis
FDP resection + DIP
joint arthrodesis
Tendon graft
III Osteosynthesis Osteosynthesis
(±suture of the (±suture of the
tendon) tendon)
*Classifications by Leddy and Packer.1
B
Figure 20(A)-9 Type I lesion treated by resection of the
FDP tendon (A), and tenodesis of the remnant of the FDP
tendon at the DIP joint (B).
Peritendinous adhesions and scar tissue were excised

along with the FDS tendon.5 If a bony fragment is
attached to the tendon, it is removed with the tendon.6
POSTOPERATIVE CARE
Postoperatively, in type I and II lesions after reinsertion
of the FDP tendon to the distal phalanx, a dorsal splint
is used to hold the wrist in slight flexion, the MCP joints
in 75° of flexion, and the PIP and DIP joints in relative
extension (Figure 20[A]-10). Passive flexion exercises
are started early in the postoperative course. Active exer-
cises are begun at 3 weeks when the splint is removed.
The pull-out wire and button are removed 3 to 4 weeks
postoperatively, and the remaining rehabilitation is
similar to that for other flexor tendon injuries.
Figure 20(A)-10 Dorsal splinting to place the MCP joint in
In type III, IV, and V lesions, immobilization of the
flexion and PIP and DIP joints in extension.
DIP joint of 45 days is necessary for consolidation of the
fracture. Then passive and active mobilization is begun.
et al.3 For type II lesions according to Mansat and Bonn-
OUTCOMES
evialle’s classification, reinsertion of the FDP tendon on
For acute lesions of the FDP tendon, surgical repair is the distal phalanx must be performed without tension
always indicated, and satisfactory results varied from to obtain satisfactory results.2 If not, the finger becomes
70% for Gaston et al4 to 80% for Mansat and Bonne stiff with limitation of active motion of the DIP and PIP
vialle2 and 100% for Leddy and Packer1 and Tropet joints. For type III, IV, and V lesions, the prognosis
depends on the quality of articular surface reduction, For patients seen more than 3 weeks after injury, the
often with loss of few degrees of active motion of the FDP tendon was resected in one case, the FDP tendon
DIP joint.4 was resected with a DIP joint capsulodesis in 4 cases,
For chronic lesions, if the patient has no or slight and tendon grafting using the palmaris longus was per-
impairment, conservative management is the best formed in one case.
option. If the patient complains of digital pain, with Patients were reviewed at an average of 7 years
flexion deficit of the PIP joint, resection of the avulsed (3 months to 13 years) from treatment (Table 20[A]-2).
tendon must be proposed. If there is instability of the Four of the 10 patients had a complete recovery (range
DIP joint, capsulodesis, or arthrodesis of the DIP joint of motion and strength), 3 had an incomplete recovery
can be added. Tendon grafting should be limited to (range of motion of the DIP joint between 60° and 80°
young and active patients with specific needs. Preopera- of flexion, normal strength), and one had an unsatisfac-
tive normal passive motion of the PIP and DIP joints is tory result (range of motion of the DIP joint of 20° and
a prerequisite to a good result. The patient must be loss of strength). Two ruptures were observed within the
aware that a tendon graft usually does not allow com- first month postoperatively: one type I lesion with
plete recovery of DIP active flexion. McClinton et al,41 tendon reinsertion using a barb-wire suture, and one type
reviewing 100 cases of tendon graft for isolated FDP II lesion with direct tendon suture. In the 3 patients with
tendon laceration, obtained 48° of average DIP active type III lesion, one was lost to follow-up, one had a
flexion. Liu and Yang,42 reviewing 15 cases of tendon complete recovery, and one developed osteoarthritis of
graft for isolated FDP tendon rupture, obtained an the DIP joint (Figure 20[A]-11).
average of 33° of DIP active flexion. Main complica-
tions were loss of PIP joint extension (more than 30°
in 27% of the cases of Liu et al,42 less than 10° in 55%
of the cases, and more than 10° in 9% of the cases of
McClinton et al41).
OUR PERSONAL EXPERIENCE
We recently reviewed our experience of treating avulsion
of the FDP tendon in 20 patients.4 These included 17
men and 3 women (average age, 31 years; range, 20 to
52 years). In 12 cases, the injury was related to sports
injury (football or rugby), and in 8 cases, to domestic or
work-related trauma. The ring finger was involved in 14
cases, the middle finger in 3 cases, and the little finger A
in 3 cases. In 14 cases the patients were seen within 3
weeks from the injury. According to Leddy and Packer’s
classification,1 the lesion was staged as type I in 5 patients,
type II in 6, and type III in 3. In 6 cases, the patient was
seen more than 3 weeks from the initial trauma. These
lesions were classified as type I in 5 and type II in 1.
For the 14 patients seen acutely (within 3 weeks), all
type I and II injuries except one were treated surgically.
The FDP tendon was reattached to the distal phalanx B
using a micro-anchor in 4 cases, a pull-out suture in 4,
and barb-wire fixation in one case. In one case, a direct
tendon-to-tendon suture was performed with a distal
remnant of the FDP on the distal phalanx. In one case
of type I lesion, the FDP tendon was resected. Postop-
eratively, early mobilization was proposed using a dorsal
splint with the MCP joint in flexion and the PIP and
DIP joints in extension. Passive flexion exercises were
started immediately in 6 patients and after 2 weeks in
4 patients. Active exercises were begun at 4 weeks when
the splint was removed. An osteosynthesis of the distal
phalanx was performed in type III lesions, using K-wire C
to fix the avulsed bone in all 3 cases, along with a pull- Figure 20(A)-11 A, Another example of type III lesion.
out suture of the FDP tendon in one case. The fingers B, Subsequent development of malunion of the avulsed
were immobilized with a splint for 4 weeks. bone fragment. C, Secondary arthritis of the DIP joint.
Table 20(A)-2 Treatment Results of Avulsion of the FDP Tendon in Our Unit
Number of Patients
Methods of Treatment and Types Results* Complications
Surgery: <3 wk after injury
Transosseous reinsertion (micro-anchors) 3, Type I 2 Excellent 0
1, Type II 1 Good
1 Poor
Transosseous reinsertion (pull-out) 4, Type II 2 Excellent 0
2 Good
Transosseous reinsertion (barb-wire) 1, Type I 1 Poor Rupture
Direct FDP repair 1, Type II 1 Poor Rupture
FDP resection 1, Type I Lost to follow-up —
Osteosynthesis (K-wire) 2, Type III 1 Excellent 0
1 Lost to follow-up
Osteosynthesis (K-wire + pull-out) 1, Type III 1 Poor DIP joint osteoarthritis
Surgery: >3 wk after injury
FDP resection + capsulodesis 4, Type I 3 Good Capsule lengthening and
1 Fair Loss of strength
FDP resection 1, Type I 1 Fair Loss of strength
Tendon graft 1, Type II 1 Poor PIP/DIP joint stiffness
*Assessed with Strickland and Glogovac criteria.
Of the 5 patients seen lately with resection of the delay between injury and treatment, and the presence
FDP tendon, 3 of 5 were satisfied with their surgery and size of a phalangeal bony fragment affect the final
despite an ongoing loss of strength. The patient with a results of treatment. In acute cases (less than 3 weeks
tendon graft had poor results, with 10° of extension after injury), direct reinsertion of the FDP tendon on the
deficit and 60° of flexion of the PIP joint, and had a distal phalanx gives satisfactory results. Long-standing
stiff DIP joint. lesions with tendon retraction and impaired tendon
vascular supply should not be treated by reinsertion, to
SUMMARY
avoid finger stiffness. No surgery is recommended when
Diagnosis of the closed FDP tendon can often be missed. function loss is slight, the PIP joint is mobile, and the
History of the mechanism of injury as well as the clinical DIP joint is stable. If the PIP joint is stiff, the retracted
presentation is typical; tracing pain along the finger, FDP tendon should be resected, followed by tenodesis
ecchymosis, and loss of active DIP joint flexion can be or capsulodesis of the DIP joint. One-stage tendon graft
helpful in making a diagnosis. Radiographs are essential should be reserved for patients whose strength and range
to diagnose a fracture of the distal phalanx. The level of of active finger flexion are not acceptable but passive
retraction of the tendon, the status of the vinculae, the motion of the PIP and DIP joints are normal.
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B Tendon Rupture After Fractures
or Carpal Disorders
Hiroshi Yamazaki, MD, PhD, Hiroyuki Kato, MD, PhD,
and Shigeharu Uchiyama, MD
OUTLINE tendon and the FDP tendon of the little finger were
most frequently affected in 10 patients with flexor
Closed flexor tendon ruptures can be caused by some tendon ruptures. Yamazaki et al15 reported 21 patients
pathologies of the carpal bones and joints, such as with closed rupture of the flexor tendons caused by
fracture of the hook of the hamate, Kienböck’s disease, carpal bone and joint disorders and described useful-
scaphoid nonunion, and pisotriquetral disorders. We ness of radiocarpal arthrography as a diagnostic tool.
analyzed 21 patients with closed rupture of the flexor In this section, characteristic clinical and roentgeno-
tendons caused by carpal bone and joint disorders. In graphic features of closed rupture of the flexor tendon
most patients the closed flexor tendon rupture occurred secondary to fractures or carpal disorders are reviewed.
when mild resistance forces were applied to the finger Pathophysiology and reconstruction are discussed.
or spontaneously. The mechanism of the tendon rup-
tures is attrition from passage back and forth over a METHODS AND OUTCOMES
rough bone surface. We found it difficult to identify
the causes of these tendon ruptures using plain radio- Patients
graphs, especially in the elderly or in manual laborers We analyzed 21 patients with closed rupture of the
who have preexisting abnormal lesions, such as osteo- flexor tendons caused by carpal bone and joint disor-
arthritis, instability of the carpus, and radiographic ders.15 The mean patient age was 68 (range, 35 to 89)
evidence of previous trauma. Radiocarpal arthrogra- years. Fourteen patients were men and seven were
phy was useful in identifying the site of the lesion women. Fifteen of the 21 patients were manual laborers.
responsible for the flexor tendon ruptures. The radio- The pathological conditions included nonunion of the
graphic signs of lesions from which contrast medium hook of the hamate in six patients, pisotriquetral joint
leaked subsequently corresponded to the disruption arthritis in seven patients, nonunion of the scaphoid in
site of the periosteum or joint capsule at surgery. Our four patients, the presence of a rough surface of the
preferred management is free tendon graft reconstruc- hook of the hamate in two patients, Kienböck disease
tions followed by early controlled mobilization, and in one patient, and the presence of an intraosseous
we suggest that the projected bony parts be resected ganglion of the lunate in one patient. Affected digit was
and the capsule/periosteum repaired to prevent recur- the thumb in four patients, index finger in one patient,
rence of tendon rupture. ring and little fingers together in one patient, and little
finger in fifteen patients. Patients with tendon rupture
Most flexor tendon ruptures result from avulsion of the caused by direct invasion by synovitis associated with
flexor digitorum profundus (FDP) tendon at its inser- rheumatoid arthritis or infection were excluded. Radio-
tion. Although not common in contrast to rheumatoid carpal arthrography was performed in 14 of the 21
arthritis, closed flexor tendon ruptures caused by hidden patients and capsular perforation demonstrated by con-
pathologies of the carpal bones and joints have been trast medium leakage into the carpal canal in 11 patients
reported, namely fracture of the hook of the hamate,1-4 (Figure 20[B]-1). A free palmaris longus tendon or
Kienböck’s disease,5 scaphoid nonunion,6,7 pisotrique- plantaris tendon graft was interposed between the prox-
tral osteoarthritis,8,9 pisotriquetral instability,10 lunate imal and distal stumps of the ruptured tendon in 17
fracture,11 and chronic lunate dislocations.12 Boyes et al13 patients. Tendon transfer of the flexor digitorum super-
reported that 10 of 80 flexor tendon ruptures (12.8%) ficialis (FDS) tendon of the ring finger to the FDP
had occurred in the carpal tunnel and that 2 of the tendon of the little finger was performed in two patients.
10 had associated abnormalities of the carpal bones. End-to-side tendon transfer using the FDP tendon of the
Folmar et al14 reported the flexor pollicis longus (FPL) long finger with interposition of the palmaris longus
228
Chapter 20B: Tendon Rupture After Fractures or Carpal Disorders 229
the transverse carpal ligament was sutured developed

carpal tunnel syndrome subsequent to surgery and we
now do not recommend repairing this ligament.
Postoperative Care
After tendon reconstruction, early controlled mobiliza-
tion with a modified Kleinert elastic band technique was
used for 3 to 4 weeks. The Duran method was also per-
formed to prevent contracture of IP joint. Thereafter, the
hand was protected by a dorsal splint only and active
flexion exercise was encouraged. Active finger use was
permitted at 12 weeks postoperatively. Dorsal blocking
splint with rubber band was not used in the thumb. The
affected thumb was immobilized for 3 weeks, and active
exercise was started after that.
Outcomes
Postoperative total active range of motion (TAM) in the
finger after 13 free tendon graft reconstructions averaged
213° (range, 170° to 265°) (Table 20[B]-1). The TAM
Figure 20(B)-1 Radiocarpal arthrogram showing leakage of the thumb IP joint after free tendon graft reconstruc-
(arrow) of contrast medium into the flexor tendon sheath in tion in three cases improved from 0° to 33° on average
pisotriquetral joint arthritis. (range, 10° to 40°). In nine patients, the postoperative
grip strength ratio averaged 84% (range, 57% to 126%).
tendon to the FDP tendons of the little and ring finger Illustrative Case
was performed in one patient. A 73-year-old woman noticed the distal IP (DIP) joint
of the little finger gradually became incapable of active
Operative Techniques flexion. Radiography in an oblique lateral view in supi-
During operation, a curved and zigzag incision was nation and computed tomography (CT) imaging (Figure
made on the palm between distal palmar crease and 20[B]-2) showed pisotriquetral joint arthritis. In the
proximal crease. The patients underwent release of the operation, the FDP tendon of the little finger was seen
carpal tunnel for exposure of carpal pathologies and the to be ruptured and adherent to the FDS tendon of that
ruptured tendon stumps. We used this method to check finger. The pisiform was removed (Figure 20[B]-3), and
the neighboring tendon, which often frayed. The volar a free tendon graft from the palmaris longus tendon was
capsule/periosteum of the carpus was perforated at the interposed between the stumps. Modified Kleinert early
site of the tendon ruptures. The free or sharp bone frag- mobilization was carried out. One year after the opera-
ment was excised. At the site of mobile nonunion and tion, percent TAM was 92% and outcome according to
osteoarthritis, sclerotic cortical surface of the bone was the American Society for Surgery of the Hand criteria
curetted and filled with cancellous bone graft. The edges was good. No pain was present at the wrist. The grip
of the palmar capsule defect were approximated and strength ratio was 89%.
sutured. In free tendon grafting, the palmaris longus or
DISCUSSION
the plantaris tendon was harvested. The proximal stump
was well pulled until myostatic contracture was released. A detailed history and clinical examination allow diag-
The FDP tendon was reconstructed only in the finger in nosis of rupture of the flexor tendon to be made.
which both the FDP and FDS tendons were ruptured. However, especially in chronic cases, diagnosis of
The remnant tendon was trimmed out, and the inter rupture of the flexor tendon is often delayed or missed.
positional or transferred tendon was sutured to the In most patients, the closed flexor tendon rupture occurs
refreshed stump with interlacing or Pulvertaft weave when mild resistance forces applied to the finger or
suture. The junction of the graft with the stump was spontaneously. In some cases, flexor tendon attrition
placed away from the carpal area for preventing adhe- and rupture cause discomfort within the region of the
sion of the tendon stump within the carpal tunnel. The synovial sheath of the digit.
tourniquet was then deflated, and correct tension was Some patients have past history of trauma to the wrist,
achieved by observation of the resting position of the and others have no recollection of obvious injury. The
finger and the interphalangeal (IP) joint during passive symptoms at the wrist resulting from fractures or carpal
flexion and extension of the wrist. One patient in whom bone disorders are often free or mild, and disability is
Table 20(B)-1 Patient Data, Tendon(s) Ruptured, Findings of Arthrography, and Recovery of TAM After
Treatment
Involved Site of Contrast
Finger(s)/ Medium Leakage Functional
Age Ruptured on Radiocarpal Recovery* (% TAM
(Yr)/Sex Disorder/Hand Tendon(s) Arthrography Treatment and Grade)
35/M Hamate hook Little/FDP Not examined Tendon graft 100%, Excellent
nonunion/R
51/M Hamate hook Little/FDP Not examined Tendon graft 71%, Fair
nonunion/R
55/M Hamate hook Little/FDP, FDS Not examined Tendon graft 88%, Good
nonunion/R
58/M Hamate hook Little/FDP Not examined Tendon graft 75%, Fair
nonunion/R
63/M Hamate hook Little/FDP, FDS Triquetrohamate Tendon transfer 83%, Good
nonunion/L joint
73/M Hamate hook Little/FDP, FDS Not examined Tendon graft, tenolysis 85%, Good
nonunion/L
50/F Hamate hook Little/FDP, FDS Not examined Tendon graft Not available
projection/R
76/M Hamate hook Little/FDP, FDS No leakage Tendon graft 85%, Good
projection/L
67/F Pisotriquetral OA/R Little/FDP Pisotriquetral joint Tendon graft 75%, Fair
70/F Pisotriquetral OA/L Little/FDP Pisotriquetral joint Tendon graft 81%, Good
70/M Pisotriquetral OA/L Little/FDP Pisotriquetral joint Tendon graft 83%, Good
73/F Pisotriquetral OA/R Little/FDP Pisotriquetral joint Tendon graft, tenolysis 83%, Good
73/F Pisotriquetral OA/L Little/FDP Pisotriquetral joint Tendon transfer 92%, Good
80/F Pisotriquetral OA/L Little/FDP, FDS Pisotriquetral joint Tendon graft 77%, Good
89/M Pisotriquetral OA/R Little/FDP Pisotriquetral joint Tendon graft 85%, Good
65/M Scaphoid nonunion/R Thumb/FPL Not examined Tendon graft Good†
72/M Scaphoid nonunion/L Thumb/FPL Nonunion site no operation Not available
72/M Scaphoid nonunion/R Thumb/FPL Nonunion site Tendon graft Fair†
83/M Scaphoid nonunion/R Thumb/FPL Nonunion site Tendon graft Good†
76/F Kienböck disease/R Little, ring/FDP Radiolunate joint End-to-side, tenolysis 87%, Good; 75%,
fair
71/F Intraosseous ganglion Index/FDP, FDS Radiolunate joint Tendon graft, 65%, Fair
of the lunate/R arthrodesis
M, male; F, female; OA, osteoarthritis. R, right; L, left.
*Evaluated by the TAM method advocated by ASSH, except †by Buck-Gramcko method.
sometimes minimal. These disorders are often neglected tendon rupture should raise suspicion of concealed dis-
until the closed flexor tendon rupture occurs, because orders of the carpal bones and joints. Other nonosseous
routine anteroposterior and lateral roentgenograms of causes include anomalous tendon,18 nonspecific synovi-
the wrist fail to detect them.3,16 In approximately 14% tis,19 and crystal-induced tenosynovitis.20
of hamate hook fracture, nonunion of the hook may The mechanism of these tendon ruptures is attrition
escape discovery, until it eventually causes closed rupture from gliding back and forth over a rough bone surface,
of the flexor tendon of the little or ring finger.17 When the latter having perforated the dorsal wall of the carpal
these historical and physical features exist, closed flexor tunnel.14,21 The tendon that ruptured depended on the
Chapter 20B: Tendon Rupture After Fractures or Carpal Disorders 231
rupture caused by carpal bone and joint disorders,

detection of the underlying pathological lesion before
surgery is also extremely important for the treatment,
because the surgical approach to the lesion is needed to
prevent flexor tendon re-rupture. To prevent recurrence
of tendon rupture, the sharp bone must be resected and
the capsule/periosteum repaired. The nonunion and
osteoarthritis with instability often require bone graft-
ing. Plain radiography of the wrist is often unhelpful,
unless special views are taken. Radiography in a carpal
tunnel view, radiography in an oblique lateral view
in supination, conventional tomography,16 and CT
Figure 20(B)-2 A CT scan of the wrist showing
pisotriquetral joint arthritis. imaging3 can help make diagnosis of the pathologies.
MRI was also useful to the diagnosis. However, it is
often difficult to differentiate the causative lesion of
the tendon rupture from the other abnormal lesions
by these diagnostic imaging studies, especially in the
elderly or in manual laborers who have preexisting
carpal abnormalities, including osteoarthritis, instabil-
ity of the carpus, and radiographic evidence of previous
trauma. Radiocarpal arthrography was very useful in
identifying the site of the lesion responsible for the
flexor tendon rupture. Similarly, using arthrography, we
identified extensor tendon rupture as a result of osteo-
arthritis of the distal radioulnar joint.24 Radiocarpal
arthrography was performed in 13 patients of flexor
tendon rupture in our series, and capsular perforation
demonstrated by contrast medium leakage into the
carpal tunnel in 11 patients. A high percentage of cases
Figure 20(B)-3 Intraoperative findings. The rough surface in our investigation displayed contrast medium leakage
of the pisiform is apparent. The FDP of the little finger is (see Figure 20[B]-1), and the radiographic lesions from
ruptured at the lesion. which contrast medium leaked corresponded to the
site of disruption of the periosteum or capsule seen at
surgery. Their adjacent tendons were disrupted. Gener-
location of the bone perforation into the carpal tunnel. ally, the lesion from which contrast medium leaks will
The affected digit provides useful information about the indicate location of the tear in the soft tissues and,
location of the carpal disorders. Disorders with an ulnar hence, the bony cause of the tendon rupture.
location, such as fracture of the hook of the hamate and The goals of surgery are to reconstruct flexor tendon
arthritis involving the pisotriquetral joint, may abrade function and to prevent flexor tendon re-rupture. The
the FDP tendon of the little finger, particularly. The affected tendon(s) invariably have frayed stumps, with
neighboring FDS tendon of the little finger and the FDP a long defect between the ends. Thus, direct suture
tendon of the ring finger may subsequently be affected. is impossible. The options of tendon reconstruction
The FPL tendon lies over the ulnar surface of the scaph- include DIP joint arthrodesis, tenodesis, cross transfer of
oid, and nonunion of the scaphoid may cause FPL flexor tendons from adjacent fingers, buddying to adja-
tendon rupture. The lunate forms the dorsal wall of the cent flexors, and free tendon graft. Milek and Boulas25
carpal tunnel and contacts the FDP tendon of the index reported surgical results in four patients, three of whom
finger, the tendon located most dorsally in the carpal were treated by tendon transfer and one by tendon graft.
tunnel. Therefore, a lunate abnormality in which bone They attributed variation in the results largely to differ-
penetrates the volar capsule is most likely to cause attri- ences of the patients’ ages and recommended side-to-
tion of flexor tendons of the index finger. side tendon suture. We prefer an interposition tendon
Ultrasound, magnetic resonance imaging (MRI),20,22 graft, since use of the tendon of another finger for a
and three-dimensional CT imaging23 have been reported tendon transfer may compromise function of that finger.
to be useful tools for diagnosing flexor tendon injury Motion of the DIP joint is reconstructed only by means
and pinpointing the site of rupture, which is crucial for of free tendon grafting. We obtained mean digital TAM
preoperative planning and thus avoiding unnecessary of 213° after 13 free tendon graft reconstructions fol-
surgical exploration. In patients with flexor tendon lowed by early controlled mobilization.15 In our series,
the mean patient age was 68 years. Although most reduce grip strength. In our series, tendon reconstruc-
patients were older adults, results were satisfactory after tion does not improve grip strength.
tendon grafting and outcome did not depend on patient Postoperative management following free tendon
age or the interval between tendon rupture and recon- grafting is, therefore, important. Free tendon grafting for
struction. We believe that free tendon grafting is reason- FDP reconstruction incurs the risk of postoperative con-
able, though this technique has the risk of adhesion and tracture in the interphalangeal joint. It is our belief that
re-rupture, and the postoperative early controlled mobi- postoperative immobilization after free tendon grafting
lization could be complicated. may lead to adhesion that compromises function, so we
Tendon graft should be done early to prevent myo- adopted immediate early controlled mobilization with
static contracture in the affected digit. If the tendon a modified Kleinert elastic band technique. Early mobi-
rupture was neglected, myostatic contracture may result lization after FDP reconstruction ensures larger gliding
in undue tension of the tendon graft at surgery and excursion of the grafted tendon.
References
1. Clayton ML: Rupture of the flexor tendons in carpal tunnel 13. Boyes JH, Wilson JN, Smith JW: Flexor-tendon ruptures in the
(non-rheumatoid) with specific reference to fracture of the forearm and hand, J Bone Joint Surg (Am) 42:637–646, 1960.
hook of the hamate, J Bone Joint Surg (Am) 51:798–799, 1969. 14. Folmar RC, Nelson CL, Phalen GS: Ruptures of the flexor
2. Minami A, Ogino T, Usui M, et al: Finger tendon rupture tendons in hands of non-rheumatoid patients, J Bone Joint
secondary to fracture of the hamate. A case report, Acta Orthop Surg (Am) 54:579–584, 1972.
Scand 56:96–97, 1985. 15. Yamazaki H, Kato H, Hata Y, et al: Closed rupture of the flexor
3. Stark HH, Chao EK, Zemel NP, et al: Fracture of the hook of tendons caused by carpal bone and joint disorders, J Hand
the hamate, J Bone Joint Surg (Am) 71:1202–1207, 1989. Surg (Eur) 32:649–653, 2007.
4. Yamazaki H, Kato H, Nakatsuchi Y, et al: Closed rupture of 16. Murray WT, Meuller PR, Rosenthal DI, et al: Fracture of the
the flexor tendons of the little finger secondary to non-union hook of the hamate, Am J Roentgenol 133:899–903, 1979.
of fractures of the hook of the hamate, J Hand Surg (Br) 17. Boulas HJ, Milek MA: Hook of the hamate fractures. Diagnosis,
31:337–341, 2006. treatment, and complications, Orthop Rev 19:518–529, 1990.
5. Niwa T, Uchiyama S, Yamazaki H, et al: Closed tendon 18. Bois AJ, Johnston G, Classen D: Spontaneous flexor tendon
rupture as a result of Kienböck disease, Scand J Plast Reconstr ruptures of the hand: Case series and review of the literature,
Surg Hand Surg 44:59–63, 2010. J Hand Surg (Am) 32:1061–1071, 2007.
6. McLain RF, Steyers CM: Tendon ruptures with scaphoid 19. Prosser GH, Sterne GD, Nancarrow JD: Intratendinous
nonunion. A case report, Clin Orthop Relat Res 117–120, rupture of flexor digitorum profundus caused by non-specific
1990. synovitis, Br J Plast Surg 55:77–79, 2002.
7. Saitoh S, Hata Y, Murakami N, et al: Scaphoid nonunion and 20. Matloub HS, Dzwierzynski WW, Erickson S, et al: Magnetic
flexor pollicis longus tendon rupture, J Hand Surg (Am) resonance imaging scanning in the diagnosis of zone II flexor
24:1211–1219, 1999. tendon rupture, J Hand Surg (Am) 21:451–455, 1996.
8. Lutz RA, Monsivais JJ: Piso-triquetral arthrosis as a cause of 21. Hallett JP, Motta GR: Tendon ruptures in the hand with par-
rupture of the profundus tendon of the little finger, J Hand ticular reference to attrition ruptures in the carpal tunnel,
Surg (Br) 13:102–103, 1988. Hand 14:283–290, 1982.
9. Saitoh S, Kitagawa E, Hosaka M: Rupture of flexor tendons 22. Kumar BA, Tolat AR, Threepuraneni G, et al: The role of
due to pisotriquetral osteoarthritis, Arch Orthop Trauma Surg magnetic resonance imaging in late presentation of isolated
116:303–306, 1997. injuries of the flexor digitorum profundus tendon in the
10. Corten EM, van den Broecke DG, Kon M, et al: Pisotriquetral finger, J Hand Surg (Br) 25:95–97, 2000.
instability causing an unusual flexor tendon rupture, J Hand 23. Sunagawa T, Ochi M, Ishida O, et al: Three-dimensional CT
Surg (Am) 29:236–239, 2004. imaging of flexor tendon ruptures in the hand and wrist,
11. Minami A, Ogino T, Usui M: Delayed rupture of a flexor J Comput Assist Tomogr 27:169–174, 2003.
tendon secondary to fracture of the lunate, Ital J Orthop Trau- 24. Yamazaki H, Uchiyama S, Hata Y, et al: Extensor tendon
matol 11:233–236, 1985. rupture associated with osteoarthritis of the distal radioulnar
12. Stern PJ: Multiple flexor tendon ruptures following an old joint, J Hand Surg (Eur) 33:469–474, 2008.
anterior dislocation of the lunate. A case report, J Bone Joint 25. Milek MA, Boulas HJ: Flexor tendon ruptures secondary to
Surg (Am) 63:489–490, 1981. hamate hook fractures, J Hand Surg (Am) 15:740–744, 1990.
C Rupture of the Pulleys
Rohit Arora, MD, and Markus Gabl, MD
OUTLINE edge of the A2 pulley is especially high in rock climbers

using the “crimp grip.”5,7,8 In this position, the proximal
We present our experience with a total of 23 patients interphalangeal (PIP) joints are flexed 90° and the
with closed traumatic lesions of the flexor pulleys that distal interphalangeal (DIP) joints are hyperextended
required surgical reconstruction. The A2 pulleys were (Figure 20[C]-1). The superficial and profundus flexor
reconstructed with use of one of the two methods. In tendons are at maximum possible contractile ability
extensor retinaculum grafting, a strip of extensor reti- in order to maintain the finger position under the
naculum together with the periosteum from the floor climbers’ body weight load.9 Pulley injuries (“climber’s
of the extensor tunnel is harvested. After bilateral finger”) mostly occur as a result of grim grip when sud-
holes are drilled in the palmar aspect of the phalanx denly the climber slips off with the hand holding rock
at the distal and proximal ends of the A2 pulley, the niches, and the load to the finger is increased. Closed
graft is fixed by the periosteum to the bone of the flexor tendon pulley ruptures can also occur in other
phalanx. The ligamentous portion of the graft is situations in which a flexed finger is subjected to high
sutured to the remnants of the pulley system. It is and rapidly applied forces, causing a sudden finger
important to fix the graft adequately to the remnants extension3—for example, while lifting a heavy object or
of the sheath. In palmaris longus tendon grafting, a slip while opening a door or drawer as seen in our patients.
of the tendon is passed through holes created in the The ring and middle fingers are usually injured while
remnants of the A2 pulley, and the graft is sutured to the index and little fingers are less exposed.10 Generally,
itself or to the fibrous rim at each end of the pulley. reconstruction of both the A2 and A4 pulleys, the most
Postoperatively, the fingers were immobilized with a essential pulleys, is recommended.11
palmar splint extending from the distal interphalan- A number of surgeons reported various surgical
geal to the proximal palmar crease for 4 weeks. The methods of pulley reconstruction, using various sources
range of active digital motion, pinch strength, and grip of graft material like autogenous tendons,12,13 the exten-
power of the hand improved to the levels close to sor retinaculum,6,14 the palmar plate of the PIP joint,14
those of the contralateral uninjured hand with both or synthetic materials.15,16 Loop techniques are believed
methods. Extensor retinaculum as an intrasynovial to be stronger than nonencircling methods of pulley
tissue may have less resistance to tendon gliding than reconstruction.16 The encircling procedures are believed
a palmaris longus graft. to interfere with the function of the extensor tendon
system.16
Detailed anatomic and mechanical investigations of the We present a retrospective review of 23 patients with
finger flexor tendon sheath and pulley system have closed traumatic rupture of the flexor pulleys treated
allowed better understanding of biomechanical impor- with two techniques of nonencircling pulley reconstruc-
tance of the cruciate and annular pulleys.1 Pulleys main- tion in our unit, with special reference to the long-term
tain the digital flexor tendons close to the axes of the functional outcome after pulley reconstruction.
joints and secure efficiency in finger flexion by provid-
ing the most efficient use of flexor tendon excursion.2 If METHODS AND OUTCOMES
the pulleys are injured, the tendons are displaced volarly
(bowstringing), leading to a decreased maximum range Patients
of active joint flexion and power and to an increased Between 1996 and 2003, a total of 56 patients with
risk of developing fixed flexion contractures.3 closed traumatic lesions of the finger pulleys were
In acute cut injuries, flexor tendons are frequently cut treated in our unit. Patients with partial pulley ruptures
through a laceration in the pulley system; partial or were treated conservatively. Twenty-three patients,
complete injuries of the pulleys are common. Closed including 3 women and 20 men, with a mean age of 40
ruptures of the flexor tendon pulleys are rare injuries (range, 24 to 59) years, with a complete A2 pulley
and most of them are reported to occur during rock rupture or with a combined A2 and A3 pulley rupture
climbing.4-6 were reviewed. Of the 23 patients, 14 had isolated rup-
Biomechanical studies demonstrated that the mech tures of the A2 pulley and 9 had combined ruptures of
anical load between finger flexor tendons and the distal the A2 and A3 pulleys. The C1 pulley was ruptured in
233
Figure 20(C)-3 Significant bowstringing in a patient with

ruptures of A2, A3, and A4 pulleys.
These patients complained of reduced finger dexterity

while performing their daily activities and work. The
persisting impairment of finger function and strength
Figure 20(C)-1 Crimp grip used by rock climbers to make in these patients was the indication for surgery. Bow-
the best use of small niches in the rocks for safe support. stringing was noted in all patients (Figure 20[C]-3).
Additionally, magnetic resonance imaging (MRI) and
ultrasound were performed and the diagnosis of closed
rupture of annular pulleys was verified at surgery in all
patients. Ultrasound is very useful in diagnosis.17,18
Rupture of the pulley system was indicated by tendon
bowstringing, assessed using high-resolution ultraso-
nography (Acuson Sequoia 512, 15L8W; Siemens
Medical Solutions, Erlangen, Germany) (Figure 20[C]-
4). MRI was performed in the sagittal and coronal
planes with a 1.5-T superconductive Magnetom (Vision,
Siemens Medical Solutions) to assess the bowstringing
(Figure 20[C]-5).19
Operative Techniques
We used two methods of nonencircling pulley recon-
struction in the patients. The age, sex, affected fingers,
and ruptured pulleys of the patients with two treatment
methods are shown in Table 20[C]-1. One group con-
* sisted of 13 patients who had pulley reconstruction
using a graft from the extensor retinaculum of the wrist
(Figure 20[C]-6). As described by Gabl et al,6 a strip of
extensor retinaculum approximately 10 mm in width
together with the periosteum from the floor of the
extensor tunnel was used for reconstruction of the A2
pulley (Figure 20[C]-7). After drilling bilateral burr
Figure 20(C)-2 Intraoperative findings of complete
holes in the palmar aspect of the phalanx at the distal
ruptures of the A2 (*) and C1 pulleys in a rock climber. and proximal ends of the A2 pulley, the graft was fixed
by the periosteum to the bone of the phalanx, placing
the synovial layer innermost (Figure 20[C]-8). Addi-
all patients (Figure 20[C]-2). Fifteen injuries were tionally, the ligamentous portion of the graft was sutured
caused by rock climbing and all of these patients to the remnants of the pulley system. The other group
described inability to perform their sports at their previ- consisted of 10 patients who were treated with a free
ous level. Three injuries occurred while lifting a heavy tendon graft of the palmaris longus tendon for recon-
object and five occurred while opening a door or drawer. struction of the A2 pulley (Figure 20[C]-9). The pulley
Chapter 20C: Rupture of the Pulleys 235
was made by passing a slender slip of tendon graft were kept in full extension. Physiotherapy was started
through perforations made in the remnants of the origi- after splint removal. Manual work, full load-bearing,
nal A2 pulley, and the tendon graft was sutured to itself, and sport activities were not permitted for 3 months.
or to the fibrous rim at each end, with two sutures, The time from injury to surgery was 9 (range, 6 to 13)
resulting in a shoelace-like reconstruction, as described weeks for patients treated with extensor retinaculum
by Kleinert and Bennett13 (Figure 20[C]-10). graft and 7 (range, 5 to 9) weeks for patients treated with
palmaris longus tendon graft.
Postoperative Care
Postoperatively, patients of both treatment groups were Evaluations
immobilized with a palmar splint extended from the The mean follow-up was 48 (range, 18 to 43) months
DIP to the proximal palmar crease for 4 weeks. The after extensor retinaculum graft and 57 (range, 16 to 48)
metacarpophalangeal (MCP) joint and the PIP joint months after palmaris longus tendon graft. Evaluations
included measurement of the ranges of motion of all
joints of involved fingers using a goniometer. Pinch
strength and the power grip strength were measured.
The circumference of the finger was measured at the
distal end of the A2 pulley. The outcome was also
assessed using the Buck-Gramcko score.19 Patients were
asked if they would undergo the treatment again in the
event of the same injury occurring to another finger.
Results
The MCP and the DIP joints of all patients had almost
normal active movement at preoperative and postopera-
tive examination. The PIP joint extension was also unre-
stricted at preoperative and postoperative examination.
Before surgery, grip strength of the injured hand was
reduced to 42 kg (range, 29 to 57 kg) and pinch grip
A
reduced to 6 kg (range, 3 to 9 kg), due to pain in all
patients.
In the patients with extensor retinaculum graft, pre-
operative PIP joint flexion was 82° (70° to 90°). After
surgery, the PIP joint flexion improved to 91° (85° to
100°) (i.e., 97% of the uninjured side). Postoperative
power grip strength was 48 kg (34 to 60 kg) (96% unin-
jured side). Postoperative pinch grip strength was 8 kg
(4 to 11 kg), which was equal to that of the uninjured
side. The circumference of the finger was 76 mm (60 to
90 mm) before surgery and 70 mm (58 to 88 mm) after
surgery (94% uninjured side).
In the patients with palmaris longus graft, preopera-
B tive PIP joint flexion was 80° (75° to 90°). After surgery,
PIP joint flexion was 91° (80° to 100°) (94% uninjured
Figure 20(C)-4 A, Preoperative longitudinal
ultrasonography scans showing pulley injury (A2, C1, A3)
side). Postoperative power grip strength was 48 kg (32
with bowstringing of tendon and increased distance (arrow) to 68 kg) (98% uninjured side); the pinch grip was 7 kg
between phalanx and tendon. B, Postoperative longitudinal (3 to 10 kg), equal to that of the uninjured side. The
ultrasonography scans after pulley reconstruction (A2) using circumference of the finger was 66 mm (58 to 80 mm)
an extensor retinaculum graft showing decreased distance before surgery and 62 mm (54 to 82 mm) after surgery
(arrow) between phalanx and tendon. (94% uninjured side).
Table 20(C)-1 Patient Demographics for Two Groups of Patients

Graft Materials Total Patients Sex (M/F) Age (Yr) Fingers Pulleys Ruptured
Extensor retinaculum 13 11 : 2 41 (26–51) 10 Middle, 3 ring A2 in 8, A2 + A3 in 5
Palmaris longus 10 9 : 1 38 (24–59) 7 Middle, 3 ring A2 in 8, A2 + A3 in 4
Figure 20(C)-5 A, Preoperative MRI

demonstrating bowstringing as increased
distance between bone and tendon
(arrow) after rupture of A2, C1, and A3
pulleys. B, Postoperative MRI after pulley
reconstruction (A2) using an extensor
retinaculum graft showing decreased
distance (arrow) between phalanx and
tendon.
A B
P
Graft
FDP
R ET
Figure 20(C)-6 Fixation of the extensor retinaculum graft to

the fibro-osseous floor. P, Periosteum; FDP, flexor digitorum G
profundus tendon; R, remnants of the normal pulley.
Using the Buck-Gramcko score, 10 had excellent

result, 2 had good results, and 1 had fair results after
extensor retinaculum grafting, and there were 7 excel-
lent, 2 good, and 1 fair after palmaris longus tendon Figure 20(C)-7 Graft of extensor retinaculum 10 mm in
grafting. All 15 climbers returned to their previous stan- width, together with the periosteum from the floor of the
dard of climbing. In 13 of these climbers, the pulleys extensor tunnel. G, Extensor retinaculum graft; EPL, extensor
pollicis longus tendon.
were reconstructed using extensor retinaculum. All non-
climbers returned to their previous work and described
no restrictions of finger dexterity. All patients said that
DISCUSSION
they would want similar surgery if they had the same
injury. No significant difference was noted in active Partial ruptures and isolated single pulley ruptures can
range of digital motion, finger circumference, power, be treated conservatively by immobilization of all finger
and pinch grip strength between the two methods of motion in the acute phase and taping the injured finger
reconstruction. above the pulley after pain had been reduced.5 In
Chapter 20C: Rupture of the Pulleys 237
Figure 20(C)-8 Photograph showing reconstruction of the

A2 pulley with the extensor retinaculum graft sutured to the Figure 20(C)-10 Photograph showing reconstruction
remnants of the original A2 pulley, without encircling the of the A2 pulley with a free tendon graft sutured to the
phalanx. fibrous rims.
and DIP joints improved and satisfactory grip function

was achieved in all six patients. Karev made “belt pulleys”
at the MCP and PIP joint levels by making transverse
G parallel incisions in the palmar plates of each joint.21
The FDP tendon was re-routed through these palmar
plate incisions as pulleys. Bunnell and Böhler harvested
a free tendon graft and encircled it several times around
R the phalanx for pulley reconstruction.12 Kleinert and
Bennett used free tendon graft technique for nonencircl-
ing pulley reconstruction,13 which we have used in the
patients. Lister used the extensor retinaculum graft to
surround the phalanx as a belt loop.14 Gabl et al6
reported a combination of the technique described by
Kleinert and Bennett and Lister, using an extensor reti-
Figure 20(C)-9 Nonencircling technique using a free naculum that did not encircle the phalanx.
tendon graft. A tendon weave using the fibrous rims of the It is reported that the encircling techniques interfere
original tendon sheath, which are always present. G, Free
with extensor mechanism and may lead to an extension
tendon graft; R, fibrous rim.
block.16 Gabl et al6 reported on A2 pulley reconstruc-
tion in five patients using the free tendon graft tech-
nique described by Kleinert and Bennett.13 At mean
patients with multiple pulley ruptures, surgical repair is follow-up of 31 months, active range of motion of the
recommended in the patients who have been primarily PIP joint was reduced by 4°, relative to the contralateral
treated conservatively, but the patients have ongoing side. The circumference of the finger at the reconstruc-
pain, decreased range of finger motion, and tendon tion region was increased by 4.8 mm. All patients had
bowstringing.20 These patients are not able to resume satisfactory grip function. Bowstringing was reduced in
their previous sports and daily activities. all patients.
A number of techniques are available to reconstruct In our cases with reconstruction of pulleys in fingers,
the ruptured pulleys. The strength of belt loop pulley both nonencircling techniques had quite satisfactory
reconstructions roughly correlates with the number of outcomes with the benefit of not interfering with the
loops passing around the phalanx.21 The reconstructed extensor mechanism. We assume that the remaining
pulley of triple loops resists as much load to failure as limitation of PIP flexion of the fingers of our patients
a normal annular pulley.11 Okutsu et al22 reported the was caused by scarring and/or soft tissue swelling. In
results of six fingers with A2 pulley reconstructions using addition, intrasynovial tissue, such as extensor retinacu-
the triple loop technique in six patients. At follow-up of lum, may be more appropriate than extrasynovial grafts,
9 months to 3 years, active range of motion of MCP, PIP, such as palmaris longus, because the former produces
less frictional resistance to tendon gliding.23 We know increase the contact area of fixation and to allow bio-
nothing about the fate of free tendon grafts in recon- logical healing of the periosteum to the phalanx. The
structed pulleys. The grafted tendons likely remain avas- extensor retinaculum graft is fixed to the floor of the
cular and probably are embedded in scar. sheath with both sutures passing through the perios-
At surgery, it is very important to fix the graft ade- teum and sutures to the rims of the sheath, so that the
quately to withstand high loads. Interweaving the load can be distributed over a greater area of fixation.
tendon graft to the remnants of the sheath is difficult if Although this method is more demanding technically
the site of pulley rupture is at the side and close to the and the donor site of the extensor retinaculum is aes-
attachments of the sheath. We harvested a periosteal thetically less ideal, we obtained good functional out-
strip connecting with the extensor retinaculum to comes of the fingers and high patient satisfaction.
References
1. Doyle JR: Anatomy of the finger flexor tendon sheath and 13. Kleinert HE, Bennett JB: Digital pulley reconstruction employ-
pulley system, J Hand Surg (Am) 13:473–484, 1988. ing the always present rim of the previous pulley, J Hand Surg
2. Peterson WW, Manske PR, Bollinger BA, et al: Effect of pulley (Am) 3:297–298, 1978.
excision on flexor tendon biomechanics, J Orthop Res 4:96– 14. Lister GD: Reconstruction of pulleys employing extensor reti-
101, 1986. naculum, J Hand Surg (Am) 4:461–464, 1979.
3. Bowers WH, Kuzma GR, Bynum DK: Closed traumatic 15. Bader KF, Sethi G, Curtin JW: Silicone pulleys and underlays
rupture of finger flexor pulleys, J Hand Surg (Am) 19:782– in tendon surgery, Plast Reconstr Surg 41:157–164, 1968.
787, 1994. 16. Widstrom CJ, Johnson G, Doyle JR, et al: A mechanical
4. Arora R, Fritz D, Zimmermann R, et al: Reconstruction of the study of six digital pulley reconstruction techniques: Part I.
digital flexor pulley system: A retrospective comparison of Mechanical effectiveness, J Hand Surg (Am) 14:821–825,
two methods of treatment, J Hand Surg (Eur) 32:60–66, 2007. 1989.
5. Bollen SR: Injury to the A2 pulley in rock climbers, J Hand 17. Klauser A, Bodner G, Frauscher F, et al: Finger injuries in
Surg (Br) 15:268–270, 1990. extreme rock climbers. Assessment of high-resolution ultra-
6. Gabl M, Reinhart C, Lutz M, et al: The use of a graft from the sonography, Am J Sports Med 27:733–737, 1999.
second extensor compartment to reconstruct the A2 flexor 18. Bodner G, Rudisch A, Gabl M, et al: Diagnosis of digital flexor
pulley in the long finger, J Hand Surg (Br) 25:98–101, 2000. tendon annular pulley disruption: Comparison of high fre-
7. Schweizer A: Biomechanical properties of the crimp grip posi- quency ultrasound and MRI, Ultraschall Med 20:131–136,
tion in rock climbers, J Biomech 34:217–223, 2001. 1999.
8. Vigouroux L, Quaine F, Labarre-Vila A, et al: Estimation of 19. Buck-Gramcko D, Dietrich FE, Gogge S: Evaluation criteria in
finger muscle tendon tensions and pulley forces during spe- follow-up studies of flexor tendon therapy, Handchirurgie
cific sport-climbing grip techniques, J Biomech 39:2583–2592, 8:65–69, 1976.
2006. 20. Moutet F: Flexor tendon pulley system: Anatomy, pathology,
9. Marco RA, Sharkey NA, Smith TS, et al: Pathomechanics of treatment, Chir Main 22:1–12, 2003.
closed rupture of the flexor tendon pulleys in rock climbers, 21. Karev A: The “belt loop” technique for the reconstruction of
J Bone Joint Surg (Am) 80:1012–1019, 1998. pulleys in the first stage of flexor tendon grafting, J Hand Surg
10. Vigouroux L, Quaine F, Paclet F, et al: Middle and ring fingers (Am) 9:923–924, 1984.
are more exposed to pulley rupture than index and little 22. Okutsu I, Ninomiya S, Hiraki S, et al: Three-loop technique
during sport-climbing: A biomechanical explanation, Clin for A2 pulley reconstruction, J Hand Surg (Am) 12:790–794,
Biomech (Bristol, Avon) 23:562–570, 2008. 1987.
11. Lin GT, Amadio PC, An KN, et al: Biomechanical analysis of 23. Nishida J, Amadio PC, Bettinger PC, et al: Flexor tendon-
finger flexor pulley reconstruction, J Hand Surg (Br) 14:278– pulley interaction after pulley reconstruction: A biomechani-
282, 1989. cal study in a human model in vitro, J Hand Surg (Am)
12. Bunnell S, Böhler J: Die Chirurgie der Hand, Wein, Wilhlem 23:665–672, 1998.
Maudrich Verlag, Teil 1:533–643, 1958.
CHAPTER
21
THE EVOLUTION OF
END-TO-END SURGICAL
TENDON REPAIRS
OUTLINE of various important tissues, for example, intestine,

bladder, abdominal wall, artery and vein graft, etc., I was
Approximately 100 years ago, tendon repair for acute taught that the more suture material that crossed the
division was performed with silk sutures using two- repair site, the greater was the repair strength and distri-
strand repair methods, and although it is a gross bution of load (and prevention of leakage) and the
simplification, mediocre results with resultant poor more assured would be the subsequent result.
movement and function were attributed to tissue I was taught tendon repair by using a two-strand
adhesion and poor capacity for tendons to heal. The Bunnell or Kessler type repair and was told the outcome
problem was countered by strategies such as tendon of repair was likely to be complicated by a high inci-
grafting or excision of the tendon sheath, but ulti- dence of repair dehiscence, tendon adhesions, and stiff-
mately better methods of direct repair have evolved. It ness. I remember thinking that the repair did not match
has been realized that mobilization of the finger and the general closure principles I had learned.
the injured tendon prevents adhesion of the tendon Tendon repair has changed significantly since then
to tendon sheath and to bone and that the necessary and I would say that now it is accepted in many hand
post repair mobilization can most safely be carried out centers that a multistrand repair is required to allow
using multistrand tendon repair techniques. Current protected movement during the early stages of healing,
practice divides the tendon repair into core sutures so critical for preventing adhesions, and that in most
and peripheral sutures, which together contribute circumstances this will result in satisfactory movement,
greatly to repair strength and gap resistance. Tough a low incidence of rupture, and a good functional
synthetic suture materials that have low tissue reactiv- outcome.
ity and that retain their initial strength are now
EARLY REPAIRS AND SURGICAL STRATEGY
standard. Such a strategy of robust repair and active
protected postsurgery mobilization ensures a high In 1922, Bunnell1 described the principles of tendon
chance of obtaining clinically excellent movement and repair that we would find it hard to disagree with now.
function. In addition, the worst results that follow His details and materials then were slightly different to
partial repair failure with gap formation, and total ours now, but the idea then was similar. He described a
failure with repair rupture, are infrequent. robust criss-cross suture, in the anterior half of the
tendon to protect the tendon blood supply, sufficiently
There have been many influences on tendon repair over strong to allow early movement, with little exterior
the past century related to the history of repair methods, exposure of suture material to reduce adhesion, a splint
to our understanding of the biology and healing of with the wrist flexed but the fingers free so that “the
tendons, to laboratory studies on repair techniques, to muscles that pull the tendons are thus robbed of their
availability of suture materials, and to the practice of power of too much traction and still they can keep the
post surgical mobilization. There is a mountain of sci- tendon actively moving.” Cooperation by the patient
entific and clinical literature on this fascinating subject, was essential.
but I have drawn on a small part of it that appears most Just a year later in 1923, Lahey2 reported a method
relevant. of tendon repair that used a grasping technique where
My impression when I commenced tendon surgery the suture material encircled some of the tendon fibers,
as an orthopedic trainee in 1983 was to relate what I gripping them tightly to prevent slippage. Three addi-
saw of tendon repair as instructed, compared to other tional interrupted sutures at the tendon junction were
aspects of surgery that I had learned, mainly as a general added to promote accurate apposition. The sutures were
surgery trainee in the United Kingdom. In the closure overtightened sufficient to allow the suture to settle in
239
when the tendon was moved and active postoperative suture materials of fine caliber, 5-0 for the core repair
finger mobilization was commenced. The suture mate- and 6-0 or 7-0 for the peripheral running suture. The
rial was either silk or linen. Regrettably this work did sheath was opened sufficiently to complete the repair
not contain clinical results but it would be fascinating but was retained enough to prevent bowstringing.
to try out this method today, for it seems not dissimilar Results from primary repair were improved but signifi-
to some current methods and it used active mobiliza- cant numbers of tenolysis were required. It would be
tion prior to a very long period where immobilization interesting to speculate whether there would have been
or passive mobilization was used. advantage if they had used the probably superior Mason-
In 1944, Bunnell3 advocated overtightening the Allen or original Kessler core repair.
sutures slightly to counteract the tendency for tendon By 1981, Kleinert et al8 had changed to a modified
ends to separate and now he also immobilized the Kessler core suture of 3-0 or 4-0 braided polyester
finger for 3 weeks after surgery. He also popularized the together with a 6-0 nylon epitendon suture. Both these
use of stainless steel for its low biological reaction and repair elements persisted for most of the next 25 years
high tensile strength. To counteract the tendency of wire mainly for the good, and there was widespread develop-
to break when repeatedly bent, he developed the pull- ment of hand therapy services that were an essential part
out wire system. Bunnell had named zone 2 of the of Kleinert’s method.
fingers “no man’s land” for primary tendon repair. It is
PATHOLOGY OF TENDON HEALING
not clear exactly what caused poor results in Bunnell’s
cases, although from the discussion that follows we Our understanding of tendon healing capability has
might assume it was a subtle mix of repair quality and strongly influenced clinical practice over the decades,
postsurgical immobilization. Tissue adhesion at the sometimes for the better and sometimes for the worse.
repair site was recognized, and he popularized primary In 1932, Mason and Shearon,9 studying dog tendons,
tendon grafting, thus taking the site of surgical repair found that sheath tissues proliferated, that tendon ends
away from zone 2 and placing it at the end of the finger frequently separated, and that the resultant gap became
and within the palm or forearm. filled with blood and healing tissue that grew out from
In 1941, Mason and Allen4 devised a technique that the tendon ends. This suggested that the sheath should
was quite similar to the subsequent original Kessler be repaired and that the tendon should be moved.
repair in 1973.5 After the creation of an anchor point Although this was practiced by Bunnell in 1922 and
on each side of the tendon the suture was passed trans- Garlock in 1926,10 this practice did not seem to persist.
versely across the tendon but proximal to the anchor Other studies demonstrated that mobilized animal
point and then tied to the corresponding suture from tendons regained strength more quickly than immobi-
the opposite tendon end. Additional sutures were placed lized tendons.
at the tendon margin. Animal studies showed that the The views of Peacock (1965)11 and Potenza (1969)12
external sutures were soon covered by a thin sheet of dominated for a couple of decades. The widely held
tissue, countering the argument that sutures on the view on tendon healing was that finger and sheath
tendon surface should be avoided because they caused tendons had very little capacity for healing. Peacock
adhesions. Again, reactive silk was used and there were popularized the “one wound” concept in which healing
multiple knots, giving potential for weakness. to all tissues from skin down to bone was in the general
In 1960, Verdan6 described primary repair in zone 2 process of inflammation, granulation, and scar forma-
using a completely different strategy to counteract fre- tion, such that expecting the tendon to move within the
quently observed poor results from tendon grafting and scar appeared impractical.
from the adhesions that followed attempts at primary Potenza’s view was possibly more negative than this,
repair. His repair comprised two pins that transfixed the for he concluded that tendon had no repair potential
tendon at a distance from the cut end and a fine arterial itself and that healing only occurred when granulation
type epitendinous suture. The sheath at the repair site tissue grew from the neighboring tissues and tendon
was excised for 1 inch so that the adhesions necessary sheath into the tendon, although following subsequent
for healing were not attached to firm tissue. Results were work it seems their conclusions were misinterpreted. He
not particularly good by current standards but one of found that surgical pricking of the tendon induced
his principles has stood the test of time, for the marginal adhesions and that worse damage to the tendons pro-
peripheral suture is widely used now. duced more adhesion. Excision of the tendon sheath
In 1973, Kleinert et al7 described a simplified short caused no delay of healing and this practice was advo-
criss-cross core suture, a variant of the Bunnell longer cated by Verdan.6
criss-cross suture, and a peripheral marginal running Matthews and Richards (1976)13 and Lundborg
suture. The principle was to produce a neat repair with (1976)14 showed that tendon proliferation was seen
no gaps and then to apply the now well-known elastic in parts of rabbit tendon devoid of blood supply,
band dynamic mobilization system. They used synthetic apparently as a result of nutrition by synovial fluid.
Chapter 21: The Evolution of End-to-End Surgical Tendon Repairs 241
In addition, Matthews and Richards (1974, 1976)15 three such lock points (effectively producing a blanket
designed a very clever biological model for tendon stitch down each side of the tendon). The study used
healing experimentation. This followed a clinical obser- stainless steel sutures and sequential radiography to
vation by Harold Richards (personal communication) produce photographs of the suture unraveling: under
that sometimes when a clinical case of tendon division very light tension (3 N) the curly lock points began to
presented late, on exploring the tendon sheath, little by unravel, at 9 N the lock points were nearly untwisted,
way of adhesion and scarring was found around the and at 15 N the lock points had straightened completely
tendon end. They postulated that it was the factors that and the suture migrated progressively to the cut tendon
surgeons apply to the finger that caused poor healing end. The study showed no strength advantage to the
and adhesion formation. The laboratory experiments extra lock points and a stretch disadvantage to the mul-
were carried out in rabbit flexor tendons. The ingenious tiple lock points, because there was more suture to
part of the methodical analysis was to partly divide the unravel and to create a wider gap. The authors con-
tendon so that it could be observed within the tendon cluded that the “locking loop” should not be included
sheath in an unsutured, non–sheath-injured, and non- in designs for load-bearing tendon repair.
immobilized paw. This setup served as the control for However, Kleinert popularized the very important
subsequent addition of surgical factors, namely sutur- epitendon or peripheral suture, previously described by
ing, sheath injury, and immobilization. Verdan, with the principal aim of creating a smooth,
The control tendons showed evidence of healing neat repair. Wade et al (1989)18 investigated the mechan-
within the partial tendon gap and no sign of adhesions. ical properties of the peripheral suture. Using a simpli-
The three surgeon-induced factors each produced fied Kessler core repair without locking loops, they
modest adhesions between the tendon and the tendon added a running “over and over” peripheral stitch
sheath, but these resolved with time. When two factors (Kleinert) using 5-0 braided polyester; and they studied
were applied together, there were moderate adhesions a Halsted-type peripheral repair using 5-0 polypropyl-
that eventually resolved. But when all three factors ene. Their values for initial gap forming under a load
were applied, the adhesions were dense, restrictive, and test were core stitch alone, 3.4 N; core stitch with
unresolving. running peripheral suture, 22 N; core stitch with Halsted
These very important studies certainly changed the peripheral suture, 39 N.
view on tendon healing, although the authors did not Kitsis et al19 subsequently used the Halsted periph-
suggest how the surgical dilemma could be resolved. As eral repair clinically and reported a large series with very
I see it, that came gradually with surgeons carrying on good results and a very low rupture rate. The Halsted
doing what they thought should work clinically. I argue repair is easy to perform and the suture lies mainly
in retrospect that these and many other laboratory beneath the tendon surface.
studies support the notion that if surgical repair can be Silfverskiöld and Andersson20 taught us that a periph-
done neatly but with sufficient strength for immobiliza- eral cross-stitch repair (Figure 21-1) gave similar loads
tion to be avoided, then healing can occur without and gap resistance to Wade’s Halsted-type repair (namely
dense adhesions forming. about 50 N at a 2-mm gap and 60 N ultimate failure).
A minimum of 14 strands is necessary for best effect
FURTHER DEVELOPMENT OF SURGICAL
according to the report of Kubota et al in 1996,21 but
REPAIR TECHNIQUE
In the 1970s and 1980s, most surgeons were using a
two-strand tendon repair technique. Various ways of
making the tendon suture weave into or grip onto the
tendon fibers were devised and published. It appears
that the principle laid down by Bunnell and Kessler, that
the suture gripped firmly onto tendon fibers, was partly
lost in Kleinert’s method of the foreshortened Bunnell
core suture and the modified Kessler-type core suture,
which appears to have less gripping power onto the
tendon than the original methods.
In 1991, Mashadi and Amis16 studied the modified
Kessler technique described by Pennington in 1979,17 in
which the transverse part of the suture passed superficial Figure 21-1 A 14-strand Silfverskiöld peripheral suture.
to the longitudinal part, apparently creating a locked (Modified from Silfverskiöld KL, Andersson CH: Two new
arrangement of suture against tendon. This was com- methods of tendon repair: An in vitro evaluation of tensile
pared with Verdan’s technique, which had two of the strength, and gap formation, J Hand Surg [Am] 18:58–65,
lock arrangements, and the Ketchum repair, which had 1993, Figure 1b.)
Anchor
point
Figure 21-3 A six-strand Sandow single-cross grasp:

modified Savage technique. (Modified from Sandow MJ,
McMahon MM: Single-cross grasp six-strand repair for acute
Anchor Anchor flexor tenorrhaphy: Modified Savage technique, Atlas Hand
point point Clin 1:65–76, 1996, Figure 16.)
points (Figure 21-2B) without an epitendon suture,

A Dorsal showed a 2-mm gap force of about 4 kg and a maximum
strength of about 6 kg. These values were about three
Tendon Tendon times greater than two-strand core repairs without a
peripheral suture and quite similar in strength to Wade’s
1 2 peripheral type repair. Both the Wade and the Savage
studies indicated the very powerful effect of multistrand
3 4 repairs whether the sutures be peripherally or centrally
placed. I used my method clinically and without formal
5 6 physiotherapy produced excellent outcomes with a low
B rupture rate.23 Interestingly, Sandow and McMahon’s
Figure 21-2 A six-strand Savage repair. A, Position of (1996) anchor point in their modified six-strand Savage
anchor points. B, Six type 3 anchor points: six strands. repair24 and Xie and Tang’s (2005) type B “embedded
(Modified from Savage R: In vitro studies of a new method of cross-lock” anchor point25 were the same as my type 2
flexor tendon repair, J Hand Surg [Br] 10:135–141, 1985, anchor point in the 1985 study.
Figure 6a, b.) Other simpler methods of creating six-strand core
repairs have evolved. In 1996, Sandow and McMahon24
published a simpler anchor point (as noted earlier)
this is easy to achieve with seven suture bites on each (Figure 21-3) with reduced needle passes, now known
side of the tendon: their repair was combined with a as the Adelaide repair in four-strand form, also has a
two-strand modified Kessler core suture. Suture material simple epitendon suture. In 1994, Tang et al26 com-
in Silfverskiöld’s cross-stitch was left on the outside of bined the principles of Savage’s six-strand repair with
the tendon, something that has worried many surgeons, Tsuge et al’s (1975)27 two-strand technique, thus creat-
but many recent studies have used the repair without ing a six-strand Tsuge-type repair. A simple peripheral
apparent extra adhesion. epitendon suture was added to prevent gapping.
In 1985 I published a laboratory study on the deriva- A way of inserting two strands easily emerged with
tion of a new technique of core suture.22 The principle Gill et al’s (1999)28 use of a looped suture; being a
was to use the most effective suture material, to find the single needle swaged onto two ends of a nylon suture,
most effective junction of suture onto tendon (then it could be easily anchored into the tendon by a single
called “grasp” but which I now call “anchor point”), and transverse pass of the needle through tendon, with the
to use multiple strands of suture material. In addition, needle hooking through the loop. Then it was run down
the three anchor points were positioned on the radial to the cut end and into the other tendon end where the
lateral, ulnar lateral, and volar sectors of the tendon to suture was inserted about 1 cm; one thread was cut and
avoid the dorsal vascular supply to the tendon (Figure the other was passed transversely to create an anchor
21-2A). I tested three patterns/types of anchor point: point and was knotted at the correct length: an epiten-
type 1 (least intricate) had the lowest strength and the don suture was added to prevent gapping. Critics will
greatest slippage under tension, and type 3, the most notice that although there are six suture strands, there
complex anchor point, gripped the tendon fibers reli- are only two anchor points on each side, so the repair
ably with little slippage, such that in the test on pig is potentially weaker than a repair with three anchor
extensor tendon, at the point of ultimate failure either points.
the suture snapped or a piece of tendon was stripped Four-strand core repairs have proliferated, as a com-
out from the tendon substance. The type 2 anchor point promise to the complexity of six-strand repairs, where
characteristics were between those of types 1 and 3. A smaller tendons do not accommodate six strands and
six-strand repair created by using the “type 3” anchor three anchor points, and for those who fear, with some
Tang method
A F
F F
M -Tang method
Figure 21-4 A six-strand Tang method—three Tsuge
sutures and six-strand M-Tang method. (Modified from
Wang B, Xie RG, Tang JB: Biomechanical analysis of a
modification of Tang method of tendon repair, J Hand Surg
[Br] 28:347–350, 2003, Figure 2.)
F
B F
Figure 21-5 A, Effective anchor points with no slack to
justification, that extra damage to the tendon may result
allow lengthening in a four-strand repair. B, Ineffective grip
from more needle insertions. Patterns used include of tendon by suture allowing lengthening in a two-strand
combinations of modified Kessler, in line, at right repair. (Modified from Xie RG, Xue HG, Gu JH, et al: Effects
angles, and side by side, and looped sutures have been of locking area on strength of 2- and 4-strand locking
paired, tripled, or looped at one end, the “M Tang” tendon repairs, J Hand Surg [Am] 30:455–460, 2005,
described by Wang et al29 in 2003 and Cao and Tang30 Figure 4.)
in 2005 (Figure 21-4).
Optimum anchor point position is about 1 cm from
the cut end, according to Cao et al (2006)31 and Tang a proportionate increase in ultimate strength related
et al (2005),32 and optimum anchor point diameter is to core strand number. Load sharing between suture
about 2 mm, according to Xie et al (2005).33 Despite strands appears to be an important part of the repair
much research, it is not clear exactly what style of anchor and it has been argued that a less complex anchor point
point is best; indeed, it may be emerging from Xie and contributes to equal load sharing between suture strands
Tang’s (2005) studies25 and Viinikainen et al (2004)34 and thus overall improved strength across the whole
that perhaps the anchor point pattern is not as impor- repair.
tant as the multiplication of anchor points and strand An important element of repair design is that sutures
numbers. At least this may be true for repairs treated by should pass from the cut end to the anchor point, and
the current favored controlled semiactive mobilization then back to the cut end immediately, then to the
regimen, but it might not be true, for example, if the opposite cut end to make another anchor point, and
repair was not protected after surgery, although this has then return to the cut end, etc., so that the sutures cross-
not been tried formally. ing the tendon gap are multiplied (Figure 21-5A),
It is a possibility that anchor point type cannot be according to Xie et al.33 In the modified Kessler repair,
tested adequately in pig flexor tendons, for Hausmann the suture crosses from the first to the second anchor
et al35 and Peltz et al36 showed there was more resistance point by crossing to the opposite side of the same
to suture pull-out in pig flexors than sheep or human tendon end, losing the mechanical effect of suture cross-
flexor tendons in 2009 and 2010. Similarly, a single pull ing the tendon gap, halving the number of strands in
test could be insufficiently sensitive to distinguish one the repair and creating coils to lengthen under tension
anchor point type from another and cyclic load tests (Figure 21-5B).
would better mimic real life: In 2005, Matheson et al37 Studies have demonstrated the very clear mechanical
showed minor differences and poor survivorship for advantage of increasing the suture caliber from size 4-0
both simple and Silfverskiöld peripheral repairs but to 3-0 but, again, in smaller tendons, larger sutures
marked differences comparing these repairs to the Savage may not sit comfortably within the tendon. More con-
repair, which showed 100% survivorship under cyclic troversial is the choice of suture material, weighing
tests. In 1998, Thurman et al,38 in cyclic load tests the advantage of tougher materials (fiberwire, braided
in human tendons, showed less gapping with four- polyester) with a rough surface against more flexible
strand Strickland repairs and six-strand Savage repairs materials (polyethylene, polypropylene), which are
compared to two-strand original Kessler repairs and slightly weaker but have a with a smooth surface. There
is no advantage to absorbable materials, which may while in 1994, Elliot et al42 reported a 4% rupture rate,
weaken and cause tissue reaction. again raising the possibility that the surgical repair was
not sufficiently strong for CAM. Among other possible
RELATION OF POSTSURGICAL MOBILIZATION
differences between the two series, the repair techniques
METHODS TO SURGICAL REPAIR TECHNIQUE
were slightly different: even though both used a two-
Once it became clear that postsurgical mobilization of strand core suture together with the simple over-and-
fingers could result in excellent outcomes, varying forms over epitendon suture, the 46% rupture rate was
of postsurgical mobilization have evolved and, I believe, associated with the probably weaker modified Kessler
have influenced the way in which surgical repair is core suture popularized by Kleinert, and the 4% rupture
carried out. rate was associated with a more original version of
In 1973, Kleinert et al, using “dynamic passive mobi- Kessler’s, which Elliot describes as Kessler/Kirchmayer
lization,” showed us that with a relative weak tendon (personal communication). The Manchester group now
repair, good mobility could be achieved. However, some uses four or six strand core sutures with much improved
of the poor results with repair rupture39 and repair results with CAM. There are other examples of this real-
stretching and subsequent scar formation40 suggested ization around the globe.
that with a stronger tendon repair technique, these poor
outcomes could be improved.
SUMMARY
What we now call “controlled active mobilization”
(CAM), initially described by Small et al41 in 1989, dis- It does appear that 90 years later we have more or less
carded the elastic band of Kleinert, replacing gentle met Bunnell’s goal. Robust suture repairs have evolved
active movement within a tendon splint, and the authors by multistrand design, both in core sutures and in
showed good results in the majority of cases but a 10% peripheral sutures. These are in the main sufficiently
rupture rate. Interestingly, they used the original Kessler/ strong to allow early movement but within the restric-
Mason-Allen core suture with the epitendon part of tions of a careful program of exercises and curtailed
Kleinert’s repair technique but not the modified Kessler activity to protect the repair during healing, and the
core suture, which arguably is weaker. results are mainly good. It has taken this time to advance
Following the good results of Small et al, CAM has gradually, learning from use of synthetic low reactivity
been used widely (with variations in exact technique), sutures, correcting errors in the principles of repair
although in the United Kingdom at least, it did not yield and mobilization, resolving misunderstandings of the
the good results in all centers. For example in 1998, pathology of healing, and applying simple mechanics
Peck et al,39 in Manchester, reported a 46% rupture rate, to suture design.
References
1. Bunnell S: Repair of tendons in the fingers, Surg Gynec Obstet 13. Matthews P, Richards H: Factors in the adherence of flexor
35:88–97, 1922. tendon after repair: An experimental study in the rabbit,
2. Lahey FH: A tendon suture which permits immediate motion, J Bone Joint Surg (Br) 58:230–236, 1976.
Boston Med Surg J 188:851–852, 1923. 14. Lundborg G: Experimental flexor tendon healing without
3. Bunnell S: Surgery of the Hand, Philadelphia/London/ adhesion formation: A new concept of tendon nutrition and
Montreal, 1944, JB Lippincott. intrinsic healing mechanisms. A preliminary report, Hand
4. Mason ML, Allen HS: The rate of healing of tendons: An 8:235–238, 1976.
experimental study of tensile strength, Ann Surg 113:424– 15. Matthews P, Richards H: The repair potential of digital flexor
459, 1941. tendons: An experimental study, J Bone Joint Surg (Br)
5. Kessler I: The “grasping” technique for tendon repair, Hand 56:618–625, 1974.
5:253–255, 1973. 16. Mashadi ZB, Amis AA: The effect of locking loops on the
6. Verdan CE: Primary repair of flexor tendons, J Bone Joint Surg strength of tendon repair, J Hand Surg (Br) 16:35–39, 1991.
(Am) 42:647–657, 1960. 17. Pennington DG: The locking loop tendon suture, Plast Recon-
7. Kleinert HE, Kutz JE, Atasoy E, et al: Primary repair of flexor str Surg 63:648–652, 1979.
tendons, Orthop Clin North Am 4:865–876, 1973. 18. Wade PJF, Wetherell RG, Amis AA: Flexor tendon repair: Sig-
8. Kleinert HE, Schepels S, Gill T: Flexor tendon injuries, Surg nificant gain in strength from the Halsted peripheral suture
Clin North Am 61:267–286, 1981. technique, J Hand Surg (Br) 14:232–235, 1989.
9. Mason ML, Shearon CG: The process of tendon repair: An 19. Kitsis CK, Wade PJF, Krikler SJ, et al: Controlled active motion
experimental study of tendon suture and tendon graft, Arch following primary flexor tendon repair: A prospective study
Surg 25:615–692, 1932. over 9 years, J Hand Surg (Br) 23:344–349, 1998.
10. Garlock JH: Repair of wounds of the flexor tendons of the 20. Silfverskiöld KL, Andersson CH: Two new methods of tendon
hand, Ann Surg 83:111–122, 1926. repair: An in vitro evaluation of tensile strength and gap for-
11. Peacock EE: Biological principles in the healing of long mation, J Hand Surg (Am) 18:58–65, 1993.
tendons, Surg Clin North Am 45:461–476, 1965. 21. Kubota H, Aoki M, Pruitt DL, et al: Mechanical properties of
12. Potenza AD: Mechanisms of healing of digital flexor tendons, various circumferential tendon suture techniques, J Hand Surg
Hand 1:40–41, 1969. (Br) 21:474–480, 1996.
22. Savage R: In vitro studies of a new method of flexor tendon 34. Viinikainen A, Göransson H, Huovinen K, et al: A com
repair, J Hand Surg (Br) 10:135–141, 1985. parative analysis of the biomechanical behaviour of five
23. Savage R, Risitano G: Flexor tendon repair using a “six-strand” flexor tendon core sutures, J Hand Surg (Br) 29:536–543,
method of repair and early active mobilisation, J Hand Surg 2004.
(Br) 14:396–399, 1989. 35. Hausmann JT, Vekszler G, Bijak M, et al: Biomechanical com-
24. Sandow MJ, McMahon MM: Single-cross grasp six-strand parison of modified Kessler and running suture repair in 3
repair for acute flexor tenorrhaphy: Modified Savage tech- different animal tendons and in human flexor tendons,
nique, Atlas Hand Clin 1:41–64, 1996. J Hand Surg (Am) 34:93–101, 2009.
25. Xie RG, Tang JB: Investigation of locking configurations for 36. Peltz T, Haddad R, Savage R, et al: A comparison of human,
tendon repair, J Hand Surg (Am) 30:461–465, 2005. porcine and ovine deep flexor tendons. What is the ideal
26. Tang JB, Shi D, Gu YQ, et al: Double and multiple looped animal model for in vitro flexor tendon studies? Proceedings
suture tendon repair, J Hand Surg (Br) 19:699–703, 1994. of 15th Congress of the FESSH. June 23–26, 2010. Bucharest,
27. Tsuge K, Ikuta Y, Matshuishi Y: Intra-tendinous tendon suture Romania.
in the hand: A new technique, Hand 7:250–255, 1975. 37. Matheson G, Nicklin S, Gianoutsous MP, et al: Comparison
28. Gill RS, Lim BH, Shatford RA, et al: A comparative analysis of zone II flexor tendon repairs using an in vitro linear cyclic
of the six strand double loop flexor tendon repair and three testing protocol, Clin Biomech 20:718–722, 2005.
other techniques: A human cadaveric study, J Hand Surg (Am) 38. Thurman RT, Trumble TE, Hanel DP, et al: Two-, four- and
24:1315–1322, 1999. six-strand zone II flexor tendon repairs: an in situ biome-
29. Wang B, Xie RG, Tang JB: Biomechanical analysis of a modi- chanical comparison using a cadaver model, J Hand Surg
fication of Tang method of tendon repair, J Hand Surg (Br) (Am) 23:261–265, 1998.
28:347–350, 2003. 39. Peck FH, Bucher CA, Watson JS, et al: A comparative study of
30. Cao Y, Tang JB: Biomechanical evaluation of a four-strand two methods of controlled mobilization of flexor tendon
modification of the Tang method of tendon repair, J Hand repairs in zone 2, J Hand Surg (Br) 23:41–45, 1998.
Surg (Br) 30:374–378, 2005. 40. Ejeskar A: Finger flexion force and hand grip strength after
31. Cao Y, Zhu B, Xie RG, et al: Influence of core suture purchase tendon repair, J Hand Surg (Am) 7:61–65, 1982.
length on strength of four-strand tendon repairs, J Hand Surg 41. Small JO, Brennen MD, Colville J: Early active mobilisation
(Am) 31:107–112, 2006. following flexor tendon repair in zone 2, J Hand Surg (Br)
32. Tang JB, Zhang Y, Cao Y, et al: Core suture purchase affects 14:383–391, 1989.
strength of tendon repairs, J Hand Surg (Am) 30:1262–1266, 42. Elliot D, Moiemen NS, Flemming AF, et al: The rupture
2005. rate of acute flexor tendon repairs mobilized by the con-
33. Xie RG, Xue HG, Gu JH, et al: Effects of locking area on trolled active motion regimen, J Hand Surg (Br) 19:607–612,
strength of 2- and 4-strand locking tendon repairs, J Hand 1994.
Surg (Am) 30:455–460, 2005.
CHAPTER
22
OUTCOMES OF FLEXOR
TENDON REPAIRS AND
METHODS OF EVALUATION
Jin Bo Tang, MD
OUTLINE topics in hand surgery. The reports of outcomes of

primary repair of the injured flexor tendons were spo-
Reports of clinical flexor tendon repairs over the past radic before the 1980s, because this practice had not
20 years have documented good or excellent recovery become the mainstay of surgical repair of the injury in
of function in three-fourths of patients treated in the the early and middle of the last century. From the 1980s
finest hand centers worldwide. The most significant up to the recent years of this century, we have seen a
changes in conception and technique regarding flexor great number of reports1-31 that document the outcomes
tendon repairs are (1) use of stronger surgical repair of primary, or delayed primary, tendon repair, end-to-
techniques (either multistrand core suture or stronger end surgical tendon repair methods and evolving post-
peripheral suture) and (2) inception and development surgical rehabilitation methods.
of active finger flexion exercise regimens. Over the past
OUTCOMES OVER THE PAST 20 YEARS
two decades, rupture rates of the flexor tendon repair
in the fingers gradually declined from around 10% to I reviewed the outcomes of primary tendon repair in
less than 2% to 4%, and rupture rates of thumb flexor a 2005 article in Hand Clinics.1 An updated review of
tendon repair declined from 10% to 17% to 0%. The the outcomes of flexor tendon repairs in fingers and
original Strickland and Glogovac criteria are most thumb over the past 20 years (1989–2009) is provided
popularly used to evaluate the recovery of total active in Table 22-1.
motion of the fingers. A few novel evaluation methods A few important observations can be summarized
emerged, including Moiemen-Elliot’s distal interpha- from an analysis of outcomes over this period (as well
langeal joint–only method for zone 1 repair outcomes, as the results presented in Chapter 13):
and the author’s method, which incorporates modifi-
cations in grading the total active motion, measure- 1. Good or excellent recovery of function from the
ment of grip strength, and assessments regarding the centers involved (which are among the leading
nature of finger motion. In the final part of this chapter, hand surgery units treating flexor tendon inju-
I discuss a few issues relating to functional evaluation, ries) were in around three-fourths, or 75% of the
such as a framework of comprehensive assessment of cases.
outcomes, the need for separate evaluation of recovery 2. The most common method of quantifying out-
of the tendon repair in the little fingers, and grading comes is the original Strickland and Glogovac
the expertise of physicians in clinical reports regarding method.
outcomes. 3. Primary or delayed primary tendon repairs were
prioritized over secondary repair by all surgeons.
The well-recognized importance and challenges in flexor 4. Early tendon motion, either passive or active (or
tendon repair in the hand are reflected in the number combined), was advocated in all cases by sur-
of the past investigations (publications) relating to this geons and participating therapists, except for
subject. The inaugural issue of the widely read Hand children.
Clinics was devoted to flexor tendon repair. Twenty years 5. Early active motion regimens were adopted in
later, in the preface of the second issue of Hand Clinics the late 1980s, initially producing a high rate of
for flexor tendon repair in 2005, Daniel Mass and Craig repair rupture (around 10%) with conventional
Phillips wrote that this controversial complex topic “has (weaker) two-strand repairs, which has been a
produced more articles in the peer-reviewed hand litera- great concern.
ture than any other single topic.” It is true that flexor 6. There has been a gradual but clear shift from
tendon repairs have been and remain one of the hottest using two-strand core suture repairs to stronger
246
Chapter 22: Outcomes of Flexor Tendon Repairs and Methods of Evaluation 247
Table 22-1 Some Major Reports of Function of Primary Flexor Tendon Repairs Over the Past 20 Years
Number of Excellent/ Rupture
Years Authors Digits Zones Repair Methods Good* Rate
Finger flexor tendons
1989 Small et al 138 2 2-strand Kessler 77% (TAM) 9.4%
1989 Cullen et al 38 2 2-strand Kessler 78% 6.4%
1989 Savage and Risitano 23 2 6-strand Savage 69% (Buck- 4%
Gramcko)
1989 Pribaz et al 43 2 Becker 70% (White) 7%
1992 Tang and Shi 54 2 2-, 4-, and 81% …
6-strand repairs
1994 O’Connell et al 95 (children) 1, 2 2-strand methods 69%† 0%
†
1994 Silfverskiöld and May 55 2 Silfverskiöld 90% 3.7%
1994 Grobbelaar and 38 (children) 1–5 2-strand Kessler 82% (Lister) 7.9%
Hudson
1994 Elliot et al 244 1, 2 2-strand Kessler 79% 5.8%
1994 Tang et al 51 2 4- or 6-strand 77% (White) 4%
Tang
1996 Sandow and McMahon 23 2 4-strand Savage 78% 0%
1998 Kitsis et al 208 1–5 2-strand Kessler 92% 2.9%
87 2 88% 5.7%
1999 Fitoussi et al 58 (children) 1–5 2-strand Kessler 89% 0%
1999 Harris et al 626 1, 2 2-strand Kessler … 4.3%
129 1 … 5.0%
397 2 … 4.0%
†
2006 Elhassan et al 16 (children) 1 Bunnell pull-out 89% 0%
†
25 (children) 2 2- and 4-strand 71% 0%
Kessler
2008 Caulfield et al 416 1–4 4-strand 74% 2%
Strickland
2008 Haffmann et al 51 2 6-strand Lim/Tsai 78% 2%
26 2 2-strand Kessler 43% 11%
2008 Novali and Rouhani 16 (children) 2 6-strand 94% 0%
Strickland
16 (children) 2 2-strand Kessler 88% 6%
Thumb FPL tendon
1989 Percival and Sykes 51 1–3 2-strand Kessler 53% (White) 8%
1992 Nunlev et al 38 1, 2 2-strand Tajima or …‡ 3%
2-strand Kessler
*The results were evaluated with Strickland and Glogovac criteria unless specified.
†
These percentages are percent return of TAM judged by Strickland and Glogovac criteria.
‡
Excellent and good rates were not reported. The active IP joint motion was, on average, 35°.
Continued
Table 22-1 Some Major Reports of Function of Primary Flexor Tendon Repairs Over the Past 20 Years—cont’d
Number of Excellent/ Rupture
Years Authors Digits Zones Repair Methods Good* Rate
1999 Sirotakova and Elliot 30 (1st period) 1, 2 2-strand Kessler 70% (White) 17%
73% (Buck-
Gramcko)
39 (2nd period) 1, 2 2-strand Kessler 67% (White) 15%
72% (Buck-
Gramcko)
49 (3rd period) 1, 2 2-strand Kessler 76% (White) 8%
80% (Buck-
Gramcko)
2004 Sirotakova and Elliot 48 1, 2 Silfverskiöld 73% (White) 0%
77% (Buck-
Gramcko)
2009 Giesen and Elliot et al 50 1, 2 6-strand Tang 78% (White) 0%
82% (Buck-
Gramcko)
four- or six-strand surgical repairs, or to use treated over a 3-year period. Ninety-eight patients were
stronger peripheral repair since 1990s. followed and graded using the total active range of
7. Use of stronger surgical repairs has lowered motion (TAM) method of the American Society for
rupture rates, but in most reports, ruptures have Surgery of the Hand (ASSH). The active range of motion
not been eliminated, with 2% to 4% rupture rates was graded excellent or good in 77% of the digits, fair
frequently recorded. in 14%, and poor in 9%. Repair rupture occurred in
8. Over the past decade, more surgeons have 9.4% of the fingers (11 digits). The ruptured tendons
adopted (and reported) some type of early active were re-repaired immediately and a similar early motion
motion regimen, together with use of stronger program was applied. Cullen et al3 treated 34 adult
surgical tendon repairs. patients with 70 zone 2 flexor tendon injuries in 38
9. New tendon repair materials (such as fiberwire) fingers; 78% fingers were rated excellent or good by the
emerged, and surgeons have reported good func- original Strickland criteria after a mean follow-up of 10
tional outcomes and fewer repair ruptures with months. Two tendons ruptured during active finger
fiberwire repair. flexion exercise. Savage and Risitano4 used their six-
10. Multiple methods are currently used to evaluate strand method of repairs to treat flexor tendon lacera-
and record the outcomes of tendon repair. Some tions in 36 fingers followed by protective active finger
worldwide consensus on methods of recording flexion exercise; 63% of lacerations were zone 2 and
outcomes is necessary to facilitate comparisons 27% were zone 1, and 69% and 100% (respectively)
of results. achieved an excellent or good result using Buck-
Gramcko’s assessment method.
MAJOR REPORTS AND
Silfverskiöld and May5 reported outcomes of use of
IMPORTANT INFORMATION
an innovative strong peripheral suture (cross-stitch epi-
Over the past 20 years, a number of excellent clinical tendinous suture) combined with a modified Kessler
reports have highlighted some important facts regarding core suture in treatment of flexor tendon injuries in
primary flexor tendon repairs. In 1989, The Journal of zone 2 in 55 digits among 46 patients. For the first 4
Hand Surgery (British Volume) simultaneously published weeks after surgery, fingers were mobilized with a com-
clinical reports of primary tendon repairs with con- bination of active extension and passive and active
trolled early active tendon motion by Small et al,2 Cullen flexion. Repair ruptures occurred in two tendons. Six
et al,3 and Savage and Risitano.4 Small et al2 presented months after surgery, the mean TAM of the distal and
114 patients with 138 zone 2 flexor tendon injuries proximal interphalangeal (DIP and PIP, respectively)
joints in the remaining fingers was 63° and 94°, respec- tendon repairs with looped suture to repair the tendon
tively. Elliot et al11 reported 233 patients with complete injuries in zone 2 with good functional outcomes.
divisions of the flexor tendons in zones 1 and 2. Their Several other reports also provide interesting and
cases included 203 patients with 224 finger injuries (317 important information about tendon repairs. Kitsis
divided flexor tendons) and 20 patients with 30 com- et al16 reported results of treatment of 339 flexor tendon
plete divisions of the flexor pollicis longus (FPL) tendon. repaired with two-strand modified Kessler core suture
The patients were treated with a controlled active motion and a Halsted peripheral suture in zones 1 to 4 of 208
regimen postoperatively. Repaired tendons ruptured in fingers. The important message from this large case
13 (5.8%) fingers and 5 (16.6%) thumbs. In follow-up series is that among 6 ruptures of the repaired tendons,
of the patients treated during the last year of the study, 5 occurred in zone 2 and one in zone 5. Repair rupture
10 (62.5%) of 16 fingers with zone 1 repairs and 50 was most frequent in zone 2 and the rupture rate was
(79.4%) of the 63 fingers with zone 2 repairs were 5.7%. Harris et al18 reviewed the results of 728 primary
rated good or excellent using the original Strickland and zone 1 and zone 2 flexor two-strand modified Kessler
Glogovac criteria. core suture tendon repairs in 526 fingers of 440
Emphasis on the need and application of strong patients. A total of 23 fingers (6 in zone 1 and 17 in
(four- or six-strand) core repairs in clinical tendon zone 2) ruptured 28 tendon repairs. One hundred
repairs appeared first in Savage and Risitano’s report4 in twenty-nine fingers with zone 1 injuries had a rupture
the late 1980s, followed by the report of Tang and Shi7 rate of 5% (6 fingers) and 397 fingers with zone 2 inju-
and Tang et al7,12 in 1992 and 1994 and then a series of ries had a rupture rate of 4% (17 fingers). The ruptures
reports in Atlas of the Hand Clinics by Taras et al,13 occurred in 6 tendons within the first week, 5 in the
Sandow and McMahon,14 and Lim and Tsai15 in 1996. second week, 6 in the third week, 5 in the fourth week,
In 1992, Tang and Shi7 reported the results of treatment 3 in the fifth week, and 1 in the tenth week. An impor-
of 72 flexor tendon injuries in zone 2 in primary tant message from this case series is that rupture can
or delayed primary stages; 80.4% of the fingers were occur anytime from the first week to the tenth week
rated good or excellent results on assessment by the after surgery. The “dangerous period” is postsurgical
Strickland and Glogovac criteria. Among 72 tendons, 32 weeks 1 to 6, and postoperative week 2 is not associ-
tendons were repaired with four- or six-strand core ated with a higher incidence of repair ruptures than
sutures using looped sutures, together with simple week 1 or weeks 3 to 6. More recently, Dowd et al19
peripheral stitches. In 1994, Tang et al12 reported 51 analyzed the results of immediate re-repair of zones 1
fingers from 46 patients with zone 2 flexor tendon lac- and 2 flexor tendon repairs that rupture during postop-
erations. Doubled threads of the looped suture were erative early motion exercise. The outcomes of the
placed to repair injured flexor digitorum profundus re-repair of the ruptured tendons were generally poorer
(FDP) or superficialis (FDS) tendons, or three threads than the primary repairs, but function of re-repaired
of the looped suture to repair the FDP tendons. The tendons were still clinically acceptable, with 9 (24%)
results were good or excellent in 76.5% using White’s excellent, 10 (27%) good, 5 (14%) fair, and 13 (35%)
criteria. They reported two repair ruptures (4%) during poor when assessed by the Strickland and Glogovac
the postoperative motion program. Taras et al13 used criteria out of a total of 37 fingers with re-repair of the
double-grasping Kessler-type core and cross-stitch peri tendon.
pheral sutures in repairing 21 flexor tendons (three In 2008, The Journal of Hand Surgery (European Volume)
FPL, four FDP in zone 1, and 14 FDS or FDP in zone published a series of reports on flexor tendon repairs
2) of 14 digits. The patients underwent active finger using stronger core tendon sutures (multistrand core
flexion motion initiated on the first postoperative day, sutures) combined with early active flexion exercise.20-22
including place-and-hold exercise three times weekly These reports indicate lower rupture rates among
under supervision. Between therapy sessions, a standard tendons with strong core tendon repairs but also illus-
elastic-thread traction passive flexion and active exten- trate that it is not always possible to avoid repair rup-
sion program was maintained. Overall recovery of tures. Caulfield et al20 reported 416 tendon repairs in
digital motion was graded as excellent in 12 and good zones 1 to 4 repaired with a four-strand Strickland core
in 2. The seven fingers with FDP and FDS repairs in zone suture in 272 patients. The results were 74% good or
2 averaged 83% recovery of motion. Sandow and excellent graded by the Strickland criteria, with only 2%
McMahon14 reported 37 FDP tendons in zones 1 to 5 repair ruptures. They had identical outcomes using
using a modified single-cross six-strand repair based on absorbable and nonabsorbable sutures. Hoffmann
the original Savage method followed by early active et al21 reported 51 fingers of 46 patients undergoing
tendon motion. Of 23 zone 2 tendon injuries in 18 zone 2 flexor tendon repair using the Lim/Tsai repair
patients, 78% were rated as good or excellent using the method combined with a Kleinert and Duran early
Strickland and Glogovac criteria, with no ruptures or motion regimen and place-and-hold exercises. Repair
need of secondary surgery. Lim and Tsai15 used six-strand rupture occurred in 1 (2%) of 51 repaired fingers. Two
(4%) fingers required tenolysis. In the cases they treated The use of stronger surgical repairs improved out-
with the two-strand modified Kessler repair and the comes compared with the earlier reports using weaker
Kleinert and Duran motion regimen alone, they had repair methods but has not entirely eliminated postop-
repair ruptures in three fingers (11%) and tendon adhe- erative repair rupture.20-22 It is the combination of strong
sions, or dehiscence, in three fingers (11%), which surgical repair, proper venting of the pulleys, and early
required secondary surgery. The good or excellent active motion, which reported recently,31,39,41 that has
outcome rate was 78% with the Lim/Tsai method and produced more consistently good or excellent outcomes
43% with the two-strand Kessler method. Navali and without postoperative repair ruptures.
Rouhani22 reported on 32 flexor tendon repairs in zone The above reports indicate that clinical flexor tendon
2 of 29 children using either the two-strand modified repairs had excellent or good functional return in about
Kessler method (16 tendons) or the four-strand Strick- three-quarters of primary tendon repairs. Nevertheless,
land method (16 tendons). They achieved good or it should be noted that most of these reports came from
excellent outcomes in all fingers, except one rupture and the finest hand surgery centers and that these teams
one fair outcome among the tendons with the two- were supervised by at least one expert hand surgeon
strand repair and one fair outcome in the tendons with with experience in treating flexor tendon injuries. We
the four-strand repair. may reasonably assume that outcomes in a general hos-
In children, repairs of flexor tendons produced gener- pital setting might achieve a lower level of success. In
ally good or excellent results. Early motion exercise is other words, flexor tendon repairs might have been
not essential for a tendon to regain a good range of unsatisfactory in a larger proportion of patients when
active motion. These observations were validated in treated in a general hospital setting.
reports by Elhassan et al23 in 2006 and by Navali and Over the past 20 years, the conceptual evolution in
Rouhani22 in 2008. tendon repair has been remarkable and the technical
Repair of the FPL tendons is usually discussed sepa- innovations have been numerous. The most significant
rately from flexor tendon repair in the fingers.24-31 Siro- changes are (1) use of stronger surgical repairs (includ-
takova and Elliot27,30 analyzed the results of primary ing core and peripheral sutures), (2) incorporation of a
repairs of the FPL tendon followed by early active variety of early active motion regimens in postsurgical
motion with only the thumb splinted. The first 30 exercise, and (3) a redefinition of the management of
patients were repaired with a Kessler suture and simple the pulleys (see Chapters 9 and 10). Compared to those
epitendinous suture. The later 49 patients underwent in earlier reports, the incidence of repair ruptures in
repair with a Kessler suture and a reinforced epitendi- the most recent series has declined, typically being less
nous suture but in a splint with the thumb position than 2% to 4%. Initiation of early active motion in the
altered and the fingers also splinted. Other reports late 1980s, use of stronger surgical repair methods and
include those from Percival and Sykes,24 Noonan and active motion regimens in the 1990s, and incorporation
Blair,25 Nunley et al,26 Fitoussi et al,28 and Kasashima of strong surgical repairs and venting the critical pulleys
et al.29 Most recently, Giesen et al31 published the latest with delicate early active motion in the past decade
results of repair of the FPL tendon. They analyzed 50 represent three steps in the pursuit of optimal tendon
FPL tendon repairs using a six-strand core repair method, repair and ideal recovery of function. These efforts have
without peripheral sutures. Excellent or good results transformed the outcomes of flexor tendon repairs from
were recorded in 78% and 82% of cases (White and being very unpredictable to their current state: fairly
Buck-Gramcko criteria, respectively). No patients rup- predictable. My feeling is that when treated by ade-
tured repairs as a result of early active mobilization. quately trained hand surgeons, using updated concepts
None developed tendon dehiscence postoperatively. and thorough knowledge of flexor tendon repairs, the
The important message from this report is perhaps that outcomes of zone 2 repairs are likely to be comparable
a strong core suture can adequately tolerate early active with repairs in the other areas of the hand.
tendon motion without the incorporation of peripheral
METHODS OF EVALUATIONS
sutures, which is a conceptual evolution in the treat-
ment of flexor tendon injuries and may lead to signifi- The most common method of recording outcomes is
cant simplification of surgery. the original Strickland and Glogovac method intro-
The case series presented by Elliot and his col- duced in 1980 (Table 22-2).32 This grading system is a
leagues27,30,31 over the past 20 years reflects some unique simplification of the method postulated by the ASSH
findings relating to repair of FPL injury. Their outcomes (Table 22-3).33 The Strickland criteria include TAM of
were increasingly improved from a rupture rate of 17% only the DIP and PIP joints, without inclusion of the
to the present 0% rate. Their methods of tendon repair metacarpophalangeal (MCP) joint motion as in the
and rehabilitation evolved greatly. The thumb flexor ASSH method. Strickland pointed out that inclusion of
tendon appears capable of returning to near-ideal func- the MCP joint in assessment of zone 2 repairs artificially
tion after proper repair and rehabilitation. biased the results to be better as the MCP joint was
Table 22-2 Criteria of Assessment of Functional Outcomes of Flexor Tendon Repairs

% Return of Motion* Grip Strength† Quality of Motion‡ Function Grade
Strickland criteria (1980) 85–100 (>150°)
70–84 (125°-149°) Excellent
50–69 (90°-124°) Good
0-49 (<90°) Fair
Moiemen-Elliot criteria (2000)—for Poor
zone 1 injuries, the DIP joint only
85–100 (>62°) Excellent
70–84 (51°-61°) Good
50–69 (37°-50°) Fair
0–49 (<36°) Poor
Tang criteria (2007)
90–100 + Excellent or good Excellent +
− Poor Excellent −
70–89 + Excellent or good Good +
− Poor Good −
50–69 Fair
30–49 Poor
<30 Failure
*Percent return of a theoretical normal value or contralateral hand. Strickland and Tang criteria use the sum of active range of motion of the
DIP and PIP joints. The theoretical normal is 175°. Moiemen-Elliot criteria use motion of the DIP joint only compared with 74°.
†
Grip strength is recorded as (+) when it is greater than that of the contralateral hand (the nondominant hand) or over 70% of that of the
contralateral hand (dominant hand). Otherwise, grip strength is considered abnormal and recorded as (−).
‡
Quality of motion is rated on a basis of direct observation of finger motion by the evaluators. It is recorded as “Excellent” when all three
aspects—motion arc, coordination and speed—are normal; as “good” when any two are normal; as “poor” when only one, or none, is
normal.
Function is graded as excellent − or good − when either the grip strength is (−) or quality of motion is “poor.”
Table 22-3 ASSH Method of Evaluation requires the injured fingers to recover a normal active
range of motion. In reality, excellent functional status
Grade TAM*
requires a sufficiently ample TAM, but it does not neces-
Excellent 100%, Normal sarily demand that the active range of motion returns
Good >75% of the normal side to normal. In addition, flexion of the MCP joint does
not relate only to function of the FDS and FDP tendons;
Fiar >50% of the normal side
exclusion of the MCP joint from measurement yields
Poor <50% of the normal side more accurate documentation of TAM of the PIP and
Worse worse than before surgery DIP joints. Strickland modified the original criteria in
1985,34 but the modified criteria have not gained popu-
*Sum of the active range motion of the MCP, PIP, and DIP joints. larity and are considered very lenient.
The Buck-Gramcko method consists of TAM (the sum
of angles formed by the MCP, PIP, and DIP joints in
always nearly normal.32 Most subsequent authors maximal active flexion minus active flexion deficit at
adopted Strickland criteria but have not actually stated each joint) and the distance between fingertip and distal
why they preferred the Strickland criteria to the ASSH palmar crease (Table 22-4).35 This method is mainly
method. However, my experience indicates that the used by members of the German-speaking societies for
ASSH method is very strict in its “excellent” grade, which surgery of the hand. The Tubiana method is used mostly
Table 22-4 Buck-Gramcko Method Elliot38 in 2000, and my suggestion39 in 2007 of a

Item Measurement Points
method that includes modified criteria to redefine the
grades of TAM of the DIP and PIP joints and incorpora-
Distance finger pulp to 0–2.5 cm/>200° 6 tion of grip strength and quality of finger motion into
distal crease
the criteria (see Table 22-2).
Composite flexion 2.5–4 cm/>180° 4 Admittedly, my suggested method initially appears
4–6 cm/>150° 2 more complex. However, one can easily break it down
into components that can be used separately. For
>6 cm/<150° 0 example, the simplest method is to measure TAM of the
Extension deficit 0°-30° 3 DIP and PIP joints, and then use the redefined grades
to record outcomes, the essential function of the criteria.
31°–50° 2
The results can be classified into “excellent,” “good,”
51°–70° 1 “fair,” “poor,” and “failure,” without a tag of “+” or “−.”
>70° 0 It is noteworthy that I have set a more stringent bar for
grading the results as “excellent,” requiring recovery of
TAM* >160° 6 TAM to 90% of the contralateral side. Additionally, I
>140° 4 added the grade “failure” to designate cases that defi-
nitely require further surgery to restore essential digital
>120° 2
function. Nevertheless, the active range of motion
<120° 0 required for grading as good or excellent (i.e., overall
*Sum of the active range of motion of the MCP, PIP, and DIP good and excellent rate) remains the same as in the
joints. Strickland method. In this way, reports regarding total
good or excellent rates using the new method are made
comparable to those in the past using the Strickland and
Table 22-5 The White Method Glogovac method.
By adding measurement of grip strength and assess-
Grade TAM* ment of quality of finger motion, the functional status
Excellent 70%–100% of the normal side of digits can be further indicated with “+” or “−” to
provide supplementary information about hand func-
Good 60%–69% of the normal side
tion. The information relates to fine functional status of
Fair 40%–59% of the normal side the repaired tendon and indicates the degree of perfec-
Poor <40% of the normal side tion of hand function attained.
*Active range of motion of the interphalageal (IP) joint only.

FACTORS AFFECTING OUTCOMES
Adhesion Formation
Table 22-6 Finger-to-Palm Distance Method
(Boyes-Lister) Adhesion is a frequent cause of incomplete recovery of
active range of digital motion after tendon repairs
Finger-to-Palm
(Figure 22-1). Adhesions arise because trauma to the
Grade Distance* (cm) Extension Deficit (°)
tendon surface, inappropriate surgical maneuvers, and
I 0–1 0–15 lack of sufficient innate healing capacity of the tendon.
II 1–1.5 16–30 The amount and density of the adhesions are decided
by the severity of the trauma to the tendon and periten-
III 1.5–3 31–50
dinous tissues and the originating tissues. The influ-
IV >3 >50 ences of adhesions on tendon function vary according
to both the amount and density of adhesions. Repair of
*Distance between the finger pulp and the distal palmar crease in
full finger flexion.
clean-cut tendon injuries, when sufficiently moved after
surgery, may not develop adhesion or only develop
filmy adhesions. The filmy adhesions do not affect
in France. Among the less popular methods in current tendon gliding. The formation of restrictive adhesions
use are White’s method (Table 22-5)36 and the linear are seen after extensive trauma to the tendon or its sur-
measurement method introduced by Boyes and then rounding structures and jeopardize the gliding of
Lister et al (Table 22-6).37 repaired tendons. During postoperative tendon motion,
Two more recent methods introduced to record out- loose adhesions can be disrupted, or modified, to avoid
comes include the “DIP motion-only” method for the reducing the amplitude of tendon motion. However,
zone 1 tendon repairs advocated by Moiemen and moderate or dense adhesions are difficult to alter and
Trauma factors Surgical factors Postoperative factors (rehabilitation)
Trauma to tendons Surgical skills Strength of repair methods Hand position in splint
Peritendinous injuries Treatment options Healing strength of tendon Motion range of finger joints
Friction of tendon on sheath Synergistic motion of joints
Gap formation, edema Incorporation of particular
protocols for joint stiffness
Adhesion formations Repair rupture Joint stiffness
Outcome of tendon repairs
Figure 22-1 Factors that affect the outcomes of the flexor tendon repairs in the hand.
should, instead, be prevented through careful surgery of narrow pulleys. Annular pulleys, particularly the
and well-supervised postoperative treatments. Tenolysis A2 and A4, are narrow and restrict tendon gliding.
is indicated when postoperative treatments cannot sub- Edematous, or bulky, tendons are easily entrapped
stantially improve tendon motion. by these pulleys. Edematous and bulky tendons
can trigger on the edge of the sheath or pulley
Repair Rupture openings as well. The narrow part of the annular
Among all the consequences of flexor tendon surgery, pulley constricts the gliding tendons and increases
repair ruptures are the worst and are of prime concern the resistance to tendon movement, which lead to
to hand surgeons, because they require secondary oper- gapping or elongation of the tendon repair site.
ations. If ruptures occur soon after primary repair, direct Catching of the tendon on the edges of narrow
re-suture of the ruptured tendons may be attempted; if pulleys, halting finger flexion or extension, and
ruptures occur at the late period, a secondary tendon causing patients to feel a sudden increase in resis-
graft is indicated.40 The following factors trigger the rup- tance to finger motion, is a major cause of rupture
tures of repaired tendons (see Figure 22-1): of tendon repairs. After surgery, a forceful pull to
overcome the resistance frequently leads to rupture
1. Overload of the repaired tendons. Forceful or resisted of the repairs.
active flexion or extension of the fingers may 4. Unexpected finger motion. During the period of
subject the repaired tendons to a load exceeding wearing protective splints or casts, patients may
the limit of the tensile resistance of the repairs. sustain unexpected finger actions, such as when
2. Tendon edema or bulky tendons. Edema of the falling down on the outstretched hand or sud-
tendons is inevitable after surgery, although its denly gripping. These actions impose a sudden
severity varies among patients. Severely trauma- increase in the force transmitting through the
tized wounds, extensive soft tissue injuries, long repaired tendons with a higher risk of ruptures.
duration of surgery, and poor surgical repair 5. Misuses of the fingers. Misuses of the repaired
maneuvers all contribute to postsurgical edema. fingers, such as using the hand to lift a heavy
Edema makes the tendon bulky. In addition, object, may exceed the repair strength of the
excessive suture materials also contribute to bulki- tendon and cause rupture.11,18
ness. A bulky tendon increases the pressure of the 6. Unprotected active motion. Unprotected active
tendon on the surrounding tissues and its friction flexion of the finger can cause the repaired tendon
against the sheath and pulleys during tendon to disrupt due to great tension in the tendon.
mobilization after surgery. A greater force must be
applied to the finger to move the bulky tendons Joint Stiffness
within the sheath, increasing the likelihood of Stiffness of the DIP and PIP joints is frequently observed
ruptures. during the rehabilitation after primary flexor tendon
3. Triggering in pulleys or edges of opened sheath and repair. Stiffness of finger joints is troublesome. The
increased resistance of the repaired tendons by presence postoperative protective finger position may cause
contracture of soft tissue structures of finger joints, par-

DEVELOPMENT OF COMPREHENSIVE,
ticularly the palmar ligaments of the PIP joints. Because
UNIVERSALLY ACCEPTABLE CRITERIA
active finger motion requires both an ample gliding
amplitude of the tendons and a normal passive range Currently, functional recovery after tendon surgery is
of motion of the joints, to improve the outcomes of assessed by recording TAM of the digits or distance from
tendon repairs, emphasis should be placed upon pre- the fingertip to the palm. Grip strength and other factors
venting stiffness of these joints. Rubber band traction to relating to tendon function have recently been inte-
the fingertip holds the PIP joint in a flexed position for grated into new criteria.39 Assessment of motion of a
long periods, which may lead to development of palmar specific joint relating closely to the repaired tendon,
ligament contracture and joint stiffness. Modifications such as assessment of only the DIP joint after zone 1
have been suggested to improve the finger motion and tendon repairs, has gained popularity.42 For both the
reduce the risk of finger stiffness. In recent years, we Strickland and the Moiemen-Elliot methods, issues
have begun to see fewer cases of finger stiffness after the remain regarding standardizing the criteria of each
use of more delicate active and passive finger motion grade in terms of joint angles. Whether to use a fixed
regimens, without rubber band traction.20,21,41 degree of finger motion or the motion range of the
contralateral hand as the baseline has not yet been
Extent of Injuries agreed. In my experience, contralateral hand motion is
Extensive destruction of the peritendinous structures, always more reliable than a fixed degree of finger motion
the presence of tendon defects, and epitendinous abra- as the baseline for grading. I record angles of the affected
sion of the tendon are frequently associated with fingers and compute a percentile recovery of TAM com-
poorer recovery of function. It is sometimes difficult to pared with the contralateral hand.
judge whether primary tendon repairs are justified for There are no universal criteria for documenting the
wounds that do not involve clean cuts but where direct outcomes of flexor tendon repairs. I suggest that the
approximation of the severed stumps is still possible. authors consider reporting the outcomes at different
These wounds, which are typified by loss of soft tissues levels (i.e., details) (Box 22-1). My preliminary sugges-
(sometimes with a short segment of flexor tendons tions about such a framework are as follows:
and a portion of pulleys) over a limited area of the
fingers or palm and defects of soft tissues, are border-  Level 1. The basic level (essential and relating to
line contraindications to primary tendon repair. Repair active hand motion only) chiefly includes TAM of
of tendon injuries in severely traumatized wounds the related joints. Ranges of motion are graded
may exacerbate adhesion formation and increases the more stringently. Requirements should be more
likelihood of requiring secondary tenolysis or tendon rigorous for grading the function as “excellent,”
reconstruction. and a separate grade for failure is necessary. Other
grades of the currently popular Strickland criteria
Surgical Skill can be unchanged.
Surgical skill affects the outcomes greatly. The flexor The criteria can be used independently as the
tendon system is composed of anatomic structures basic level criteria; grip strength and items describ-
with an intricate biomechanical relationship. Satisfac- ing the nature of motion can be integrated to con-
tory repairs of the tendons and associated structures, struct the expanded basic level criteria.
particularly those in the intrasynovial regions, remain a  Level 2. The intermediate level (more comprehen-
challenge even to an experienced surgeon. In practice, sive, but limited to hand function). Criteria incor-
these difficult injuries are frequently treated by residents porate TAM, grip strength, other components
or general orthopedic (or plastic) surgeons without suf- reflecting hand motion, sensibility, and assess-
ficient expertise of flexor tendon surgery. With currently ment of vascular circulation. Multiple aspects of
available knowledge and technical advances, favorable hand function are reflected at this level.
outcomes may be achieved by an experienced surgeon,  Level 3. The advanced, or comprehensive, level (com-
but an individual who lacks expertise may affect repairs prehensive, relating to entire body function, and
no better than those seen decades ago. It should be incorporating social environmental impacts). Cur-
emphasized that when no surgeons experienced in rently, the World Health Organization (WHO) is
tendon surgery are readily available, patients should developing universally adaptable sets of criteria to
be referred to hand centers with more experience in reflect the functional status of the hand. This set
dealing with flexor tendon injuries. Alternatively, after of criteria takes into consideration whole body
primary closure of the skin wounds, tendon injuries are function, activities, and both environmental and
repaired at a delayed primary stage by an experienced personal factors. One study has utilized this
surgeon. concept to evaluate function after flexor tendon
Box 22-1 Suggestion About Three Levels in Recording Outcomes of Tendon Repairs in the Hand
Level 1—Basic: Relating to Motion of the Finger/Hand Only

My suggested 5 grades according to the criteria:
Excellent: 90% to 100% TAM* of the contralateral side
Good: 70% to 89%
Fair: 50% to 69%
Poor: 30% to 49%
Failure: <30%
Basic expanded: Relating to hand motion and force
Add: Grip strength and quality of finger motion (detailed in Table 22-2)
Level 2—Intermediate: Relating to Hand Motion, Force, Sensation, Circulation, and Cosmetics
Add: Sensation of the hand, blood circulation, and cosmetic appearance
Level 3—Comprehensive: Relating to Hand Function and Cosmetics; Impact on Whole Body; Personal, Social,
and Environmental
Add:
 Whole body function
 Activities
 Environmental and personal factors
*Include the MCP joint when injuries are proximal to this joint (i.e., zone 3 and proximal); otherwise, exclude the MCP joint.
repairs.43 The criteria will reflect entire body func- pulleys, with the A2 pulley being especially narrow, and
tion after flexor tendon repairs. (4) have a greater gliding curvature of the tendon, which
predisposes the tendon to a greater bending force.
I expect that, in the future, surgeons and therapists will Repairs in this finger are easier to disrupt.19,44,45 Dowd
record in medical charts, report to social welfare offices, et al19 identified a much higher rupture rate and
and publish in the medical literature using criteria with re-rupture rate and poorer results in the little finger. I
different details, according to the needs of individual have found it difficult to pass the repaired FDP tendon
patients and different levels of academic rigor. Basic under the A2 pulley. Another practical difficulty is that
Level criteria may meet the essential requirement. If the it is hard to accommodate repairs of over four strands;
impact of tendon injuries (recovery) on the whole hand although I can put in a six-strand repair, it makes the
or entire human being is a matter of concern, the record- tendon gliding surface remarkable rough.
ing should move up to Levels 2 and 3. I would bring repair of the flexor tendon injuries in
the little finger to the attention of hand surgeons. I
suggest that this injury be discussed as a separate injury
CONSIDERATIONS RELATING TO OUTCOMES
and its repair outcomes be reported separately, as we do
At the closing of this section on primary flexor tendon for tendon repairs in the thumb. The anatomical fea-
repair, I bring to the attention two issues relating to tures and biomechanics of the tendon in the little finger
outcomes that are likely to receive more attention in the are very different from those of other fingers, and treat-
future. ment of injuries in the little fingers might also have to
be different from those in the index, middle, and ring
Repair of the Flexor Tendons in the fingers. Unsatisfactory return of function and repair
Little Fingers failure plausibly are more frequent in the little finger.19
It is now a well-accepted practice to analyze tendon Repair of flexor tendon injuries in the little finger
repairs in the thumb separately from other digits. In produce less satisfactory function compared with the
contrast, another issue gaining little specific attention is other fingers, which remains a concern.
repair of the flexor tendons in the little finger. The flexor
tendons in the little finger have a few special character- Report Levels of Expertise of Physicians
istics. The flexor tendons (Figure 22-2) (1) are the in Clinical Studies
smallest in diameter, (2) move along a multidirection- It is well known and has been popularly written that
ally and significantly curved path, not only flexing but outcomes of flexor tendon repairs are expertise depen-
also curving laterally during finger flexion, (3) are dent. However, currently we do not have any objective
subject to large structural variations of the sheath and method to scale the expertise of caregivers. Thus far, the
A B
Figure 22-2 A, The little finger is much smaller in size
and its flexion arc is much smaller than that of the other
finger. B and C, The pulleys are very narrow and tendons
are much smaller in the little finger, and the repaired FDP
tendon is relatively unsmooth with multi-strand core
suture. The treatment of the tendon injuries in this finger
should be separately discussed; different principles or
methods may be required.
reports, including those of flexor tendon repairs, have This concept holds particular importance in comparable
rarely contained information about the degree of profi- studies conducted in different institutions or geographi-
ciency of the caregivers. cal areas—which exhibit divergences in prevalence of,
This is a topic that does not limit to the reports of and consequently physicians’ exposure to, the study
outcomes of flexor tendon repairs. However, flexor condition.
tendon repairs are a perfect example of such needs. To To date, no report of clinical outcomes of flexor
varying extents in all medical practices, treatment out- tendon repair has documented the level of expertise of
comes are influenced—and biased—by the skill with the surgeon(s). We cannot be certain whether worse
which medical personnel perform procedures. In clini- outcomes of a specific surgical method relate to the level
cal studies, because experience with implemented tech- of mastery of the surgeon or to the techniques
niques is not paralleled by job position, simply themselves.
categorizing caregivers as residents, attending surgeons, I suggest that expertise levels of the caregivers who
or consultants, etc., provides little, if any, scientific infor- conduct the treatment be reported, perhaps, under
mation regarding their expertise in specific techniques “Methods.” An example of such criteria is detailed in
adopted. Individuals grouped into one such category Table 22-7.46 In reporting the expertise, we should note
often differ in their abilities to perform treatment that the documented expertise levels are those of the
techniques. caregivers performing the treatment, rather than the
On account of such differences, in reports of treat- expertise of the senior authors of the report. The exper-
ments that rely heavily on methodology, the use of tise levels should also relate to specific techniques (or
technique-performance evaluation criteria is critical for disorders) under investigation, not to the caregivers’
clear, objective interpretation of treatment outcomes. overall expertise in practice.
Table 22-7 Levels and Criteria Suggested to Document Expertise of the Physicians in Reporting
Clinical Outcomes
Level Category Criteria
I Nonspecialist A physician who is under training, or is a general practitioner of medicine or surgery.
II Specialist—less A physician who has completed training and is a specialist in a subspecialty of
experienced medical or surgical techniques involved, but who has not yet acquired in-depth
knowledge or high-volume experience in the use of the techniques pertinent to the
report.
His or her less degree of experience can be judged by his or her shorter duration of
practice (for example, less than five years) as a specialist, or limited exposure to the
investigated disorder.
III Specialist—experienced A physician who has obtained sufficient experience in the use of the techniques
pertinent to the report.
He or she has practiced as a specialist over a longer period (five years or beyond),
with reasonably extensive exposure to the disorder.
IV Specialist—highly A specialist who possesses in-depth knowledge/treatment experience with use of
experienced the techniques being investigated.
This experience is best indicated by having performed, or having been involved as a
leading participant in, scholastic studies relevant to the disorder or techniques being
investigated.
V Expert A highly experienced specialist who has made recognized contribution to
advancements of knowledge/treatments related to the disorder being investigated.
Or, a physician who has pioneered the technique in the report.
This category is distinct in that the physician need not first be a specialist if fulfilling
the criteria.
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CHAPTER
23
TENOLYSIS
Nada Berry, MD, and Peter C. Amadio, MD
OUTLINE insufficient active motion, a cooperative patient, and

access to postoperative therapy. Only when all these
Tenolysis is often necessary when adhesions develop conditions are met should the surgeon consider pro-
and seriously affect tendon movement. Tenolysis is ceeding with tenolysis.
indicated for a supple finger with insufficient active A supple digit is important. Releasing contractures
motion in a cooperative patient after plateau in therapy and freeing adhesions at the same time make therapy
has been reached. Ideally, tenolysis is done in an unnecessarily complex. Where possible, correcting con-
awake patient under local anesthesia, so that active tractures by serial casting or dynamic splinting should
motion can be assessed continuously. Special knives be performed. Tenolysis must be performed through
may help free the tendons from beneath intact pulleys. supple skin. Skin grafts may be replaced with flaps
Any patient being consented for tenolysis should also beforehand. It is of course logical to require a plateau
be consented for tendon grafting, since it is impossible in therapy prior to tenolysis; if the patient is still making
to be sure preoperatively that adequate tendon integ- progress nonoperatively, an intervention might reverse
rity will be present postoperatively. Most commonly, rather than accelerate progress. A cooperative patient is
two-stage grafting is appropriate to salvage a failed also essential. A patient who, for example, is not willing
attempt at tenolysis. Early active motion is critical to to manage their own therapy every day for 6 weeks or
the success of tenolysis. Special protocols may be nec- longer, defer vacations and other personal gratification,
essary if the tendons are noted to be frayed at the and otherwise demonstrate a strong desire to assume
completion of the tenolysis. responsibility for their own recovery is unlikely to
benefit from tenolysis. Finally, patients need to have
Tendon adhesions form frequently after tendon repairs access to therapy supervision postoperatively. A patient
and reconstructions, phalangeal fractures, and deep who lives at a long distance from the surgeon and thera-
tissue (e.g., flexor sheath) infections.1 Multiple postop- pist, or who is prevented from access due to financial or
erative modalities including early active range of motion insurance constraints, will similarly fail to achieve the
protocols have been developed to optimize tendon maximum benefit from tenolysis surgery.
gliding. Aggressive therapy may be sufficient to restore
TIMING OF SURGERY
full range of motion for mild adhesions.2 Alternatively,
tenolysis can be a beneficial procedure for patients who Tenolysis should be carried out after therapy has been
have provided sufficient effort during vigorous therapy exhausted and the patient does not show improvement
and have plateaued in their range of motion progress.3-8 despite conscientious effort. All scars and affected sur-
One must approach these surgeries with caution, as rounding tissues should be supple, without evidence of
additional surgery on a less than supremely compliant inflammation. Scar erythema and firmness indicate cor-
patient can lead to further edema, scaring, and worsen- ollary deep tissue reaction and should advise the surgeon
ing stiffness. Patient and physician expectations should against additional surgery.
be thoroughly discussed as it may be difficult to gain All fractures and wounds should be healed, and
back the hand function, even if the adhesion is not chronic infections cleared. Joint contractures must be
extensive. Patients with severe trauma requiring multiple mobilized. Patient-dependent passive joint motion
secondary procedures, including nerve repair, tendon should be near normal prior to tenolysis.9 Occasionally,
grafting, capsulotomies and osteotomies, those older serial casting or a dynamic external fixator may be useful
than 40 years, tenolysis delayed by a year, and diffuse prior to the procedure to correct stubborn joint contrac-
adhesions have worse prognosis than those with isolated tures, especially of the proximal interphalangeal joint.10
tendon injuries and short segments of adhesions.9 Some authors have previously recommended waiting
6 months prior to secondary tendon surgery, as strip-
INDICATIONS
ping of the tissues surrounding the tendon may devas-
The indications for tenolysis are a supple digit, a plateau cularize the healing tendon scar and can lead to late
in motion following a well-supervised therapy program, tendon rupture.5 Other studies show that delayed
261
262 Section 3: Secondary Flexor Tendon Surgery
tenolysis after a year results in a decreased postoperative especially in longer standing cases. Only “wide awake”
improvement, possibly due to a developing joint con- surgery can detect such adhesions.
tracture.11 It has been our practice to perform tenolysis The incision for tenolysis is usually placed over the
when all of the following conditions have been met: the previous scar and extended proximally and distally so
digit and soft tissues are supple and well perfused; active that the tendon and other vital structures can be
motion is unacceptable to the patient; a plateau in approached from virgin tissue. If there is a choice, a
therapy progress has been reached, with no improve- mid-lateral incision may have an advantage of providing
ment in motion over at least 4 weeks, and the patient easy access to both flexors and extensors, such as in cases
has been cooperative with the therapy regimen. It is rare of fractures or known extensor tendon injury (Figure
for these conditions to be met in less than 3 or even 4 23-2). This approach is also useful when resistant joint
months from the time of initial tendon injury or repair, contractures need to be released.17
but it is our opinion that tenolysis can be safely per- In addition to the preservation of the crucial A2 and
formed as soon as 3 months after the injury, providing A4 pulleys, the flexor tendon sheath should be mini-
that previously mentioned criteria have been met. mally traumatized. Releasing any of the pulleys exposes
the tendon to the surrounding tissues and predisposes
SURGICAL TECHNIQUE
it to further scarring. In addition, active grip applies
Patient involvement during the tenolysis procedure is additional force to the remaining pulleys, leading to
considered important by many surgeons and is advis- potential pulley rupture and bow stringing of the tendon.
able whenever possible. Use of local anesthesia, with or A transverse opening is made into the tendon sheath.
without limited sedation, allows the patient to aid in Tenotomes (Figure 23-3) or Freer elevator can be passed
confirmation of release of all the motion-limiting adhe-
sions.7,12-14 Intraoperative active range of motion is the
best predictor of adequate release. In addition, visual-
izing the expected outcome may motivate the patient to
work through the tenderness of the fresh incision and
new edema. While a sterile forearm tourniquet may be
better tolerated than an upper arm tourniquet during
the procedure, it is our preference to eschew all tourni-
quet use, in favor of the “wide-awake” technique advo-
cated by Lalonde and others.13,15
If “wide-awake” surgery is not feasible, a traction test
can be used.16 The involved tendon is exposed proximal
to the area of injury and retracted until digit flexion is
visualized (Figure 23-1). Restrictions in movement
indicate incomplete adhesion release. However, this test
is not infallible; adhesions between muscle bellies may
be well proximal to the zone of initial injury and surgery, Figure 23-2 Extensor tenolysis is performed through an
additional incision in this patient with a healed proximal
phalanx fracture and limited active range of digital motion.
Figure 23-1 Traction test is performed on a patient after Figure 23-3 Tenolysis knives are very useful in releasing
tenolysis. Complete finger flexion is noted in this patient dense adhesions between the tendon and the flexor sheath.
under general anesthesia, indicating adequate tenolysis. She Meals tenolysis knives shown are available from George
had previously undergone flexor tendon repair in zone 2. Tiemann & Co, Hauppauge, NY.
Chapter 23: Tenolysis 263
A3
A B
Figure 23-4 A, MR image shows normal relationship between the flexor tendon (T), overlying bone, and the A3 pulley. B,
MR image shows increased distance between the tendon and the bone, as well as the attenuated pulley.
under the pulley system to separate the tendon from the immediately, than to have this happen in the postopera-
sheath. Active finger flexion can aid in lysis of distal tive period.
adhesions. If the critical A2 pulley is not intact, it can In some cases the profundus is intact but the
be reconstructed, but this is likely to compromise the superficialis is not. In such cases, the superficialis can
result of the tenolysis, since vigorous active postopera- be resected, always with care not to compromise the
tive motion will be contraindicated in the face of a blood supply or integrity of the profundus tendon
pulley reconstruction.18 In such cases, a staged recon- or the pulley status. A similar approach can be taken
struction may be an alternative consideration.19,20 Pre- if the superficialis tendon is intact and the profundus
operative magnetic resonance imaging (MRI) (Figure is not.
23-4) or ultrasound may aid in determining pulley We prefer early active range of motion and aggressive
status.21 In contrast, the A4 pulley may not be so critical; postoperative therapy to prevent further adhesion for-
if it is not intact and the profundus is also compromised mation. New studies involving absorbable mechanical
but the superficialis is intact, then the distal interpha- barriers and lubricants to prevent adhesion formation
langeal joint can be stabilized and the profundus and substances to improve tendon gliding show pro
excised. A superficialis finger can be superior to both a mising results both experimentally22-24 and clinically.25
staged reconstruction and even a heroic attempt at Antimetabolites such as 5-fluorouracil may also be of
tenolysis of the profundus and A4 reconstruction. benefit.26 We tend to use these adjunctive agents on a
The tendon quality should be examined. Pseudo- second tenolysis but not usually with initial procedures,
tendon formation in the gap between the tendon because usually the result of a first tenolysis is satisfac-
ends can mislead the surgeon into thinking that the tory without these agents, which may compromise
tendon healing is complete and result in surgical failure. wound healing.
Hunter has advised that a tendon defect involving
REHABILITATION
more than 30% of the tendon is grounds to consider a
staged tendon reconstruction,20 and we agree with this Early active motion is a key factor in the success of any
approach. Such a defect may be obvious initially or at tenolysis procedure and should be instituted as soon as
the completion of tenolysis. An additional advantage of possible.27-32 If hemostasis is not a concern and the pain
the “wide-awake” approach is that the patient can be is tolerable, we prefer to begin rehabilitation in the
asked to make a strong fist at the end of the procedure. operating room, taking advantage of the “wide-awake”
It is far better that a compromised tendon rupture intra- method, and continue in the recovery room. In general,
operatively, where a staged procedure can then be done we prefer light dressings and regular active motions—if
possible, 10 repetitions every hour while awake or at of dehiscence, it is important to use a very careful tech-
least two sessions per day. Splinting is usually not neces- nique when elevating skin flaps, in ensuring hemostasis
sary unless the tendon is frayed, in which case the wrist at the time of closure, and in establishing a secure skin
and metacarpophalangeal joints can be splinted in closure.
flexion, especially while the patient sleeps. Formal
RESULTS
therapy continues until the patient has reached a plateau
in recovery, with no improvement in active range of Overall, larger reviews in the literature suggest that 80%
motion over 3 weeks. In general, patients will maintain of patients show improvement with tenolysis proce-
their gains in the long term if they improve during the dures, 10% remain mostly unchanged, and 10% worsen
first postoperative week and maintain the gains for the their range of motion or sustain a rupture of the tenoly-
following 2 to 3 weeks.5 sis.4,5,14,25 It is unusual for a patient to regain active
Indwelling catheters for administration of local anes- control of the full passive range that is present preopera-
thetic can be useful postoperatively.33-37 Painful, rigor- tively, however. These statistics and expectations should
ous activity may lead to additional swelling and an be discussed with the patient preoperatively. Tenolysis
overall setback. requires a combination of patient cooperation, skillful
Wound dehiscence may require a halt in therapy, therapy, and careful surgery to achieve a satisfactory
especially if the tendon is exposed. To minimize the risk outcome.
References
1. Matthews P, Richards H: Factors in the adherence of flexor 18. Foucher G, Lenoble E, Ben Youssef K, et al: A post-operative
tendon after repair: An experimental study in the rabbit, regime after digital flexor tenolysis. A series of 72 patients,
J Bone Joint Surg (Br) 58:230–236, 1976. J Hand Surg (Br) 18:35–40, 1993.
2. Ipsen T, Barfred T: Early mobilization after flexor tendon 19. Amadio PC, Wood MB, Cooney WP 3rd, et al: Staged flexor
grafting for isolated profundus tendon lesions, Scand J Plast tendon reconstruction in the fingers and hand, J Hand Surg
Reconstr Hand Surg 22:163–167, 1988. (Am) 13:559–562, 1988.
3. Azari KK, Meals RA: Flexor tenolysis, Hand Clin 21:211–217, 20. Hunter JM: Staged flexor tendon reconstruction, J Hand Surg
2005. (Am) 8:789–793, 1983.
4. Eggli S, Dietsche A, Egglis S, et al: Tenolysis after combined 21. Drape JL, Silbermann-Hoffman O, Houvet P, et al: Complica-
digital injuries in zone II, Ann Plast Surg 55:266–271, 2005. tions of flexor tendon repair in the hand: MR imaging assess-
5. Fetrow KO: Tenolysis in the hand and wrist. A clinical evalu- ment, Radiology 198:219–224, 1996.
ation of two hundred and twenty flexor and extensor tenoly- 22. Zhao C, Sun YL, Amadio PC, et al: Surface treatment of flexor
ses, J Bone Joint Surg (Am) 49:667–685, 1967. tendon autografts with carbodiimide-derivatized hyaluronic
6. Schneider LH: Tenolysis and capsulectomy after hand frac- acid. An in vivo canine model, J Bone Joint Surg (Am) 88:2181–
tures, Clin Orthop Relat Res 327:72–78, 1996. 2191, 2006.
7. Strickland JW: Flexor tenolysis, Hand Clin 1:121–132, 1985. 23. Zhao C, Sun YL, Kirk RL, et al: Effects of a lubricin-containing
8. Yamazaki H, Kato H, Uchiyama S, et al: Results of tenolysis compound on the results of flexor tendon repair in a canine
for flexor tendon adhesion after phalangeal fracture, J Hand model in vivo, J Bone Joint Surg (Am) 92:1453–1461, 2010.
Surg (Eur) 33:557–560, 2008. 24. Karakurum G, Buyukbebeci O, Kalender M, et al: Seprafilm
9. Strickland JW: Flexor tendon surgery. Part 2: Free tendon interposition for preventing adhesion formation after tenoly-
grafts and tenolysis, J Hand Surg (Br) 14:368–382, 1989. sis. An experimental study on the chicken flexor tendons,
10. Kawakatsu M, Ishikawa K, Terai T, et al: Distraction arthrolysis J Surg Res 113:195–200, 2003.
using an external fixator and flexor tenolysis for proximal 25. Riccio M, Battiston B, Pajardi G, et al: Efficiency of Hyaloglide
interphalangeal joint extension contracture after severe crush in the prevention of the recurrence of adhesions after tenoly-
injury, J Hand Surg (Am) 35:1457–1462, 2010. sis of flexor tendons in zone II: A randomized, controlled,
11. Verdan C: Tenolysis. In Verdan C, editor: Tendon Surgery of the multicentre clinical trial, J Hand Surg (Eur) 35:130–138,
Hand, Edinburgh, 1979, Churchill Livingstone, pp 137–142. 2010.
12. Hunter JM, Schneider LH, Dumont J, et al: A dynamic 26. Zhao C, Zobitz ME, Sun YL, et al: Surface treatment with
approach to problems of hand function using local anesthe- 5-fluorouracil after flexor tendon repair in a canine in vivo
sia supplemented by intravenous fentanyl-droperidol, Clin model, J Bone Joint Surg (Am) 91:2673–2682, 2009.
Orthop Relat Res 104:112–115, 1974. 27. Alba CD, LaStayo P: Postoperative management of function-
13. Lalonde DH: Wide-awake flexor tendon repair, Plast Reconstr ally restrictive muscular adherence, A corollary to surgical
Surg 123:623–625, 2009. tenolysis: A case report, J Hand Ther 14:43–50, 2001.
14. Whitaker JH, Strickland JW, Ellis RK: The role of flexor teno 28. de Soras X, Thomas D, Guinard D, et al: Use of an implanted
lysis in the palm and digits, J Hand Surg (Am) 2:462–470, electrode for rehabilitation after tenolysis of the flexor
1977. tendons, Ann Chir Main Memb Super 13:317–327, 1994.
15. Higgins A, Lalonde DH, Bell M, et al: Avoiding flexor tendon 29. Feldscher SB, Schneider LH: Flexor tenolysis, Hand Surg 7:61–
repair rupture with intraoperative total active movement 74, 2002.
examination, Plast Reconstr Surg 126:941–945, 2010. 30. Foucher G, Marin Braun FM: An original mobilization technic
16. Strickland JW: Flexor tendon injuries. Part 5. Flexor tenolysis, after tenolysis of zone II flexor tendons, Ann Chir Main 8:
rehabilitation and results, Orthop Rev 16:137–153, 1987. 252–253, 1989.
17. Saffar P: Total anterior teno-arthrolysis. Report of 72 cases, 31. Goloborod’ko SA: Postoperative management of flexor tenol-
Ann Chir Main 2:345–350, 1983. ysis, J Hand Ther 12:330–332, 1999.
Chapter 23: Tenolysis 265
32. McCarthy JA, Lesker PA, Peterson WW, et al: Continuous 35. Kirchhoff R, Jensen PB, Nielsen NS, et al: Repeated digital
passive motion as an adjunct therapy for tenolysis, J Hand nerve block for pain control after tenolysis, Scand J Plast
Surg (Br) 11:88–90, 1986. Reconstr Hand Surg 34:257–258, 2000.
33. Braun C, Bauer M, Bühren V: Experiences with continuous 36. Kulkarni M, Elliot D: Local anaesthetic infusion for postop-
nerve block of the wrist, Handchir Mikrochir Plast Chir 23: erative pain, J Hand Surg (Br) 28:300–306, 2003.
207–209, 1991. 37. Lurf M, Leixnering M: Ultrasound-guided ulnar nerve
34. Jablecki J, Syrko M: The application of nerve block in early catheter placement in the forearm for postoperative pain
post-operative rehabilitation after tenolysis of the flexor relief and physiotherapy, Acta Anaesthesiol Scand 53:261–263,
tendon, Orthop Traumatol Rehabil 7:646–650, 2005. 2009.
CHAPTER
24
SINGLE-STAGE FREE TENDON
GRAFTING FOR FLEXOR
TENDON INJURY IN FINGERS
Pierre-Yves Barthel, MD, and Pierre Mansat, MD, PhD
 Delayed presentation of closed FDP avulsion inju-

OUTLINE
ries from the insertion associated with significant
tendon retraction.
Successful primary flexor tendon repair has limited the
 Closed rupture of the flexor tendons at any level
indications for flexor tendon grafting. Tendon grafting
from zone 1 to zone 3, with retraction of the
is an alternative treatment for patients with neglected
proximal tendon that does not permit a direct
digital flexor tendon lacerations and after failure of
end-to-end repair.
primary flexor tendon repair. Tendon grafting can be
considered if the local conditions of the hand are Preoperative prerequisites include the following:
favorable. However, the outcomes after flexor tendon
 The wound should be healed, the joints should be
grafting are inferior to those of primary flexor tendon
free of contracture, and maximum passive motion
repair. A decision must be made after careful discus-
should have been obtained.
sion with the patient of the risks and benefits of this
 There is no extensive scarring.
procedure and specific needs of the patient.
 Passive movements are full, or nearly full.
 The circulation is satisfactory.
Single-stage free tendon grafting is a common secondary  At least one digital nerve in the affected digit is
procedure for tendons not suitable for or not treated by
intact.
primary repair. The surgery must be carefully discussed
between the surgeon and the patient to evaluate the risk Contraindications to single-stage free tendon grafting
and benefits of the procedure. This operation is usually are:
indicated for injury of both flexor digitorum profundus  Extensive scarring, pulley incompetence, or joint
(FDP) and flexor digitorum superficialis (FDS) tendons
contracture.
in zone 2 in the presence of a good pulley system and
 Insensate or poorly vascularized digits.
without serious scarring. The decision as to the need for
staged reconstruction is often made during surgery The best indication for single-stage free tendon graft for
depending on the state of the pulleys and the extent of flexor tendon injury is the grade 1 hand according to
adhesions. The injured tendons are excised and replaced Boyes’ classification (Table 24-1)1 or according to Merle
by a harvested tendon graft sutured to the base of the and Dautel’s classification (Table 24-2).2 For grade 2 or
distal phalanx at the FDP insertion and to a proximal 3 hands, staged tendon grafting is preferred.
motor in the palm or distal forearm. In cases of disruption of both the FDP and FDS
tendons, general surgical principles for this procedure
include:
INDICATIONS
 Place only one graft in each finger.
Single-stage free tendon graft is carried out as an initial
 Use a graft of a suitable caliber to fit into the finger.
procedure in selective cases including:
 Place the proximal junction outside the tendon

sheath.
Flexor tendon injuries with segmental tendon loss.
 Avoid damage to the fingernail or fingertip, in
 Severe damage to peritendinous tissues, or obvious
making the distal junction.
risk of wound infection that prevented primary
 Ensure adequate graft tension.
repair.
 Delay in repair of more than 3 weeks that com- In cases with an intact or functioning FDS tendon, the
promises primary repair. following additional principles apply:
266
Chapter 24: Single-Stage Free Tendon Grafting for Flexor Tendon Injury in Fingers 267
Table 24-1 Boyes’ Preoperative Classification1 distal FDP tendon is preserved. The remainder of the
Grade Preoperative Condition
damaged FDP tendon is excised distal to the lumbrical
origin in the palm. The FDS tendon is resected, leaving
1 Good: Minimal scar with mobile joints and no 1 or 2 cm of the insertion of the FDS tendon to provide
trophic changes
stability and avoid hyperextension deformity of the
2 Cicatrix: Heavy skin scarring because of injury interphalangeal joint (Figure 24-1).
or prior surgery; deep scarring because of failed
primary repair or infection Graft
3 Joint damage: Injury to joint with restricted The most frequent donors are the palmaris longus and
range of motion the plantaris tendons. The palmaris longus tendon is
preferred for palm-to-fingertip reconstruction, and the
4 Nerve damage: Injury to digital nerves resulting
plantaris for forearm-to-fingertip reconstruction. Other
in trophic changes in finger
possibilities include the long extensors of the three
5 Multiple damages: Involvement of multiple middle toes, the toe flexors, the extensor indicis pro-
fingers with combination of above problems prius, and the extensor digiti minimi (Figure 24-2).
Placement of the Graft

Table 24-2 Preoperative Classification Based on
A suture is placed at the end of the graft, and the graft
Modified Grading of Merle and Dautel2
is passed atraumatically under the pulleys using a flex-
Grade Preoperative Condition ible catheter or a Silastic Hunter rod in a distal-to-prox-
1 Minimal or mild scar without major damages to imal direction. Care must be taken to minimize trauma
digital vascular bundles and nerves to the intact sheath to limit the risk of adhesion and
secondary stiffness (see Figure 24-1).
2 Extensive scar in the digit causing or together
with:
 Destruction to multiple annular pulleys Sequence of Attachment of the Graft Ends
 Joint stiffness Creating the distal juncture first may allow easy judg-
 Damage of one digital neurovascular ment of tension and determination of the graft length
bundle in the palm. The proximal suture is accomplished after
the distal juncture has been completed.3 The alternative
3 Serious scar in the digit with:
 Injury of bilateral digital neurovascular is to create the proximal juncture first, with adjustment
bundles of the graft length at the fingertip. In our opinion, the
 Injury of main vascular supplies to the hand latter is more difficult and less reliable for restoring
proper tension to the graft.
 Carefully explain the risk of no or limited recovery Distal End Attachment

of digital function before surgery. Several techniques are available to anchor the tendon
 FDS-only fingers may have sufficient function graft to the distal phalanx, depending primarily on the
without using free tendon grafting to reconstruct length and condition of the distal FDP tendon. (1) If
the FDP tendon. enough FDP tendon is available, the graft can be sutured
 Never sacrifice an intact FDS or damage the surface to this tendon or through it. (2) When the length of
of the FDS tendon during surgery. distal FDP tendon is not sufficient, the tendon is attached
to the distal phalanx using a tendon-to-bone pull-out
OPERATIVE METHODS technique. A drill hole is made in the palmar cortex
of the distal phalanx into which straight needles are
Injuries to Both FDP and FDS Tendons passed through the nail plate. A sterile button is usually
Incision used to tie over the surface on top of the nail plate. This
Surgery is usually performed under local or regional conventional method has been criticized for damaging
anesthesia with tourniquet control. A Bruner-type or the fingernail and risking infection.4 Although surgeons
mid-lateral incision is used to expose the tendon system. still use this method, many have started using other
The lower limb must be prepared if the surgeon intends methods for distal juncture that have no interference
to harvest a graft from there. with the nail complex (see Figure 24-1).
More recent alternatives to the conventional method
Dissection of the Flexor Tendons include (1) drilling a transverse drill hole across the
The neurovascular bundles are preserved throughout base of the distal phalanx with the graft passed through
the dissection. The tendon sheath is explored and pro- and sutured to itself. This technique allows for easy
tected as much as possible. Approximately 1 cm of the judgment of graft tension, but the graft must be thin
B Two methods of distal tendon junction
A Preservation of pulleys and passing the graft within the sheath C Pulvertaft repair for proximal junction
Figure 24-1 A, Incision and methods of insertion of a grafted tendon into preserved tendon sheath. B, Two methods of
distal tendon juncture. C, Pulvertaft method of proximal tendon juncture.
to pass through the bony tunnel. Risk of fracture must complications of pull-out techniques.5-8 Metallic anchors
be known (Figure 24-3). (2) For patients with good are preferred to avoid possible complications of auto
bone quality, some authors have proposed distal fixation lysis associated with bioabsorbable anchors.9 Surgeons
with metallic suture anchors (Figure 24-4) and non in some units have virtually abandoned the conven-
absorbable sutures. Biomechanical studies have shown tional pull-out suture, replacing it with these metallic
that metallic anchors are sufficient to provide stable anchors for distal juncture. For patients with poor bone
fixation of the graft to the distal phalanx, avoiding the quality, a pull-out suture method is preferred to avoid
Palmaris longus
Extensor
digitorum
longus
Plantaris tendon Tendon stripper
C Achilles tendon B
Figure 24-2 Methods of harvesting tendons from donor sites in forearm or lower extremity.
After using the pull-out suture technique for many

years, we now use metallic anchor sutures to gain imme-
diate strength of the junction and also to avoid the
complications of a pull-out suture, such as nail dys
trophy, pulp ulceration, and infection. Furthermore,
Gauze
because of the strong tendon anchor, immediate mobi-
lization of the finger can be allowed with fewer risks of
anchor site rupture. After preparation of the distal
phalanx by removing the remnant of the distal FDP
tendon, one or two mini-anchors are placed into the
distal phalanx. The tendon graft is guided into position
Profundus and secured to the distal phalanx with the sutures
stump carried by the anchor. Additional sutures of 3-0 PDS
Figure 24-3 Distal tendon juncture method: passing the ensure the graft stays well coapted to the distal phalanx
tendon through a drill hole in the distal phalanx. and to the surrounding tissues, including the palmar
plate of the DIP joint. Strength of the distal fixation are
assessed by adding a traction force on the graft. A radio-
migration of the anchor.10,11 (3) Taras and Kaufmann graphic examination is always performed to verify that
describe their method of passing the suture around the the metallic anchors are well seated in the distal phalanx.
distal phalanx and tying it over the nail.3 The sutures are
threaded onto the end of the grafted tendon with straight Proximal Juncture Suture
needles. The tendon graft is woven through distal stump In the palm, the proximal end of the graft is attached to
of the FDP tendon. The needles are then passed around the FDP tendon just distal to the lumbrical origin. The
both sides of the distal phalanx and through the middle end of the motor (proximal) tendon is opened with a
third of the nail plate, avoiding the germinal nail matrix; blade, and the graft is then passed into the split. The
the ideal point to exit through the nail plate should be graft is passed transversely in different planes according
3 to 4 mm distal to the lunula and approximately 2 mm to the Pulvertaft technique. Then 3-0 PDS sutures are
from the midline. The ends of the suture are tied directly used to suture the tendons at the interconnection points,
over the nail plate. At least two reinforcing sutures on and the distal split is closed over the graft to obtain a
each side are used to reinforce the FDP–graft juncture perfect continuity between the motor tendon and the
(Figure 24-5). graft (see Figure 24-1).
A Figure 24-5 Method of distal tendon attachment to the

distal phalanx. The suture is anchored over the nail surface.
Graft Tensioning
Graft tensioning is estimated by the relaxed position of
the fingers with the wrist in the neutral position. Each
finger should fall into semiflexion, slightly less flexed
than its ulnar neighbor and more flexed than its radial
neighbor. The Pulvertaft technique is especially amen
able to adjusting tension; if the posture of the hand is
satisfactory with one suture in place, the juncture is
completed by adding additional sutures (Figure 24-6).
B
Postoperative Care
Postoperatively, the hand is immobilized with a static
dorsal blocking splint with the wrist positioned in
neutral to mild flexion, the metacarpophalangeal (MCP)
joints in 45° of flexion, and the splint distal to the MCP
joint in 0° of extension to allow the finger proximal
and distal interphalangeal (PIP and DIP) joints to rest
in the neutral position. The position of splinting is
changed after 3 to 4 weeks to place the wrist and hand
in the functional position. This splint is retained until
6 weeks after surgery. Passive range of motion exercise
can be instituted 2 or 3 days after surgery, but avoid
C extension of the MCP joint and the wrist. At 2 weeks,
slight active short-arc digital flexion and extension exer-
Figure 24-4 A, The tools for inserting a mini-anchor into cises can be added, with the MCP joint in flexion if
the distal phalanx. The upper, a drill, is used to drill a hole
strong distal suturing is obtained. However, if the distal
on the proximal palmar surface of the bone if necessary, and
sutures are less robust because of poor bone quality or
the lower, the anchor will be inserted into the bone by the
inserter. The mini-anchor, carrying two sets of suture lines, loss of the distal flexor tendon stump, active mobiliza-
is attached to the tip of the inserter. B, Drilling a hole on the tion is delayed until 4 weeks. At 4 weeks, blocked flexion
palmar surface of the distal phalanx. C, The mini-anchor is exercises of the MCP or PIP joint are started. Usually the
securely placed into the bone. After that, the tendon is splint is discarded at 6 weeks and resistance exercises
sutured with the suture lines carried by the anchor. can be started. Passive stretching splint can then be used
(Courtesy of Jun Tan, MD, and Jin Bo Tang, MD.) if flexion contracture remains.
FDP Tendon Disruption with

FDS Tendon Intact
Surgeons have mixed recommendations regarding
surgery for the patient with complete disruption of the
FDP tendon but an intact FDS tendon. FDS-tendon
A
B
Figure 24-6 The fingers’ cascade for deciding tension placed on the graft in different fingers.
fingers may function very well without surgical recon- FDS tendon if the tendon decussation is tight for the
struction of the FDP tendon. There is also a risk to grafted tendon, but we found this rarely necessary, as the
damage to the FDS function during surgery. The sur- grafted tendon is usually thinner than the FDP tendon,
geons should carefully evaluate the patient and explain though the collapse of the pulleys and sheath occurs
to the patient about the degree of improvement of func- after delay of the surgery. Fitting the grafted tendon and
tion and possible risk of reconstructing the FDP tendon intact FDS into the sheath or pulley may be difficult. In
with a tendon graft in the presence of an intact FDS such cases, surgeons may consider partial removal of
tendon. narrow parts of the sheath or pulley, but obviously the
First, function of the FDS tendon must be examined sheath and pulley should be preserved segmentally to
thoroughly. When the FDS tendon is fully functional, maintain function of the tendons. Avoiding damage to
caution must be observed before proposing a free tendon an intact, fully functioning FDS tendon is an important
graft to restore distal joint function. Because most useful principle. Incision or removal of the FDS tendon is pro-
motion is maintained when the FDS tendon is fully hibited under any conditions. In some cases, one slip of
functional, patients may have adapted perfectly, even the FDS tendon can be removed for graft passage and to
with an injured or retracted FDP tendon. The problem allow gliding of the grafted tendon. However, removal
for the patient is mostly about the DIP joint position. of a slip of FDS tendon can be risky, which the authors
If there is no hyperextension of the joint, functional do not recommend. If extensive scarring in the FDS, or
adaptation is usual. However, if there is hyperextension the flexor tendon bed, or pulleys, is found during surgery,
of the joint with instability, procedures for stabilization staged tendon grafting is preferable.
can be discussed with the patient. Simple yet effective
procedures, like distal tenodesis or arthrodesis of the OUTCOMES AND COMPLICATIONS—
DIP joint, can be proposed. Indications for tendon graft- PROGNOSIS FACTORS
ing are discussed in selected cases, especially young
patients with mobile joints and a reasonable need for Outcomes
active DIP joint function. A graft is probably more fre- In general, the outcomes after flexor tendon grafting
quently justified on the ulnar side of the hand than on are inferior to those of primary flexor tendon repair. In
the radial side because of the need to obtain a total arc Boyes and Stark’s study,12 reviewing 1000 flexor-tendon
of flexion to be able to perform power gripping. grafting, 607 at the fingers, the preoperative condition
The method of tendon grafting is the same as the of the digit was found to be the most important factor
technique described earlier for patients with injuries to affecting the result of flexor-tendon grafting. In good
both. In performing grafting for such patients, we take cases (grade 1), regardless of age, time since surgery,
great care in passing the graft through the intact FDS specific digit, or tendon used as a graft, 23% of the
tendon decussation. The graft can be laid anterior to the fingers flexed the pulp to the palmar crease; only 9%
Table 24-3 Results of Single-Stage Free Tendon Grafting for Flexor Tendon Reconstruction in the Hand
Authors Digits Type of Graft Results Complications
Boyes and 607 PL 413 Full flexion obtained in: Secondary rupture:
Starks12 PL+ paratenon 11 23% in grade 1 fingers 15 in the palm, 7
FDS 128 12% in grade 2 fingers at distal insertions
Plantaris 21 10% failures (ppd = 5 cm) PIP recurvatum 13
Toe extensor 29 Failure (i.e., ppd > 5 cm): Hematoma 6
Others 5 32 fingers Ulcer of the pulp 2
McClinton 100 PL 80 ppd: Not stated
et al13 Isolated FDP injury EDC 10 0 cm: 55
EIP 4 0-1.3 cm: 24
Toe extensor 4 1.4-2.5 cm: 15
Plantaris 1 2.6-5 cm: 6
FDS 1 AROM DIP joint: 48° on average
Failure:* 13
Leversedge 4 FDL 2nd toe Excellent 1, good 1, fair 1, poor 1 Rupture 1
et al14 64% TAM recovery Tenolysis 1
Kotwal and 264 PL Excellent 18.5% Infection 7
Gupta15 Plantaris Good: 70.5% Secondary rupture 3
Poor: 11%
EDC, Extensor digitorum communis; EIP, extensor index proprius; FDL, flexor digitorum longus; PIP, proximal interphalangeal joint;
DIP, distal interphalangeal joint; AROM, active range of motion; TAM, total active motion; PL, palmaris longus; ppd, pulp–palm distance.
*Failure was defined in this study as loss >20° from preoperative PIP joint flexion or DIP joint flexion less than 20°.
achieved this in the scar (grade 2) and nerve injury Prognosis Factors
groups (grade 4), while in the joint and salvage groups In their series, Boyes and Stark12 outlined different prog-
(grades 3 and 5), none could flex to make the finger nostic factors—scarring from injury, additional scarring
tip touch the distal palmar crease. McClinton et al13 from inept previous surgery, or failed primary reparative
reviewed 100 tendon grafts for isolated FDP injuries procedures compromised the results of secondary
and reported that 55 digits could be flexed to touch tendon grafting; fingers in which joints had been
the distal palmar crease postoperatively. Twenty-four damaged or in which the IP joints had become stiffened
digits were flexed to bring the fingertip within 1.3 cm, from neglect did not respond well to tendon grafting,
15 between 1.3 and 2.5 cm, and 6 between 2.5 and even though the joints were mobilized well before
5 cm of the distal palmar crease. Using intrasynovial surgery. In fingers with minimum scarring and only
tendon grafts and early mobilization, Leversedge et al14 one nerve injured, the results were not impaired, but
reported that recovery of active motion was 64% for fingers with both nerves damaged had much less motion.
single-stage reconstruction and 55% for multiple-stage The level of tendon injury, whether in the proximal,
reconstruction. Single digit reconstruction had the best middle, or distal part of no-man’s land, was not a deter-
outcome, with recovery of total active motion of 73%. mining factor on the result, nor was the time from
Kotwal and Gupta15 reviewed the results of one-stage injury to operation. Injury of the tendon of more than
free tendon grafting in 240 patients (264 digits) and one digit in itself was not important. They found that
found excellent results in 18.5% of the cases, good the condition of the individual digit determined the
results in 70.5%, and poor results in 11% (Table 24-3). outcome for that finger. Patients over 40 years of age
did not regain as much motion from tendon grafting
Complications as did the patients in younger age groups. The palmaris
The major complications seen after flexor-tendon graft- longus tendon was the best donor tendon, but there was
ing are hyperextension at the PIP joint, rupture of the little difference noted when a good superficialis tendon
graft in the palm, rupture at the distal juncture, and was used.
trophic ulcers of the finger pulp. A tendon graft may also
SUMMARY
become adherent and fail to move the finger through a
functional range of motion. The digit itself may become Single-stage free tendon grafting is a valuable secondary
so scarred in a flexed position that extension is limited reconstructive procedure of the injured deep flexor
and total range of the motion is very small, which requires tendons of the fingers. It is mainly used after injury to
tenolysis.12-15 both flexor tendons in zone 2. The preoperative status
of the digit is of paramount importance. Secondary after flexor tendon grafting are generally inferior to the
single-stage flexor tendon grafting is only considered results of primary flexor tendon repair. When only the
when the wound is healed, the joints are free of con- FDP tendon has been injured with an intact FDS
tracture with maximum passive motion, there is not tendon, caution must be observed before carrying out a
extensive scarring, and the patient has good circulation free tendon graft reconstruction of the FDP tendon,
and soft tissue coverage of the hand. With rigorous because the patient may have adapted his/her hand
surgical technique, appropriate tensioning of the graft, function. Alternative options, such as distal tenodesis
and postoperative therapy, patients can recover their or arthrodesis of the DIP joint, must be discussed with
hand function quite remarkably. However, the results the patient.
References
1. Boyes JH: Flexor-tendon grafts in the fingers and thumb: An digitorum profundus tendon distal fixation, J Hand Surg (Am)
evaluation of end results, J Bone Joint Surg (Am) 32:489–499, 30:471–478, 2005.
1950. 9. Galano GJ, Jiang KN, Strauch RJ, et al: Inflammatory response
2. Merle M, Dautel G: Chirurgie secondaires des tendons fléchis- with osteolysis related to a bioabsorbable anchor in the
seurs. In Michel M, Gilles D, editors: La Main Traumatique– finger: A case report, Hand (NY) 5:307–312, 2010.
Tome 2–Chirurgie Secondaire/Le Poignet Traumatique, Paris, 10. Matsuzaki H, Zaegel MA, Gelberman RH, et al: Effect of
1995, Masson, pp 55–92. suture material and bone quality on the mechanical proper-
3. Taras JS, Kaufmann RA: Flexor tendon reconstruction. In ties of zone I flexor tendon-bone reattachment with bone
Wolfe SW, Hotchkiss RN, Pederson WC, et al, editors: Green’s anchors, J Hand Surg (Am) 33:709–717, 2008.
Operative Hand Surgery, ed 6, Philadelphia, 2011, Elsevier, pp 11. Giannikas D, Athanaselis E, Matzaroglou C, et al: An unusual
207–238. complication of Mitek suture anchor use in primary treat-
4. Kang N, Marsh D, Dewar D: The morbidity of the button-over- ment of flexor digitorum profundus tendon laceration: A case
nail technique for zone 1 flexor tendon repairs. Should we still report, Cases J 14:9319, 2009.
be using this technique? J Hand Surg (Eur) 33:566–570, 2008. 12. Boyes JH, Stark HH: Flexor-tendon grafts in the fingers and
5. Bonin N, Obert L, Jeunet L, et al: Réinsertion du tendon flé- thumb. A study of factors influencing results in 1000 cases,
chisseur par ancre de suture: etude prospective continue avec J Bone Joint Surg (Am) 53:1332–1342, 1971.
mobilisation active précoce, Chir Main 22:305–311, 2003. 13. McClinton MA, Curtis RM, Wilgis EF: One hundred tendon
6. Brustein M, Pellegrini J, Choueka J, et al: Bone suture anchors grafts for isolated flexor digitorum profundus injuries, J Hand
versus the pullout button for repair of distal profundus Surg (Am) 7:224–229, 1982.
tendon injuries: a comparison of strength in human cadaveric 14. Leversedge FJ, Zelouf D, Williams C, et al: Flexor tendon
hands, J Hand Surg (Am) 26:489–496, 2001. grafting to the hand: an assessment of the intrasynovial donor
7. McCallister WV, Ambrose HC, Katolik LI, et al: Comparison tendon—A preliminary single-cohort study, J Hand Surg (Am)
of pullout button versus suture anchor for zone I flexor 25:721–730, 2000.
tendon repair, J Hand Surg (Am) 31:246–251, 2006. 15. Kotwal PP, Gupta V: Neglected tendon and nerve injuries of
8. Latendresse K, Dona E, Scougall PJ, et al: Cyclic testing the hand, Clin Orthop Relat Res 431:66–71, 2005.
of pullout sutures and Micro-Mitek suture anchors in flexor
CHAPTER
25
A HISTORICAL PERSPECTIVE
ON FLEXOR TENDON
RECONSTRUCTION AND
SURGICAL PROCEDURES
Andrew E. Farber, DO, and Daniel P. Mass, MD
OUTLINE paving the way for modern tendon repair and

reconstruction.
Flexor tendon reconstruction is a spectrum of
DEVELOPMENT OF TENDON
challenging treatment options ranging from non-
RECONSTRUCTION
operative treatment to tenolysis to single-stage
and multistage reconstructive surgical procedures. Sec- Until the 1960s, tendon lacerations in zone 2, or “no
ondary tendon reconstruction is indicated in the man’s land,” were treated with removal of the tendon
patients whose tendon injuries are not treated at the with grafting of new tendons. Sterling Bunnell taught “it
primary or delayed primary stages, whose injuries is better to remove the tendons entirely from the finger
to the tendon are too serious, or where destruction of and graft in new tendons smooth throughout its
the flexor pulleys are too extensive, which prevents length.”2,3 Based on Bunnell’s classic work in the early
primary repair of the tendon. In the presence of twentieth century, repair of tendon lacerations in zone
severe scar in the tendon gliding bed or extensive 2, “no man’s land,” involved removal of the tendon and
pulley damages, both patient and surgeon are to be grafting new tendons.3 The techniques of single-stage free
prepared for multiple surgical procedures. This chapter tendon grafting were later refined by a number of master
starts with a concise review of the development of hand surgeons, including Pulvertaft, Graham, Littler,
secondary flexor tendon reconstruction, followed by Boyes, and Stark.5-17 Boyes’ large series of tendon grafts
descriptions of surgical procedures and postoperative popularized the procedure in 1950s and 1960s.13,14,17
rehabilitation of tendon grafting and staged tendon In 1963, Bassett and Carroll subsequently first
reconstructions. described this type of two-stage flexor tendon recon-
struction using a silicone implant.18 In 1965, Hunter
In the tenth century, Avicenna, an Arabian surgeon, was first published his experience with tendon implants for
credited with performing the first tendon repair surgery. tendon reconstruction.19 As is widely reported, Hunter
In Europe, however, Galen teachings resulted in infre- further refined this process in the early 1970s, resulting
quent tendon repair. Galen did not differentiate between in the naming of the Hunter silicone rod and staged
nerves and tendons, noting that nerves entered muscles tendon reconstruction techniques currently used.19,20 An
and muscles ended with whitish cords. Accordingly, alternative method was described by Paneva-Holevich
teaching at that time (circa 150 AD) involved an intimate in 1969,21 who sutured the proximal cut end of the
relationship between tendons and nerves, so much so flexor digitorum superficialis (FDS) tendon to the proxi-
that physicians feared severe consequences from damag- mal cut end of the profundus tendon in the palm. At
ing or even touching a nerve or a tendon. They further the second stage, the FDS tendon was severed as far
believed that suturing of a nerve or a tendon would proximal as possible and this end was brought out to
result in pain, convulsions, and gangrene.1 be inserted at the distal phalanx as a pedicle graft. In
In 1752, Galen’s concept that complications are asso- 1982, Paneva-Holevich reported secondary repair of
ciated with tendon damage was finally refuted by the 324 flexor tendon injuries using pedicle FDS tendon
work of Albrecht von Haller,1 who demonstrated the grafting. In 39 fingers, this technique was combined
insensibility of tendons. In England around 1850, Syme with silicone rod implantation at the first stage to
reported success with several cases of tendon repair prepare a smooth bed for the graft.22
274
Chapter 25: A Historical Perspective on Flexor Tendon Reconstruction and Surgical Procedures 275
critical to maximize the chance for a successful outcome.

SURGICAL PROCEDURES
Boyes and others have described indications for single-
It is helpful to think of flexor tendon reconstruction as stage grafting including: (1) injuries with segmental
a spectrum of challenging treatment options ranging tendon loss and (2) delayed presentation resulting in the
from nonoperative treatment to tenolysis to single-stage inability to perform a primary end-to-end repair. This
and multistage reconstructive surgical procedures. Both may include injuries older than 3 to 6 weeks.4,11-17
patient and surgeon need to be prepared for multiple The hand and finger should also demonstrate at least
surgical procedures and strict compliance with postop- one intact digital nerve in the affected finger, a well-
erative rehabilitation protocols. It is therefore impera- healed wound without extensive scarring, adequate cir-
tive to carefully consider surgical and nonsurgical culation; and near full-passive motion of all joints.
indications when selecting the best treatment protocol. Insufficient passive range of motion should be addressed
Additionally, it is essential to discuss the range of out- with a course of hand therapy prior to considering surgi-
comes with the patient including the likelihood of stiff- cal intervention. Patients should also be prepared to
ness and the possible need for amputation. In some participate in a rigorous and complex postoperative
cases, doing nothing or performing a primary amputa- rehabilitation program. This requirement generally
tion or arthrodesis may avoid a series of painful proce- excludes growing children and some elderly patients.19
dures that may ultimately provide or restore minimal Excellent surgical technique is imperative and should
function. be carried out under loupe magnification and tourni-
Bunnell’s extensive work on flexor tendon injury and quet control.
reconstruction resulted in the widely accepted belief Except in the case of preexisting scar, choice of surgi-
that injured tendons should be removed and replaced cal incision is generally a matter of surgeon preference.
with new tendon graft.2,3 Bassett, Carroll, and Hunter Options include the Bruner zigzag or mid-lateral inci-
refined this recommendation with their works on the sions. During dissection, neurovascular structures are
silicone rod, which was designed to create a smooth bed identified and protected. Damaged sheath is excised
for tendon grafting. These developments led to the and effort is made to protect the sheath and pulley
widespread acceptance and use of the two-stage tendon system.23-26 Missing pulleys, in particular the A2 and A4
reconstruction. pulleys, need to be reconstructed.
Over the four decades that followed, however, signifi- While several donor tendon options exist, the ipsilat-
cant advancements in flexor tendon repair and recon- eral palmaris longus or plantaris tendons remain the
struction led to revised indications for both primary most common choices. Since these tendons are both
repair and secondary reconstruction. When considering nonsynovial tendons, some surgeons prefer to use toe
secondary repair, the decision needs to be made whether extensors from beneath the ankle retinaculum within
to graft and reconstruct the tendons in a single stage or the sheath. Toe flexors are also intrasynovial; however,
to perform a two-stage repair. This decision requires their sheaths tend to be much shorter than those of
careful preoperative and intraoperative examinations. the fingers. In the event of harvesting the tendon from
Regardless of the surgical technique chosen, patients the lower extremity, the incision in the hand is at
should be counseled and should be prepared to partici- this point covered with moistened sponges and the
pate in a complex rehabilitation program. This may tourniquet deflated. Additionally, although vascularized
preclude performing the procedure on children younger tendon grafts have been described and investigated, they
than 3 years of age. are rarely used and little is written about their use in the
English literature.
Single-Stage Reconstruction The FDP insertion site is next identified distally. In
Preoperatively, patients considered for single-stage the case of an intact distal FDP, the stump is reflected
reconstruction with tendon grafting must display a well- and the graft is secured in the method of Bunnell. Spe-
healed, neurovascularly intact digit without excessive cifically, a 3-0 Prolene or similar suture is placed at the
scarring. Intraoperatively, an intact, smooth tendon bed end of the graft and criss-crossed twice. In an adequate
should be present with an adequate pulley system. FDP stump, the graft may be woven to reinforce fixation.
Patients with inadequate soft tissue coverage, those Otherwise, the FDP stump is split and the suture ends
with significant, dense scarring, or an inadequate pulley are threaded onto a Keith needle. The needles are then
system generally benefit from a two-stage reconstruc- passed around both sides of the distal phalanx or, alter-
tion. Additional indications and limitations are described natively, drilled obliquely from the proximal aspect of
next. the volar distal phalanx, exiting through the middle-
Although primary flexor tendon repair has become third of the nail plate, approximately 3 to 4 mm distal
increasingly popular, select patients can still benefit from to the lunula and approximately 2 mm from the midline.
single-stage flexor tendon reconstruction.4-10 Careful Whenever possible, avoid letting them exit through the
patient selection and intraoperative evaluation are germinal nail matrix. The sutures are then passed
Figure 25-2 Position of the fingers and tension set during

operation.
Figure 25-1 Demonstration of a suture anchor for distal

fixation of the grafted tendon.
through the holes and tied over a padded button.4 If

available, a suture anchor can be used for fixation to the
distal phalanx (Figure 25-1).
The proximal aspect of the graft is then secured to the
FDP tendon just distal to the lumbrical origin. Any
remaining scar or frayed tissue is removed from the
native FDP tendon and a Brand tendon braider or a fine
scalpel is used to pass the graft. The graft should be
passed through several planes in the native tendon and
the tendon junctures are sutured in place. Figure 25-3 Hand demonstrating adequate passive range
of motion.
Estimating proper tension is often difficult, especially
in the anesthetized patient; however, this remains
among the most important aspects of this procedure. extensive destruction of flexor pulleys, those with crush-
Placing the wrist in a neutral position allows for evalu- ing injuries with extensive soft tissue damage or under-
ation of the relaxed position of the fingers.24,27-30 Each lying fractures, and patients with extensive scarring of
semiflexed finger should be slightly more flexed than the flexor tendon bed. Adequate passive range of digital
the next radial finger and slightly less flexed than the motion and pliable skin are essential for the patients as
next ulnar finger (Figure 25-2). The Pulvertaft weave candidates of the staged reconstruction (Figures 25-3
technique is commonly used for securing the tendon and 25-4).
graft to the proximal tendon stump in the palm or distal Hunter, among others, is credited with describing
forearm. This technique is particularly useful in that it and refining these techniques with the goal of creating
allows for adjustment of graft tension. a new flexor tendon bed allowing for gliding of the
Postoperative protocols typically included 3 weeks of implanted tendon graft. As mentioned earlier, it is
immobilization. More recently, however, active motion imperative to maintain or recreate a sufficient and func-
protocols have become prevalent in primary flexor tional pulley system. Traditional teaching has said that
tendon repairs,31,32 at a minimum, the A2 and A4 pulleys at the proximal
and middle phalangeal levels respectively must be in
Two-Stage Reconstruction place. However, more recent data suggest that a four-
Despite significant improvements in primary repair pulley system may be superior whenever possible.4 At
and single-stage tendon reconstruction, two-stage recon- the same time, however, tight pulleys can inhibit tendon
struction remains a valuable option for some patients, graft gliding; accordingly, constricted pulleys can be
including patients who suffer severe trauma, those with dilated. Damaged but intact pulleys should be repaired
Chapter 25: A Historical Perspective on Flexor Tendon Reconstruction and Surgical Procedures 277
Figure 25-4 Hand demonstrating pliable skin.
Figure 25-6 At the first stage, with a Bruner incision in

the middle of the finger and two incisions at the fingertip
and the palm, the Hunter rod is placed to replace the FDP
tendon and to stimulate formation of tendon gliding bed.
avoid damage to the rod and talc-free gloves should be

used as talc contamination is known to cause implant
adherence.
A tendon passer is used to pass the implant from
proximal to distal or from distal to proximal (Figure
25-6).37-39 The implant is then secured distally below the
FDP stump, taking care to pass sutures through the
Dacron tape in the implant since the silicone itself offers
Figure 25-5 Reconstruction of flexor pulley at the middle
of the proximal phalanx. little holding strength. Hunter rods are also available
fitted with a metal eyelet that can accommodate a
2.0-mm screw for fixation into the distal phalanx. When
and missing or irreparable pulleys must be reconstructed using this technique, it is important to avoid penetrating
(Figure 25-5). A variety of options exists for pulley the dorsal cortex, inuring the nail bed. Additionally, the
reconstruction, including grafting of extensor retinacu- screw must be distal enough in the distal phalanx to
lum, remnant of free tendon, or synthetic materials.33,34 avoid blocking DIP motion.
Bunnell originally recommended reconstructing the Next, range of motion is performed and observed to
pulley with placement of the tendon graft deep to the ensure an adequate pulley system and free passage of
extensor mechanism at the A2 level and superficial at the graft with no bowstringing. Revision or additional
the A4 level;35 however, Taras and others more recently pulley reconstructions may be indicated at this point in
suggested placing the tendon graft deep at all levels.36 the procedure.
As in other flexor tendon procedures, volar Bruner Wounds are then irrigated and closed. A bulky dress-
incisions are ideal and should incorporate previous ing is applied, supporting the wrist in approximately
scars where possible. Flexor tendons are then excised 35° of flexion, metacarpophalangeal joints in 60° to
leaving a 1-cm FDP stump attached to the distal phalanx. 70° of flexion, and the interphalangeal joints relaxed in
A 1-cm FDS stump should also be maintained at the extension. Passive motion may be started 2 to 3 days
middle phalanx. If necessary, collateral ligaments and postoperatively.
the volar plate can be released freeing remaining joint To allow for adequate wound healing and develop-
contractures. ment of a gliding tendon sheath in response to the
With a sufficient pulley system in place, the silicone implant, typically 3 months is allowed between stages
or Hunter rod is placed. A smooth forceps is used to of reconstruction. The criteria for proceeding with the
second stage of reconstruction are similar to those The graft is harvested, the silicone implant is detached
mentioned for the first stage and include a soft scar, near from its distal insertion site, and the graft is sutured to
full passive range of motion, and intact protective the proximal end of the implant for passage through the
sensation. sheath. The graft is passed from proximal to distal as the
In the second stage of flexor tendon reconstruction, implant is removed.
the implant is removed and a tendon graft is placed. As previously described, the graft is secured distally.
Previous surgical scars are opened and distally, the The incisions are washed and closed and a short-arm
implant is identified and removed from the FDP stump. dorsal blocking splint is applied. Typically, the wrist is
Depending on the site of injury, the proximal incision placed in neutral, the metacarpophalangeal joints in
in the hand or forearm is reopened and the implant is 45° of flexion and the interphalangeal joints in neutral.
carefully exposed to avoid injuring the tendon sheath. Protected passive range of motion with early controlled
Typically, the adjacent profundus motor unit is selected.4 active motion is employed postoperatively.39-41
References
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silicone rod implants, J Bone Joint Surg (Am) 45:884–885, using the Hunter tendon implant, J Hand Ther 2:107–113,
1963. 1989.
19. Hunter JM. Artificial tendons. Early development and appli- 40. Mackin EJ: Physical therapy and the staged tendon graft: pre-
cation, Am J Surg 109:325–338, 1965. operative and postoperative management. In AAOS Sympo-
20. Hunter JM, Salisbury RE: Flexor-tendon reconstruction in sium on Tendon Surgery in the Hand, St Louis, 1975, CV Mosby,
severely damaged hands. A two-stage procedure using a sili- pp 283–291.
cone Dacron reinforced gliding prosthesis prior to tendon 41. Stanley BG: Flexor tendon injuries: late solution. Therapist’s
grafting, J Bone Joint Surg (Am) 53:829–852, 1971. management, Hand Clin 2:139–147, 1986.
CHAPTER
26
EXPERIENCE WITH SECONDARY
FLEXOR TENDON REPAIRS
Peter C. Amadio, MD, and Chunfeng Zhao, MD
OUTLINE Between roughly 1920 and 1960, secondary repair was

the preferred choice when dealing with flexor tendon
Between roughly 1920 and 1960, secondary repair was injuries in zone 2.1-4 Subsequent advances in primary
the preferred choice when dealing with flexor tendon repair, especially with newer suture designs and reha-
injuries in zone 2. Subsequent advances in primary bilitation techniques, have made primary repair the pre-
repair, especially with newer suture designs and reha- ferred option for the vast majority of zone 2 injuries.
bilitation techniques, have made primary repair the Nonetheless, secondary repair options remain viable in
preferred option for the most zone 2 flexor tendon many circumstances. Newer research may also expand
injuries. Currently, secondary repair options remain the role of secondary reconstruction, as described in the
viable in a number of circumstances. Secondary repair final section of this chapter.
in zone 2 include neglected injuries, in which retrac-
tion and adhesion of the tendon ends preclude reap- ONE-STAGE GRAFT
proximation, or only permit reapproximation with
extreme positioning of the finger and wrist in flexion, Indications
and segmental injuries, especially with segmental The classic one-stage tendon graft was described and
tendon loss. In such cases primary repair is not techni- popularized by Bunnell,1 with definitive descriptions of
cally possible. A good tendon bed is an indication for outcomes reported by Boyes, Stark, and others in the
one-stage grafting, such as when there is no or very middle years of the twentieth century.2,5,6 These descrip-
little scar, the pulleys (or at least the major pulleys A2 tions have not been bettered and serve as the reference
and A4) are intact, and there are no or minimal associ- point here for a description of the classic indications,
ated joint contractures. In addition, soft tissue nutri- technique, and results of one-stage grafting.
tion must be adequate, with preservation of at least The classic indications for a one-stage graft are a zone
one neurovascular bundle. Finally, soft tissue coverage 2 injury for which repair is not appropriate, with an
must be normal or nearly normal: tendon grafts do otherwise good tendon bed, in a cooperative patient.
not thrive under scar or skin grafts. When tendon graft- These criteria remain valid; indeed, the only difference
ing is indicated to restore tendon function and a one- between the 1950 and 2010 indications at all is the
stage graft is relatively contraindicated because of assessment of which zone 2 injuries might not be appro-
excessive scar, joint contracture, pulley loss, or a need priate for primary repair.
for better soft tissue cover, a two-stage reconstruction Another feature that has not changed over the years
can be considered. The patient should be fully informed is that it is often difficult to be certain beforehand
as to the time commitment to the staged surgery: the whether a tenolysis, one-stage graft, or two-stage graft
initial stage, to address the scar, contracture, pulley and will be needed preoperatively; a procedure that begins
soft tissue issues that contraindicate a one-stage graft; as a tenolysis may easily end with a shredded tendon,
an interval for soft tissue healing, which is usually 3 damaged pulleys, and a two-stage reconstruction. The
months or longer; a second stage, a “one-stage” graft; surgical consent should include consideration of each
and interval for graft healing; and the potential need of these options, whenever tendon reconstruction is
for a third stage, namely tenolysis or some sort of discussed.
salvage if the two-stage graft fails. Current research Currently, tendon injuries not suitable for primary
efforts indicate improvement of the gliding character- repair in zone 2 include neglected injuries, in which
istics of extrasynovial autografts after tendon surface retraction and adhesion of the tendon ends preclude
modification with carbodiimide-derivatized hyalu reapproximation, or only permit reapproximation
ronic acid mixture and possibility of using tendon with extreme positioning of the finger and wrist in
allografts, which point to future promise of changes flexion, and segmental injuries, especially with segmen-
in secondary tendon repair or reconstruction. tal tendon loss. In such cases primary repair is not
279
Figure 26-1 A finger suitable for one-stage tendon graft:

tendon bed is good; scarring is minimal; the pulleys are
intact; and the soft tissues are supple.
Figure 26-2 The Pulvertaft weave is useful, especially to
join tendons of dissimilar sizes.
technically possible. Even so, one-stage grafting might
not be indicated—in the presence of an intact and
functioning flexor digitorum superficialis (FDS) tendon,
grafting to restore flexor digitorum profundus (FDP) quality of the soft tissues. The wound should be clini-
function might cause more harm than good.6 It is always cally stable; the skin soft and pliable. If good soft tissues
important to recall that in the presence of a normal are not present, the procedure is almost certain to
FDS, the FDP contributes only to distal interphalangeal fail. Indeed, poor soft tissues are an indication for an
joint (DIP) motion. Due to inevitable adhesions, the alternate procedure, such as a staged tendon graft, as
amount of restored DIP motion is often limited, and described next.
the amount of incremental grip strength may also be The finger can be approached through either a volar
limited. These limited gains must be counterbalanced by Bruner or midaxial incision. The key decision is whether
the risks of infection and contracture, the time and effort to put the proximal juncture in the palm or the distal
required for a successful tendon graft procedure, includ- forearm. This decision should be based on the quality
ing the possible need for a tenolysis, and the impact of of the soft tissue bed; the palm is preferred provided
these on the patient’s life and livelihood. Except in that the soft tissues there are soft and supple. Otherwise,
special circumstances, such as a musician who plays a a longer graft, repaired proximal to the carpal tunnel, is
stringed instrument, serious consideration should be preferred.
given to simpler alternatives, such as DIP tenodesis, with At least under the pulleys, the old tendon should be
FDS tenolysis and lumbrical release as needed. excised. If the pulleys are not intact, especially the key
Certainly, the criterion of a good tendon bed has not A2 pulley, pulley reconstruction as a two-stage proce-
changed as an indication for one-stage grafting (Figure dure should be strongly considered.
26-1). A good bed is one in which there is no or very The tendon graft donor should be considered care-
little scar, the pulleys (or at least the major pulleys A2 fully. Ideally, in an intrasynovial location, an intrasyno-
and A4) are intact, and there are no or minimal associ- vial graft should be used, but these are rarely available.
ated joint contractures. In addition, soft tissue nutrition In addition, to minimize bowstringing, a graft that fits
must be adequate, with preservation of at least one the pulley should be used, but again, a good diameter
neurovascular bundle.5 Finally, soft tissue coverage must match is rarely on offer. When such tendons are avail-
be normal or nearly so: Tendon grafts do not thrive able, they should be considered. Some creativity can
under scar or skin grafts. sometimes fashion a better choice: an index extensor is
Finally, the patient must be capable of cooperating intrasynovial at the extensor retinaculum; such a tendon,
with the grafting procedure. Sufficient voluntary motor harvested and then reversed, so that the distal end is
control must be available to power the graft motor, and proximal and vice versa, can serve as a good alternative
the patient must be able to cooperate with the rehabili- to a palmaris longus, when a short graft is needed.8
tation program, which will include typically several When a long graft is needed for a juncture in the distal
months of protected mobilization. Children, especially forearm, usually only a plantaris or toe extensor have
under the age of 10, may not be fully capable of coop- the required length. Alternatively, tendon allografts can
eration; reconstruction should be undertaken with be used, but without some modification (see later) the
caution in such patients.7 results may be suboptimal.
The proximal juncture is classically made with a Pul-
METHODS
vertaft weave (Figure 26-2), but other weaving tech-
The technique of one-stage tendon grafting has not niques can provide similar or even superior holding
changed over the years. Timing is dependent on the strength, with less bulk.9 There is little question, though,
Chapter 26: Experience With Secondary Flexor Tendon Repairs 281
first few weeks, to provide a limited range of graft

gliding, and then progressing along a rehabilitation
pathway similar to that for tendon repairs.
RESULTS
The results of one-stage grafting are best summarized in
the classic 1971 report by Boyes and Stark,5 which
reviewed their results in 1000 cases. It is unlikely that
anyone will ever duplicate this experience, so it is worth
reviewing. They classified the digits as being either good,
scarred, with joint contractures, as one of multiple
injured digits in the same hand, and as salvage cases, in
which there were associated skin, bone, or nerve inju-
ries. Results were graded based on active flexion; resid-
ual flexion contractures were not considered unless they
were more than 40° in the index and middle fingers and
60° in the ring and little fingers. According to this
scheme, the good digits did best, with two of three
flexing to within 0.5 inch to the palm, and 85% flexing
within 1 inch. The corresponding figures for the mul-
tiple and scar categories were a little worse: 30% and
Figure 26-3 Tendon cascade after repair; tension should 60%, respectively. The digits with joint contractures
be set slightly tighter than normal. were worse again: 10% and 50%, respectively, while the
salvage cases did extremely poorly: no digits in this
group could flex with 0.5 inch and only 20% could flex
within 1 inch. Patients over age 30 did worse, and
that when joining tendons of grossly dissimilar diam- patients over age 40 did much worse, for similar grades
eter, a weaving method is superior in strength to a direct of digit. So long as the digit remained supple, delay to
repair. The choice of donor motor depends to some surgery did not seem to matter.
extent on what is available, but usually either the pro-
fundus or superficialis tendon of the affected digit is TWO-STAGE GRAFT
chosen.
Distally, the graft is usually fixed with a pullout Indications
suture. There is some controversy as to whether the When tendon grafting is indicated to restore tendon
tendon graft should be drilled into bone or fixed to function and a one-stage graft is relatively contraindi-
the bony surface of the distal phalanx; recent research cated because of excessive scar, joint contracture, pulley
suggests that surface fixation may result in better loss, or a need for better soft tissue cover, then a two-
healing.10 Tension may be adjusted proximally or dis- stage reconstruction can be considered. One aspect of
tally; the operated finger should usually be slightly the indications that does not change between the one-
more flexed than the normal cascade would suggest and two-stage procedure is the absolute need for a coop-
(Figure 26-3). erative patient, who is fully informed as to the time
Postoperatively, the patient is managed usually with commitment that is likely to be necessary: the initial
early passive mobilization, to reduce the risk of joint stage, to address the scar, contracture, pulley and soft
contracture. The role of active motion is somewhat con- tissue issues that contraindicate a one-stage graft; an
troversial in tendon grafting; unlike a direct repair, the interval for soft tissue healing, which is usually 3 months
graft is avascular, and must have its nutrition restored or longer; a second stage, which is a “one-stage” graft as
somehow. Thin grafts may be able to survive on synovial described earlier; and interval for graft healing, again as
nutrition, but thicker grafts will almost certainly require described earlier; and then consideration of the need for
some adhesions to deliver a vascular source. The balance a possible third stage, namely tenolysis or some sort of
that results is extremely delicate and likely explains the salvage if the two-stage graft fails. Only a patient willing
usually mediocre results of tendon grafting—moving and able to travel this long road with the surgeon should
too much and too soon disrupts adhesions and may be considered for surgery; only a need great enough to
jeopardize long-term graft viability; protecting too long justify such an arduous journey should prompt the
will result in too many, short adhesions that unaccept- surgeon to suggest it. Thus, for example, such proce-
ably limit function of a better vascularized graft. Our dures are rarely indicated in young children7 or in those
compromise has been to use passive mobilization in the who live at such a distance from the surgeon that close
follow-up becomes impossible.11 Reconstruction of a and when they break they are difficult to reconstruct.
profundus tendon in the presence of a normally func- Proximal failure typically leaves a destroyed muscle–
tioning superficialis must be carefully considered—Will tendon junction, which is hard to salvage.
the potential benefit outweigh the considerable risks6? After stage 1, the finger is passively mobilized as the
Even reconstruction of the thumb flexor should be care- wound conditions permit. Stage 2 is performed when
fully thought through—How does the risk/benefit ratio the incisions are soft and supple and passive finger
compare, for example, with a much simpler interpha- motion has reached a maximum. Stage 2 surgery is a
langeal arthrodesis? tendon graft, repaired and rehabilitated as for one-stage
grafts. The main difference is that often longer grafts are
METHOD
needed, such as plantaris or a toe extensor.
The first-stage procedure involves addressing the soft
RESULTS
tissue issues outlined earlier and then using a silicone
rubber spacer to maintain a place for the second-stage The results of two-stage grafts are certainly better than
tendon graft (Figure 26-4). Thus, each operation is those of a one-stage graft performed for similar indica-
unique. Nevertheless, some basic principles are useful tions but remain unexciting in many cases.13-19 Flexion
to note. Joint contractures should be released prior to contractures and limited flexion remain common; the
soft tissue reconstruction, so that the full length of recovery period is long, and patient satisfaction is often
needed tissue can be ascertained. When releasing con- low, with expectations incompletely met. Among the
tractures in the presence of pulley loss, it is especially more common complications are graft rupture and late
important to excise all scar anterior to the bone; often contracture, especially of the DIP joint. This latter com-
a hard triangle of scar will feel like bone and may deceive plication can be avoided if the graft is used to recon-
the unwary surgeon, who then reconstructs a pulley that struct the flexor superficialis, and the distal joint is
does not hold the graft close enough to the bone to fused.
prevent postoperative bowstringing.
SECONDARY REPAIR IN THE FUTURE
As with one-stage grafting, a key decision is where
to put the proximal junction—in the palm or forearm. Improving the gliding characteristics of extrasynovial
In the case of one-stage grafts, which ought to have autografts may lead to improved clinical results
good surrounding tissues, usually the palm is appropri- after tendon graft surgery. Recent studies have shown
ate. In the case of two-stage grafts, usually it is the that extrasynovial graft surface modification with
opposite—the palm and the finger are scarred, and the carbodiimide-derivatized hyaluronic acid mixture
most hospitable location is often the distal forearm. decreased gliding resistance of the tendon and
Regardless, the tendon implant should be inserted and increased the durability after repetitive motion in the
fixed distally to bone, with either screw or suture. It is in vitro studies.20,21 Zhao et al conducted an in vivo
threaded through any intact pulleys and pulleys are then flexor tendon graft in canine model using autologous
reconstructed around the graft where needed. When peroneus longus tendon. They demonstrated that the
completed, the graft should fit snugly within the new surface of an extrasynovial tendon autograft with
sheath but should piston smoothly, without any ten- a carbodiimide-derivatized hyaluronic acid gelatin
dency for buckling with passive flexion. Any buckling at decreases adhesions and increases tendon gliding.22
this stage will simply become synovitis and infection These encouraging experimental results potentially
postoperatively. provide surgeons with a new and useful method to
We do not use active implants.12 The literature sug- improve the quality of tendon graft surgery.
gests that their results are no better than passive ones, Although intrasynovial tendon autologous grafts
are rarely obtained without compromising the donor
site morbidity, allograft-matched intrasynovial flexor
tendons are possibly available. Allograft tendon grafts
are frequently used for anterior cruciate ligament recon-
struction,23-27 but flexor tendon reconstruction with
allograft tendon has been rarely reported.28 The use
of allografts for tendon reconstruction merits serious
consideration for the following reasons: intrasynovial
allograft tendon sources are abundant, which permits
easy clinical application; allograft use limits surgical
morbidity, as no graft harvest is necessary; allograft use
Figure 26-4 Stage 1 surgery with a silicone implant in reduces the surgical time required by eliminating the
place. Note pulley reconstruction at the middle part of the graft harvesting procedure, which directly translates into
proximal phalanx. a cost reduction29; and better size matching. A major
Chapter 26: Experience With Secondary Flexor Tendon Repairs 283
Figure 26-6 Scarred digit after initial surgery in an animal

Figure 26-5 Lubricated tendon graft after chemical model of tendon grafting.
modification of tendon surface.
disadvantage is the potential for an immune reaction,

but this can reduced by processing the allograft prior to
use. A lyophilized, decellularized allograft is less immu-
nogenic, better tolerated, and as effective as autograft.30-32
Preserved allografts also maintain their mechanical
properties with the convenience of availability at any
desired time.25,33,34
In addition to the needs of mechanical strength and
appropriate tendon/bone healing, the flexor tendon
allograft also requires a smooth gliding surface. However,
Ikeda et al found that the procedures used to prepare
allografts damage the tendon surfaces leading to greater
frictional force in canines.35 This adverse effect can
be reversed by surface treatment with carbodiimide-
derivatized hyaluronic acid and gelatin (Figure 26-5).35 Figure 26-7 Treated (top) and untreated (bottom) grafts in
A flexor tendon reconstruction with surface modified a canine model. Adhesions were markedly reduced in the
treated graft.
allografts has been studied in a canine in vivo model of
failed primary repair.36 In this experiment, the flexor
tendons were lacerated and repaired, and the animals
were allowed free active motion postoperatively. The function, reduced adhesions, and decreased gliding
repaired tendons were all ruptured within 2 weeks. After resistance compared with allografts without such modi-
6 weeks, a scarred digit with a uniform failure pattern fication (Figure 26-7).36 We believe that treated allografts
was routinely produced (Figure 26-6). Subsequent may similarly improve the results after flexor tendon
grafting with surface-treated allografts improved digital reconstruction in humans.
References
1. Bunnell S: Hand surgery, J Bone Joint Surg (Am) 29:824, 6. Stark HH, Zemel NP, Boyes JH, et al: Flexor tendon graft
1947. through intact superficialis tendon, J Hand Surg (Am) 2:456–
2. Boyes JH: Evaluation of results of digital flexor tendon grafts, 461, 1977.
J Surg (Am) 89:1116–1119, 1955. 7. Amadio PC: Staged flexor tendon reconstruction in children,
3. Hauge MF: The results of tendon suture of the hand: A review Ann Chir Main Memb Super 11:194–199, 1992.
of 500 patients, Acta Orthop Scand 24:258–270, 1955. 8. Nishida J, Amadio PC, Bettinger PC, et al: Excursion
4. Kelly AP Jr: Primary tendon repairs: A study of 789 consecu- properties of tendon graft sources: interaction between
tive tendon severances, J Bone Joint Surg (Am) 41:581–598, tendon and A2 pulley, J Hand Surg (Am) 23:274–278,
1959. 1998.
5. Boyes JH, Stark HH: Flexor-tendon grafts in the fingers and 9. Tanaka T, Zhao C, Ettema AM, et al: Tensile strength of a new
thumb. A study of factors influencing results in 1000 cases, suture for fixation of tendon grafts when using a weave
J Bone Joint Surg (Am) 53:1332–1342, 1971. technique, J Hand Surg (Am) 31:982–986, 2006.
10. Silva MJ, Thomopoulos S, Kusano N, et al: Early healing of 25. Tejwani SG, Shen W, Fu FH: Soft tissue allograft and
flexor tendon insertion site injuries: Tunnel repair is mechan- double-bundle reconstruction, Clin Sports Med 26:639–660,
ically and histologically inferior to surface repair in a canine 2007.
model, J Orthop Res 24:990–1000, 2006. 26. Dustmann M, Schmidt T, Gangey I, et al: The extracellular
11. Amadio PC, Wood MB, Cooney WP 3rd, et al: Staged flexor remodeling of free-soft-tissue autografts and allografts for
tendon reconstruction in the fingers and hand, J Hand Surg reconstruction of the anterior cruciate ligament: A compari-
(Am) 13:559–562, 1988. son study in a sheep model, Knee Surg Sports Traumatol
12. Hunter JM, Singer DI, Jaeger SH, et al: Active tendon implants Arthrosc 16:360–369, 2008.
in flexor tendon reconstruction, J Hand Surg (Am) 13:849– 27. Scheffler SU, Schmidt T, Gangéy I, et al: Fresh-frozen
859, 1988. free-tendon allografts versus autografts in anterior cruciate
13. Sun S, Ding Y, Ma B, et al: Two-stage flexor tendon reconstruc- ligament reconstruction: delayed remodeling and inferior
tion in zone II using Hunter’s technique, Orthopedics 33:880, mechanical function during long-term healing in sheep,
2010. Arthroscopy 24:448–458, 2008.
14. Alnot JY, Masmejean EH: The two-stage flexor tendon graft, 28. Liu TK: Clinical use of refrigerated flexor tendon allografts to
Tech Hand Up Extrem Surg 5:49–56, 2001. replace a silicone rubber rod, J Hand Surg (Am) 8:881–887,
15. Smith P, Jones M, Grobbelaar A: Two-stage grafting of flexor 1983.
tendons: results after mobilisation by controlled early active 29. Cole DW, Ginn TA, Chen GJ, et al: Cost comparison of
movement, Scand J Plast Reconstr Surg Hand Surg 38:220–227, anterior cruciate ligament reconstruction: Autograft versus
2004. allograft, Arthroscopy 21:786–790, 2005.
16. Amadio PC, Wood MB, Cooney WP 3rd, et al: Staged flexor 30. Webster DA, Werner FW: Mechanical and functional proper-
tendon reconstruction in the fingers and hand, J Hand Surg ties of implanted freeze-dried flexor tendons, Clin Orthop
(Am) 13:559–562, 1988. Relat Res 180:301–309, 1983.
17. Wehbé MA, Mawr B, Hunter JM, et al: Two-stage flexor- 31. Gulati AK, Cole GP: Nerve graft immunogenicity as a factor
tendon reconstruction. Ten-year experience, J Bone Joint Surg determining axonal regeneration in the rat, J Neurosurg
(Am) 68:752–763, 1986. 72:114–122, 1990.
18. Schneider LH: Staged flexor tendon reconstruction using the 32. Fromm B, Schäfer B, Parsch D, et al: Reconstruction of the
method of Hunter, Clin Orthop Relat Res 171:164–171, 1982. anterior cruciate ligament with a cyropreserved ACL allograft.
19. Paneva-Holevich E: Two-stage reconstruction of the flexor A microangiographic and immunohistochemical study in
tendons, Int Orthop 6:133–138, 1982. rabbits, Int Orthop 20:378–382, 1996.
20. Momose T, Amadio PC, Sun YL, et al: Surface modification 33. Goertzen MJ, Clahsen H, Schulitz KP: Anterior cruciate liga-
of extrasynovial tendon by chemically modified hyaluronic ment reconstruction using cryopreserved irradiated bone-
acid coating, J Biomed Mater Res 59:219–224, 2002. ACL-bone-allograft transplants, Knee Surg Sports Traumatol
21. Sun YL, Yang C, Amadio PC, et al: Reducing friction by chemi- Arthrosc 2:150–157, 1994.
cally modifying the surface of extrasynovial tendon grafts, 34. Mahirogullari M, Ferguson CM, Whitlock PW, et al: Freeze-
J Orthop Res 22:984–989, 2004. dried allografts for anterior cruciate ligament reconstruction,
22. Zhao C, Sun YL, Amadio PC, et al: Surface treatment of flexor Clin Sports Med 26:625–637, 2007.
tendon autografts with carbodiimide-derivatized hyaluronic 35. Ikeda J, Zhao C, Sun YL, et al: Carbodiimide-derivatized hyal-
acid. An in vivo canine model, J Bone Joint Surg (Am) 88:2181– uronic acid surface modification of lyophilized flexor tendon:
2191, 2006. A biomechanical study in a canine in vitro model, J Bone Joint
23. Jackson DW, Grood ES, Goldstein JD, et al: A comparison Surg (Am) 92:388–395, 2010.
of patellar tendon autograft and allograft used for anterior 36. Zhao C, Sun YL, Ikeda J, et al: Improvement of flexor tendon
cruciate ligament reconstruction in the goat model, J Sports reconstruction with carbodiimide-derivatized hyaluronic
Med (Am) 21:176–185, 1993. acid and gelatin-modified intrasynovial allografts: Study of
24. Kustos T, Bálint L, Than P, et al: Comparative study of auto- a primary repair failure model, J Bone Joint Surg (Am) 92:
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struction, Int Orthop 28:290–293, 2004.
CHAPTER
27
SECONDARY RECONSTRUCTION
OF THE FLEXOR POLLICIS
LONGUS TENDON
OUTLINE may be possible as late as 3 to 4 weeks after injury but,

more frequently, in my experience, there is sufficient
Primary repair of the flexor pollicis longus tendon is shortening of the muscle within a few days as to make
generally recommended, except in zone 3 or 4 injuries, direct primary repair without proximal tendon length-
when primary grafting can be advisable. Techniques ening impossible without the IP being flexed to a degree
are discussed that allow primary repair under circum- from which it never recovers extension.
stances that might otherwise require tendon grafting.
PRIMARY GRAFTING OF ZONE 3 AND
Circumstances in which no secondary repair is accept-
4 INJURIES
able are also discussed. The requisites for function that
must be met if the flexor pollicis longus muscle is to The FPL is rarely divided in zone 3, within the thenar
be used as the motor for a tendon graft are examined. muscles, where it is deeply placed. However, surgical
Some technical aspects of tendon grafting are dis- repair is difficult in zone 3 as access is past the digital
cussed and the usefulness of two-stage grafting under nerves of the thumb and through the thenar muscles,
certain circumstances is considered. with risk to the motor branches of the median nerve.
That loss of thumb sensation or opposition are greater
The technical execution of the various surgical maneu- disabilities than loss of terminal flexion should be con-
vers used in secondary reconstruction of the flexor pol- sidered before extending an already extensive injury in
licis longus (FPL) (Box 27-1) are relatively straight this zone to repair the tendon directly.5 Any direct
forward to any hand surgeon versed in the techniques tendon repair in zone 3 will also be surrounded by
of flexor tendon surgery. However, decision making as edematous and swollen muscle during rehabilitation.
to what is done in any particular circumstance is com- Except where the injury is a small puncture wound of
plicated by various anatomical peculiarities of the FPL the thenar eminence and dissection to the site of divi-
tendon compared to the flexor system of the finger, the sion can be precise and small, there is justification for
timing of presentation, the plethora of treatment the approach recommended by Matev (1983) of replac-
options, and, in some instances, by the differing flexion ing the tendon from the wrist to its distal attachment
needs of the thumb in different individuals. with a tendon graft, even if seen immediately.6 In these
injuries, the proximal end of the tendon is frequently
PRIMARY REPAIR OF FLEXOR POLLICIS
found retracted to the wrist. When presentation is even
LONGUS BY PREFERENCE
only slightly delayed, the distal end of the tendon may
Recent practice (see Chapter 16) has established that be adherent within the muscle tunnel and require
primary repair of the FPL tendon is desirable where pos- careful release from adhesions through the digital expo-
sible and 70% to 80% of the results will be within the sure, if necessary leaving the end itself within the muscles
excellent or good range, although it should be noted by division of the tendon just proximal to the metacar-
that “excellent” in our current classifications does not pophalangeal joint.
imply return to normal function. Nevertheless, these Isolated division of FPL in the carpal tunnel (zone 4)
results are better than the 30° to 40° degrees of move- is even rarer. Direct tendon repair in the carpal tunnel
ment previously perceived as necessary to good function may snag on the relatively narrow opening from the
of the interphalangeal (IP) joint of the thumb.1,2 With carpal tunnel into the tunnel through the thenar muscles
various modern suturing techniques of primary repair, or on the proximal edge of the carpal ligament. Under
early mobilization can also be progressed safely to com- these circumstances, the Matev approach of grafting the
pletion without rupture of the repair.3,4 Direct repair FPL from the wrist to the distal phalanx of the thumb
285
Box 27-1 Treatment Options for the Divided extension of primary repair or a technique of secondary
FPL Tendon reconstruction. This has been discussed in some detail
in Chapter 16 but more from the point of view of avoid-
Primary and Delayed Primary Repair
1. End-to-end suture of the cut tendon ing a tightly flexed interphalangeal (IP) joint of the
(Advised in all but zone 3) thumb and/or tendon rupture by primary suture under
2. Reattachment of the distal tendon to the distal phalanx tension.
(a) After tendon avulsion The considerable literature of the 1940–1960 period,
(b) After division close to the distal insertion when most presentations and repairs were delayed,
presents a conflict of opinion as to whether the FPL
Extended Primary Repair should be repaired by interpositional grafting or by
Primary repair with proximal tendon lengthening proximal tendon lengthening, either in the muscle or
in the tendon at the wrist, with direct repair being
Secondary Reconstruction
entirely avoided by many authors, or exceptional, except
1. No surgery
after very early presentation for others. Urbaniak and
2. Distal tenodesis of the FPL or IP joint fusion
3. Tendon grafting in one stage Goldner favored direct repair when possible and used
4. Tendon grafting in two stages the other techniques when the tendon gap was too
5. Tendon transfer wide.10,11 They found the results of tendon lengthening
in their unit to be better than those of interposition
grafting in those cases in which direct repair was not
possible. In their writings, others are more circumspect
also has some merit. With multiple tendon injuries as to whether tendon lengthening gives better results
within the carpal tunnel, swelling of the tendons makes than tendon grafting.5,6 This debate as to the relative
tethering of the multiple repairs within the tunnel likely. merits of extending primary repair by proximal length-
With this rare injury, we have previously provided suf- ening or moving on to grafting continued through the
ficient space to avoid the problem of tethering of the period after 1970 and remains in the literature with
swollen tendons and impeded movement by repairing Schneider (1999), in Green’s Operative Hand Surgery,
only the finger profundus tendons and have repaired confessing to little experience with tendon lengthen-
the FPL tendon primarily. To achieve the necessary ing,12 while Matev (1983) considered Z lengthening in
repairs in the carpal tunnel requires division of the the musculotendinous part of the tendon as a logical
carpal ligament. To allow for swelling and avoid possi- extension of primary suturing and preferable to grafting
ble compression of the median nerve, we have not when the muscle has retracted but not undergone
reconstructed the carpal ligament but have mobilized degeneration and fibrosis.6 Our experience has largely
the tendons repairs in a neutral, or slightly hyperex- been after only slight delay of presentation, with muscle
tended, wrist position. shortening sufficient for primary suture to be under
tension, or significantly flex the IP joint, but before
TECHNIQUES TO EXTEND PRIMARY REPAIR
muscle degeneration. Proximal tendon lengthening
In general, the use of primary flexor surgery can be within the muscle by the Le Viet technique13 has usually
extended and secondary surgery avoided by (1) using achieved the lengthening of up to 1 cm required in
techniques that allow one to do more primary repairs, these circumstances. My experience of “Z” lengthening
such as undertaking delayed primary repairs, using of the FPL tendon at the musculotendinous junction14,15
proximal tendon lengthening, and using techniques is limited and usually as an adjunct to lengthening
such as splitting swollen tendons distally to allow their within the muscle where this alone is not adequate
passage through the pulleys7; (2) by using techniques (Figure 27-2). Pulvertaft (1966) wrote that a gap of 11 2
that reduce the failures of primary repair, such as to 2 inches (3.8 to 5 cm) could be closed by this tech-
improved rehabilitation; and (3) by re-repairing rup- nique alone.5 The long length of FPL tendon—3 to
tures.8 Many of these techniques are applicable to the 4 cm—at the wrist with no muscle fibers attached aids
divided FPL tendon. Occasionally, the FPL may be too this degree of lengthening without impingement of the
swollen to pass through the A1 and A2 pulleys. The tendon sutures on the carpal ligament on full extension
technique of halving the distal end of the tendon that of the thumb with the wrist dorsiflexed, if the lengthen-
we described to pass a swollen flexor digitorum profun- ing is carried out at the musculotendinous junction.10
dus (FDP) tendon through the A4 pulley7 can also be The adjacent muscle can also be tacked around the
used in FPL surgery (Figure 27-1). However, the most lengthening to make it more smooth. I have no experi-
significant problem preventing primary FPL repair is ence of Rouhier lengthening within muscle, still said to
the propensity of the FPL muscle to contract after divi- be used in France.16,17
sion of the tendon,9 and proximal tendon lengthening The practice of advancing the proximal end of the
to deal with this eventuality can be considered an FPL to allow direct reattachment to the distal phalanx
A B
C D
E F
Figure 27-1 The right thumb of a 54-year-old woman
who lacerated her thumb and required skin suturing only.
Six weeks later, the partially divided FPL tendon snapped
during use. A, The swollen FPL tendon held at the base
of the thumb. B, The FPL tendon is too swollen to pass
under the A1 pulley. C, The tendon is narrowed by distal
splitting. D, Repair with two Kessler sutures at 90° and
a simple running circumferential suture, with the repair
allowing full IP extension without snagging of the repair
on the A2 pulley or the junction of the tendon split
snagging on the A1 pulley. E, IP flexion limited by
G snagging on the oblique pulley. F, Fuller flexion after
venting of the oblique pulley. G, The final position of
the thumb is a little tight, presumably due to muscle
shortening as the tendon length has not been unchanged.
A B
C D
E F
Figure 27-2 A, Exploration of the thumb of a 45-year-
old man after primary repair of the FPL ruptured through
infection, with the arrows showing a considerable length
of the tendon replaced by scar. B, The arrow on the
thumb indicates the position of the distal end of the FPL
tendon when pulled distally. C, Showing the additional
length achieved by one Le Viet cut of the tendon in
muscle. D, Tendon suture indicates that the tendon is still
too short. E, Two Le Viet cuts still not providing sufficient
tendon lengthening. F, Further advance of the tendon by
Z lengthening at the wrist. G, Achieving adequate position
G of the IP joint.
Chapter 27: Secondary Reconstruction of the Flexor Pollicis Longus Tendon 289
after very distal division is frequently mentioned in the

literature. This can be considered as a means of dealing
with a gap in the tendon, albeit one created by the
surgeon by removing the distal segment of the FPL. A
warning is often given that such an advancement can
only be done without significant flexion contracture of
the IP joint if the division is within 1 cm of the inser-
tion. I believe this practice to be unwise and likely to
give rise to IP flexion contracture if an advancement of
even 1 cm is carried out. When the distal part of the
tendon is 3 4 to 1 cm in length, it is quite possible to
insert a core suture into the distal end of the tendon.
With divisions closer to the insertion than 3 4 cm, it is A
possible to leave the distal segment of tendon in place
and anchor the suture into the distal phalanx by one of
the various described techniques, after passage of the
sutures through the distal segment of the tendon. While
the small attached segment of tendon could be excised
and any IP contracture subsequent to advancement of
the proximal tendon corrected by lengthening of the
proximal tendon, this seems a complicated way of
achieving the same end.
B
NO FPL REPAIR
In respect of patients presenting after significant delay,
management by doing nothing, particularly if the car-
pometacarpal (CMC) and metacarpophalangeal (MCP)
joints are functioning normally, is generally only sug-
gested as suitable for the elderly.12 It has been my experi-
ence with several younger-than-elderly patients who
have presented late with inability to flex the IP joint that
they have been quite happy with the function of the C
thumb for their needs and, when the option of a com-
plicated operation and a lengthy rehabilitation period Figure 27-3 A 50-year-old woman who presented several
months after division of the FPL and declined surgery as she
is explained as the logical treatment of their problem,
thought that her disability was minimal. A, Full thumb
have declined any treatment (Figure 27-3). Doing
extension. B, Pinch to the index. C, Pinch to the little finger.
nothing or a (relatively simple) distal fixation procedure
to prevent hyperextension of the IP joint, if this is
causing problems of pinching, is definitely an option to
be discussed with all patients. As the variable hyperex- grafting or tendon transfer reconstruction, presumably
tension of this joint commonly seen, particularly in because the excursion of the new tendon is largely
supple hands, appears to have no useful function,18 such taken up by movement of the MCP and the segment
fixation causes no obvious deficit of thumb function. of new tendon beyond the MCP moves little during
When fixation of the IP joint is necessary, general obser- rehabilitation. I have tried passing a K-wire across
vation suggests that plastic surgeons prefer distal tendon the MCP for 4 to 6 weeks to prevent this failure to
tenodesis and orthopedic surgeons prefer joint fusions. achieve IP joint flexion,19 but with no greater success, as
Either, performed correctly, works well, but both require the patients reverted to MCP flexion on removal of the
1 to 2 months of protection before being used for force- K-wire. Tubiana (1988) warns that satisfactory flexion
ful pinching. A small but definite group of patients who of the distal phalanx will only be achieved by grafting
may be best advised to choose this option of manage- in the absence of hyperextension of the MCP joint.20 I
ment are patients with very mobile MCP joints who have no experience of this alternative problem of MCP
routinely flex the MCP joint through 40° to 50° degrees extension hypermobility affecting FPL surgery.
when pinching. This variation of thumb flexion can be
THE IDEAL OF INTERPHALANGEAL MOTION
ascertained by examining the contralateral thumb. In
my experience, these patients will continue to flex the With these exceptions, it is generally advisable in respect
MCP joint alone, with no, or little, IP flexion after either of best function of the thumb to try to achieve some
movement of the thumb IP joint. Our experience of 21 of 35 tendons.11 Matev (1983) warned that the FPL
primary repair of the extensor pollicis longus tendon18 muscle was particularly liable to lose its contractile
identified a group of patients who developed extensor qualities quickly after tendon division at the wrist,
tendon adherence by scar tissue to the underlying bone giving poor results from grafting.6 He recommended
and overlying skin, with loss of IP joint movement that that another motor be used more readily after tendon
caused functional problems. In this study, eight patients division at this level. This observation in itself appears
complained of difficulties with fine pinch functions inexplicable until considered in the light of Pulvertaft’s
such as the handling small screws, when the IP joint of observations as mentioned earlier. Of all FPL divisions,
the thumb has to flick back and forth rapidly over a those at the wrist are the most likely to suffer complete
small range of motion within its flexion range. This is retraction of the proximal tendon and muscle as there
most likely to be a problem to those in whom fine is little to hold the tendon to length, or partial length,
degrees of movement of this joint are critical, such as and complete retraction probably occurs immediately
musicians, surgeons, craftsmen, mechanics, and electri- after tendon division.
cians. The same problem arises if the FPL is not intact, Pulvertaft usually found the tendon and sheath distal
or the IP joint imperfect, and it is the loss of rapid move- to the division to be in good condition but warned that,
ment over a small range, rather than the loss of the fuller in children, there was no stimulus to develop and the
range of motion of this joint, that we record with a tendon and sheath remained as they had been at the
goniometer, which is the problem. The stated goal of a time of injury, necessitating reconstruction of an entirely
previous generation of surgeons of achieving only 30° new set of pulleys to retain any tendon graft.1 Once in
to 40° of IP movement to provide good function of the situ and working, the graft grows with the child’s hand
thumb is in keeping with the above observations.1,2 and late contracture due to relative shortening of the
graft is not seen.
TENDON GRAFTING—THE FPL MUSCLE
There is no way of determining the quality of
Where there is a delay of presentation and a significant the muscle before exposing the proximal tendon, so
gap between the tendon ends, it is usually recommended the possible need for another motor should always be
that a tendon graft be interposed. A sine qua non for explained before surgery to the patient. The FPL has a
this to be successful is that the FPL muscle is still func- functional amplitude of excursion of 5.5 to 6 cm23: if the
tional and has not fibrosed after shortening. This is a amplitude of excursion of the cut end of the proximal
particular concern after a delay of years between tendon tendon is far short of this, then it is unlikely that using
division and reconstruction. Pulvertaft (1988) addressed it as a motor for reconstruction will achieve much in
this subject by examination of 77 tendon grafts per- respect of IP joint flexion. Matev provided a useful rule
formed more than 2 years after tendon division, of of thumb in this respect: if the passive stretch of the
which 11 were divisions of the FPL.1 This study recorded muscle fibers, measured at the wrist, is 3 to 4 cm, full
an average joint range of the IP joint of the thumb of restoration of function may be expected.6 Even with 1.0
64° in a population of patients of average age of 18 to 1.5 cm of passive stretch, the result is likely to be ade-
years at operation, after an average delay of 51 2 years. quate. If less than this, he advised using another motor.
This study showed that muscle shortening does not
TENDON GRAFTING—BRIDGE GRAFTS
occur as often, or as severely, as might be expected.
Tendons retract only as far as natural structures attached Although some authors recommend and illustrate inter-
to them permit, provided these do not rupture at the position of short segments of graft to bridge gaps,20,24 I
time of injury, or immediately after. The FPL only very believe that it is more logical in most situations to use
rarely has a lumbrical.21 The distal vinculum brevis is long grafts that take the suture lines to the wrist and the
present in 90% of thumbs and is strong.22 If intact after distal insertion of the FPL tendon, as short segment
injury at the level of the IP joint, it may transmit some grafting most commonly creates a suture line within the
amount of flexion of the IP joint and it will retain the narrow confines of the digital sheath or in the thenar
FPL within the thumb. The existence of a true vinculum muscles, or both. Because of the other tendon, artery,
longus is debated.10 Pulvertaft thought that local adhe- and nerve injuries, it is rare for a division of the FPL
sions played a part in maintaining the tendon in the tendon at the wrist not to be repaired primarily. Where
thumb. A partial division of a tendon that ruptures later it is not, a short segment of graft will reestablish contact
may have the same effect, as a result of edema in the between the distal tendon and the retracted proximal
tendon preventing retraction (see Figure 27-1). There- tendon and can be used, provided the muscle has not
fore, the muscle may still be functional, albeit partially, lost its contractility early, as discussed above. Care is
and its integrity preserved, after a considerable period necessary to avoid impingement of the distal suture line
of time. More recently, Urbaniak and Goldner (1973) on the proximal edge of the carpal ligament on full
recorded retraction of the proximal tendon to the thenar thumb extension and this part of the ligament may have
area or wrist after laceration distal to the MCP joint in to be resected.
TENDON GRAFTING—WRIST–TO–DISTAL
PHALANX GRAFTS
A length of tendon graft of 13 to 14 cm is sufficient to
replace the FPL from the wrist to the distal phalanx.
Palmaris longus (PL) is usually of suitable length, always
of suitable diameter and conveniently near to hand. It
is also present in a very high percentage of the popula-
tion. Plantaris is probably the next choice although it is
often very thin and difficulty to suture well with convic-
tion. It remains a matter of wonder to me that it usually
retains its distal attachment throughout rehabilitation.
My third option is the extensor indicis tendon as this
tendon is of adequate length, is sufficiently thick as to
be easy to sew, is near to hand, can be harvested through A
small dorsal incisions, is almost always present, and is
seldom missed, as we know from our various other
uses of it.
TENDON GRAFTING—DISTAL AND
PROXIMAL ATTACHMENT
Grafting of the FPL is generally carried out using various
techniques of distal attachment to the distal phalanx of
the thumb and a Pulvertaft weave proximally. I routinely
suture the Pulvertaft weave with a continuous 4-0
Prolene suture (Figure 27-4), which starts at one end of
the weave and returns to the same end to be knotted
with a single knot. I prefer this technique to leaving
multiple knots along the weave, which are more likely
to snag. It is seldom that the passage of the needle cuts B
a previous pass of the suture. Even if it does and a
second knot is required, this technique is still faster and Figure 27-4 A 48-year-old man who ruptured a primary
neater than the conventional use of multiple suture and repair of the FPL. Reconstruction at immediate exploration
with a one-stage PL graft from the wrist to the distal
knots.
phalanx of the thumb. A, The technique of suturing the
TENDON GRAFTING—THE THENAR TUNNEL Pulvertaft weave at the wrist using a single continuous
suture is illustrated in close-up (B).
The most difficult technical activity in secondary recon-
struction of the FPL is passing the new tendon, or the
silicon rod if a two-stage procedure is carried out,
through the thenar muscles, particularly if the tunnel is
scarred and closed. Good exposure of the entry to the the tension of the graft is set by placing the hand flat on
tunnel at the base of the thenar muscles includes fully the table with the thumb in a position of slightly
opening the carpal tunnel and identifying the motor increased flexion over its normal resting position, then
branch of the median nerve and the sensory branches using the wrist tenodesis action to check that the IP joint
to the thumb more distally. Where the tunnel is present, of the thumb is fully extended when the wrist is held in
the tendon can be pulled through to the base of the full flexion and is partially flexed and opposed when the
thumb with a fine tendon passer or attached by a suture wrist is extended to the functional position.24 Schneider
to a small-bore stiff plastic tube. Where necessary, the (1999) detailed a more precise setting of the wrist at 0°,
tunnel is recreated with McKindoe scissors and, mostly, the thumb abducted in front of the index finger meta-
blunt dissection. Under these circumstances, we would carpal, and the IP joint of the thumb in 30° of flexion.12
use a two-stage tendon graft reconstruction. Matev suggested the IP joint be set at 20° to 30°.6 All
of these recommendations are very similar in practice
TENDON GRAFTING—THE TENSION
and can all be used in combination. In general, the
OF SETTING IN THE GRAFT
tension should be a little greater than normal, allowing
The tension at which the graft is set is important. Camp- for the fact that the contracted muscle will extend
bell Reid and McGrouther (1986) recommended that slightly towards normal with subsequent use.1 A graft
A B
Figure 27-5 Exploration of a nonfunctioning FPL in a
48-year-old woman 4 months after removal of a plate
elsewhere that had been used to treat a radial fracture 5
years earlier. The plate was perceived to be the cause of
difficulties of finger and thumb movement. A, View after
extensive tenoneurolysis (with the appearance of the
median nerve as an indicator of the degree of scarring
prior to tenoneurolysis). The FPL muscle was completely
bound in scar tissue and nonfunctional. B, The FPL
tendon had snapped or been divided at removal of the
plate, with the distal end resting at the MCP level of the
thumb. C, Insertion of a silicone rod with a view to
performing a secondary FDS tendon transfer from the
ring finger.
that is too tight is more likely to gain extension than entirely without supplement by a tendon graft. This
one that is too slack to regain flexion. transfer also needs little re-education. Little has been
written in recent years about this transfer but what has
TENDON TRANSFER
been written is favorable.25,26
Where there is doubt as to the function of the FPL While some authors suggest transfer of the FDS
muscle at exploration (Figure 27-5), it is necessary to tendon of the ring finger as an alternative to grafting of
use a tendon transfer to provide another motor for the FPL,27 I do not agree with this for various reasons.
thumb flexion. While the flexor digitorum superficialis Use of this tendon transfer introduces a further com-
of the ring finger, the PL, the brachioradialis, and the plexity to the situation. Weakening the ring finger may
flexor carpi radialis have all been suggested as suitable have little functional significance, but it has been my
for this transfer, the first is that normally used. The PL experience, even with a very experienced and large
is an antagonist to the FPL, making re-education more therapy department looking after these patients after
difficult. Dissection of the brachioradialis is unnecessar- surgery, that the subsequent mobility of the ring finger
ily extensive, compared with that necessary to harvest is not always normal. In particular, in a white popula-
the flexor digitorum superficialis (FDS) of the ring tion, loss of extension of the proximal interphalangeal
finger, and leaves a long and visible forearm scar to no (PIP) joint as a result of palmar plate contracture is
particular advantage. The FDS of the ring finger can be possible. Those with more mobile joints are more
harvested without difficulty through small incisions that likely to suffer swan-necking unless the distal end of the
fade to be inconspicuous at the base of the finger and FDS tendon is carefully sutured to the sheath or A2
in the palm, if a palmar incision is needed. The length pulley proximal to the PIP joint. More significant inter-
of the tendon is such that it will always replace the FPL ference with normal flexion and extension movements
of the remaining flexor tendon may occasionally arise

as a result of adhesion formation. Ebelin et al also
reported problems with this reconstruction, including a
problem of cortical integration in two cases.16 Therefore,
I believe this transfer, although a relatively simple pro-
cedure, should only be used if the FPL muscle is not
functional or has been badly damaged in a complex
forearm injury. This view is supported by most previous
authors. Without knowledge of the mentioned possible
problems, many patients also see this as an unneces
sarily complex alternative to reconnecting the original
system.
TWO-STAGE TENDON GRAFTING
Most authors recommend single stage reconstruction of A
the FPL and this would seem reasonable where the
suture lines are placed at the wrist and the distal phalanx
and not within the digital tendon sheath or the thenar
muscles. However, there are circumstances in which two
stage reconstruction28-32 can be useful, or advisable,
whether the actual reconstruction is by grafting or
tendon transfer. Some cases in my unit requiring sec-
ondary FPL reconstruction have already had a primary
repair that has stuck and is found at tenolysis to have a
gapped tendon. Removal of the tendon may leave a
badly scarred sheath (see Figure 27-5) and/or damage
of the pulleys (Figure 27-6) to an extent that reconstruc-
tion of new pulleys is necessary. A few more primary
repairs rupture and, for a variety of reasons (see Chapter
19), cannot be re-repaired, although they generally B
re-present to us early. In all of these cases, we insert a
silicone rod, with reconstruction of new pulleys over the Figure 27-6 Immediate exploration of the FPL in a
rod if need be. This is a convenient means of both creat- 32-year-old woman after rupture of a primary repair.
A, Pulley reconstruction using the discarded distal FPL over
ing a better tendon “tunnel” and recreating pulleys that
a tendon rod as the first stage of a two-stage reconstruction.
will not be expected to withstand the forces of a func- B, The completed pulleys.
tioning tendon for a few months. Many of these failures
of primary surgery are known better to us and our thera-
pists than cases presenting acutely; a human factor also
comes into our choice of two-stage grafting. These recent reports33,34 of two-stage FPL grafting achieved the
patients have already had primary surgery fail, so they 30° to 40° of IP motion required for fine pinch func-
may be at least as likely to have secondary surgery fail tion but their results are disappointing compared to the
for reasons as diverse as that they are noncompliant extraordinary results mentioned earlier of Pulvertaft1 in
with therapy, they live too far away to attend therapy, patients presenting after long delays. However, many
other home circumstances militate against their attend- hidden factors may be at play here, not the least being
ing therapy, they have a very low pain tolerance, the the difference between the average age of Pulvertaft’s
initial injury was more severe and likely to have laid group of 18 years and that of the patients in these
down considerable scar in the thumb, etc. Under such studies. I also believe that the delay between the stages
circumstances, we believe that the two-stage process in one study34 of 8 weeks is too short.
gives them the best chance of avoiding adherence of the The presence of an annular pulley at the base of the
tendon and further tenolysis surgery. In other circum- thumb is essential to FPL function. In most circum-
stances, where presentation is delayed and the sheath is stances where pulleys need to be reconstructed, the
found to be badly scarred, such as after tendon sheath clinical situation includes a need for secondary recon-
infection, or complex thumb injuries that include major struction of the FPL tendon and we prefer to reconstruct
loss of the palmar surface soft tissues, including the the pulleys over a silicone rod at a first stage and recon-
palmar face of the sheath and/or the pulleys, two-stage struct the flexor tendon later (see Figure 27-5). This
secondary reconstruction has the same benefits. Two allows the use of a pulley reconstruction in which the
new pulley, typically made from discarded tendon, which leaves a prominent scar on the dorsum of the
which has been split longitudinally, is simply sutured wrist.
to the remnants of the sheath on either side of the sili- Many secondary reconstructions of the FPL tendon
cone rod. By the time of replacing the rod with a func- will be carried out within a few weeks of the primary
tioning tendon, the bond of the pulley at its lateral injury and the need to consider use of the techniques
margins is strong. This reconstruction also avoids enter- of tendon reconnection described in this chapter only
ing the extensor space of the thumb, with the inherent become apparent at surgery, when it is seen that a simple
risk of extensor adhesion and loss of passive flexion of primary repair cannot be carried out. Other cases will be
the thumb joints. However, the situation does arise undertaken as a one-stage reconstruction after a greater
where the patient presents with an intact FPL with bow- delay, or will undergo a two-stage reconstruction. In
stringing from previous loss of the A1 and oblique these cases, where there has been an injury but no imme-
pulleys alone (see Figure 27-6). The need to re-create a diate surgery or a first stage tendon operation, it is advis-
pulley at the base of the thumb, which must immedi- able to delay the second operation and have the patient
ately withstand the forces of a functional FPL, also arises undertake preoperative therapy with passive forced
if a decision is made to reconstruct both the pulley and flexion exercises and ultrasound to mobilize the extensor
the FPL at a single stage (Figure 27-7). These cases tendon. The thumb is no stranger to tethering of the long
require a new pulley with immediate strength. Invasion extensor tendon and tightening of the dorsal capsules of
of the extensor space with the risk of extensor tethering the MCP and IP joints with loss of passive flexion of
is surrendered here to achieve strength.35 We prefer to these joints.18,35 The result of the subsequent FPL recon-
reconstruct the pulley by use of a tendon, as described struction can only be as good as the maximum passive
in 1944 by Bunnell,36 rather than using the extensor flexion of these joints. I agree with Pulvertaft’s policy of
retinaculum, as described by Lister,37 the harvesting of allowing a minimum of 6 months between injury and
A B
C D
Figure 27-7 A, Six-year bowstringing in a 44-year-old woman. B–D Reconstruction of a pulley at the base of the thumb
over an intact FPL tendon using PL tendon passed around the phalanx and under EPL.
reconstruction whenever possible, particularly as the strong, but the other two problems, particularly those
lack of an FPL tendon does not negate use of the thumb.1 on the dorsal surface of the thumb, are common enough
We use a similar gap in time between the stages of a that full free and fast movements of the IP joint, which
two-stage procedure. This advice applies to the Northern are the long-term goals of FPL surgery, are often less
European hand, and hands of Northern European origin, than perfect, even if better than preoperatively. Patients
and may not be necessary in other parts of the world. should be advised of this accordingly and consideration
given seriously to the option described regarding no FPL
TENDON GRAFTING—REHABILITATION
repair, even if only to delay the secondary surgery for
Our splinting regimen and rehabilitation after all sec- sufficient time for the patient to assess whether recon-
ondary FPL reconstructions are exactly as for primary struction is necessary.
repair of this tendon, i.e., early active mobilization in a
CONCLUSION
protective dorsal splint (see Chapter 16), although one
could argue reasonably for a more relaxed regimen as In writing this paragraph, I make no apology for repeat-
the both tendon sutures are much stronger than an ending the opinions of some of the experts of old in this
to-end primary repair. It is necessary to include a dorsal field so freely. My generation of surgeons were brought
splint behind the fingers as well as behind the thumb up to carry out primary flexor tendon repairs for most
and prevent finger gripping activities, as these are fol- patients, as witness the 215 patients with primary repair
lowed by movement of the thumb into tight flexion over of divisions of the FPL over the 20 years of my consul-
the dorsum of the index finger, which may rupture any tant practice who are the basis of the research described
suture of the FPL. in Chapter 16. This leaves only a few who got through
the primary catchment net during this period, or failed
OUTCOMES AND PROGNOSIS
to complete rehabilitation, and required secondary
It is my impression, from accumulated experience of reconstruction, subsequently. I perform these secondary
these secondary operations over twenty years, that the reconstructions of the flexor pollicis longus now much
results of the various procedure in which the FPL tendon less than primary repairs. By comparison, the authors of
is reconstructed secondarily are mostly functionally the past carried out many more secondary reconstruc-
better than before reconstruction, although they are tions. Given that the techniques of reconstruction are
subjected to the same problems as all flexor tendon entirely unchanged, their experience is invaluable for us
surgery, namely loss of IP joint flexion as a result of and it is my impression that the uses to which they were
extensor tendon tethering and joint dorsal capsule tight- put by the masters of an earlier era were well thought
ening, repair rupture, and flexor tendon tethering. out, logical, and improved on the preoperative thumb
Rupture is uncommon as the repair techniques are function.
References
1. Pulvertaft RG: Flexor tendon grafting after long delays. In 9. Murphy FG: Repair of laceration of flexor pollicis longus
Tubiana R, editor: The Hand, Vol 3, Philadelphia, 1988, WB tendon, J Bone Joint Surg (Am) 9:1121–1123, 1937.
Saunders, pp 244–254. 10. Urbaniak JR: Repair of the flexor pollicis longus, Hand Clin
2. Schneider LH, Wiltshire D: Restoration of flexor pollicis 1:69–76, 1985.
longus function by flexor digitorum superficialis transfer, 11. Urbaniak JR, Goldner LJ: Laceration of the flexor pollicis
J Hand Surg 8:98–101, 1983. longus tendon: delayed repair by advancement, free graft or
3. Giesen T, Sirotakova M, Elliot D: Flexor pollicis longus direct suture, J Bone Joint Surg (Am) 55:1123–1148, 1973.
primary repair: further experience with the Tang technique 12. Schneider LH: Flexor tendons—late reconstruction. In Green
and controlled active mobilisation, J Hand Surg (Eur) 34: DP, Hotchkiss RN, Pederson WC, editors: Green’s Operative
758–761, 2009. Hand Surgery, Vol 2, ed 4, New York, 1999, Churchill Living-
4. Sirotakova M, Elliot D: Early active mobilization of primary stone, pp 1915–1918.
repairs of the flexor pollicis longus tendon with two Kessler 13. Le Viet D: Flexor tendon lengthening by tenotomy at the
two strand core sutures and a strengthened circumferential musculotendinous junction, Ann Plast Surg 17:239–246,
suture, J Hand Surg (Br) 29:531–535, 2004. 1986.
5. Pulvertaft RG: Flexor tendon grafting. In Flynn JE, editor: Hand 14. Nigst H, Megevand RP: La réparation du long fléchisseur du
Surgery, Baltimore, 1966, Williams and Wilkins, pp 297–314. pouce. Technique de l’élongation du tendon, Helv Chir Acta
6. Matev IB: Reconstructive Surgery of the Thumb, Brentwood, 4/5:456–459, 1956.
1983, Pilgrim’s Press, pp 50–56. 15. Vigliani F, Martinelli B: Repair of rupture of flexor pollicis
7. Elliot D, Khandwala AR, Ragoowansi R: The flexor digitorum longus by “Z” lengthening at the wrist, Ital J Orthop Trauma
profundus “demi-tendon”: a new technique for passage of 2:171–179, 1981.
the flexor profundus tendon through the A4 pulley, J Hand 16. Ebelin M, Le Viet D, Lemerle JP, et al: Chirurgie secondaire
Surg (Br) 26:422–426, 2001. du long fléchisseur du pouce, Ann Chir Main 4:111–119, 1985.
8. Dowd MB, Figus A, Harris SB, et al: The results of immediate 17. Rouhier G: La restauration du tendon du long fléchisseur du
re-repair of zone 1 and 2 primary flexor tendon repairs which pouce sans sacrifice du tendon primitif, J Chir 66:537–542,
rupture, J Hand Surg (Br) 31:507–513, 2006. 1950.
18. Khandwala AR, Blair J, Harris SB, et al: Immediate repair and 28. Bassett AL, Carroll RE: Formation of tendon sheaths by sili-
early mobilisation of the extensor pollicis longus tendon in cone rod implants. In Proceeding of the American Society for
zones 1-4, J Hand Surg (Br) 29:250–258, 2004. Surgery of the Hand, J Bone Joint Surg (Am) 45:884, 1963.
19. Brown CP, McGrouther DA: The excursion of the tendon of 29. Hunter JM: Artificial tendons: Early development and
flexor pollicis longus and its relation to dynamic splintage, application, Am J Surg 109:325–338, 1965.
J Hand Surg (Am) 9:787–791, 1984. 30. Hunter JM: Staged flexor tendon reconstruction, J Hand Surg
20. Tubiana R: Flexor tendon grafts in the hand. In Tubiana R, 8:789–793, 1983.
editor: The Hand, Vol 3, Philadelphia, 1988, WB Saunders, 31. Hunter JM, Salisbury RE: Flexor tendon reconstruction in
p 237. severely damaged hands. A two stage procedure using a sili-
21. Hollinshead WH: Back and limbs. In Anatomy for Surgeons, cone Dacron reinforced gliding prosthesis prior to tendon
Vol 3, ed 2, New York, 1969, Harper, p 410. grafting, J Bone Joint Surg (Am) 53:829–858, 1971.
22. Armenta E, Fisher J: Anatomy of flexor pollicis longus vincu- 32. Mayer L, Ransohoff N: Reconstruction of the digital tendon
lum system, J Hand Surg (Am) 9:210–212, 1984. sheath: a contribution to the physiological method of repair
23. Kaplan EB: Functional and Surgical Anatomy of the Hand, ed 2, of damaged finger tendons, J Bone Joint Surg (Am) 18:607–
Philadelphia, 1965, Lippincott, p 12. 616, 1936.
24. Campbell Reid DA, McGrouther DA: Surgery of the Thumb, 33. Frakking TG, Depuydt KP, Kon M, et al: Retrospective outcome
London, 1986, Butterworth, pp 30–36. analysis of staged flexor tendon reconstruction, J Hand Surg
25. Posner MA: Flexor superficialis tendon transfers to the (Br) 25:168–174, 2000.
thumb—an alternative to the free tendon graft for treatment 34. Unglaub F, Bultmann C, Reiter A, et al: Two-staged recon-
of chronic injuries within the digital sheath, J Hand Surg struction of the flexor pollicis longus tendon, J Hand Surg (Br)
8:876–881, 1983. 31:432–435, 2006.
26. Schneider LH, Wiltshire D: Restoration of flexor pollicis 35. Kulkarni M, Harris SB, Elliot D: The significance of extensor
longus by flexor digitorum superficialis transfer, J Hand Surg tendon tethering and dorsal joint capsule tightening after
(Am) 8:98–101, 1983. injury to the hand, J Hand Surg (Br) 31:52–60, 2006.
27. Razemon JP, El Hassar S, Meresse B: Les réparations 36. Bunnell S: Surgery of the Hand, Philadelphia, 1944, Lippin-
secondaires du long fléchisseur du pouce par transposition cott, p 315.
du fléchisseur superficial du IV, Lille Chir 26:198–205, 37. Lister GD: Reconstruction of pulleys employing extensor reti-
1971. naculum, J Hand Surg (Am) 4:461–464, 1979.
CHAPTER
28
STAGED TENDON GRAFTS AND
SOFT TISSUE COVERAGE
OUTLINE graft with fingers that simply need a graft instead of a

primary repair to reconnect the tendons.
The following quotation clearly identifies the intended Wherever one practices, the patients included in the
benefit of two-stage tendon grafting. The evolution of group “secondary flexor tendon surgery” will include
the technique is recorded and its benefits discussed, some of your “worst” injuries and “worst” patients.
including the use of the technique to deal with These cases are more likely to do badly whatever one
problems requiring pulley and skin reconstruction does and may do no better after secondary surgery than
simultaneously with reconstituting the flexor tendon they did the first time, if they have already undergone
system. primary surgery. Unfortunately, conventional one-stage
secondary flexor tendon surgery is not always followed
The objective of the two-staged flexor tendon method is
by satisfactory return of flexor function. Two-stage flexor
to improve the predictability of final results in difficult
tendon grafting was introduced with the intention of
problems dealing with tendon reconstruction.
achieving better results under circumstances where the
Hunter, 19901
likelihood of poor results can be identified. The per-
The ideal treatment of flexor tendon injuries under ceived advantage over single-stage grafting is that mobi-
almost every circumstance is primary repair. I believe lization of the tendon graft following the second
this to be true whether the injury is a simple laceration operation is started with the graft moving in a smooth-
of the finger or a replantation, as it is easier to rehabili- walled pseudo-sheath, created by the silicone rod over
tate a finger over the several months following injury several months after insertion at a first operation, and
with the finger flexing actively than being flexed pas- in a less traumatized, less painful, and more supple
sively. However, this is not always possible. A percentage hand. Despite a very small incidence of reaction to sili-
of primary repairs may also either become adherent to cone rods and a small incidence of infection and/or
their surrounds, gap, and become secondarily adherent extrusion of the rods, the two-stage procedure appears
to their surrounds, or rupture. All of these circumstances at least to reduce the influence of the “scarring” factors
may lead to “secondary flexor tendon surgery,” which is on the result.
a broad description of a variety of procedures, including The primary, and most significant, problem of flexor
tenolysis, tendon grafting, pulley reconstruction, and tendon surgery is the formation of adhesions between
skin replacement over the tendons. Although tendon injured tendons and their surrounds, particularly the
grafting may give comparable results to primary flexor tendon sheath within the digits and distal palm. Over-
tendon repair in the hands of some experts, general coming adhesion of repairs to the sheath has been
opinion would support the view that primary repair is the driving force for most research in this field over the
less difficult for most surgeons and more likely to be past 100 years. Mayer and Ransohoff (1936), writing in
more successful, even if this has never been proved by the era when delayed flexor tendon grafting was the
comparative trial. For most of us, tendon grafting is routine,2 described how “these adhesions extend from
more difficult, therapy is more vital to success and the the point of division of the tendons down to the distal
results are usually less near to normal. The reported end of the digital theca (tendon sheath)… . It is obvious
results of secondary flexor tendon surgery are generally that the normal gliding mechanism of the tendon has
worse than those of primary surgery. Undoubtedly, this been completely destroyed and that, consequently, the
relates, not only to surgical technique, but also to the conditions for re-establishing free gliding of a trans-
fact that we collect and report all secondary flexor planted tendon are so unfavorable that only in excep-
surgery cases together. We are bundling together the tional instances can an implanted tendon perform its
complex cases who also, and incidentally, need a tendon normal function.” Mayer was the first surgeon to try to
297
reestablish the milieu required for free gliding of the

CHOICE BETWEEN SINGLE-STAGE AND
tendon within the sheath by insertion of an inert rod,
TWO-STAGE GRAFTING
then, at a later stage, replace this with a tendon graft.
He used celloidin tubes but had to abandon his experi- Although much of the flexor tendon surgery performed
ment to create a “pseudo-synovial” sheath as these were in western Europe is primary surgery, we do have to
too rigid. Twenty-five years later, Bassett and Carroll undertake a surprising amount of secondary flexor
(1963) repeated the work using silicone rods.3 James surgery, some of which is because of delayed presenta-
Hunter carried this work forward through the 1960s and tion and some of which is because the flexor tendon
1970s to establish the technique clinically.1,4-10 The suc- injury quite frequently does not come as an isolated and
cessors to the rods of woven Dacron covered by silicon simple one but rather in association with injuries to
developed by him for use in staged flexor tendon graft- other tissues. Nevertheless, secondary surgery for us is
ing are known to us all today simply as “Hunter” rods. mostly that of the complications of primary repair,
Curiously, Hunter’s first use of a silicone rod was to namely ruptured and adherent primary repairs, as the
replace an extensor tendon. The rod was sutured to the results of the initial surgery are not universally good. In
extensor tendon with fine wire. It became clear that the the best units, the failures constitute about 10% of all
rod was being stretched and acting as an elastic band to primary repairs, not a small number and something of
pull the flexed finger back into extension when the an indictment of our present techniques of primary
flexor tendon relaxed. Had the wire suture not pro- flexor tendon surgery. The cases that come to secondary
truded through the skin, there would have been no surgery are mostly either the result of more severe inju-
second stage. On exploration of the protruding wire, it ries or have occurred in patients who make excessive
was clear to Hunter that a shiny mesothelium-lined amounts of scar tissue or have not cooperated with
membrane had formed around the rod. The rod was therapy because of low pain thresholds, social circum-
replaced by a tendon graft and the finger went through stances, or lack of judgment.12 Therefore, the cases
rehabilitation to achieve acceptable function. Hunter’s needing secondary surgery can be considered under the
initial intention was to design an artificial tendon for headings of either “bad injuries” or “bad patients.” Else-
permanent use and he pursued both the concept of the where in the world, many patients will only get to an
pseudo-sheath and the idea of a permanent artificial appropriate surgeon at a time when secondary repair of
tendon replacement in his research. While the former the tendon using grafts is the only option because of
has become part of the armamentarium of most hand proximal tendon retraction. This, by definition, becomes
surgeons, a permanent artificial tendon remains “experi- “secondary flexor surgery,” although the problem is
mental,” largely because of the problems of achieving a simply an extended finger with good passive but no
permanent bond between the rod and the biological active flexion but now no longer amenable to direct
tissues to which it must be attached proximally and repair. However, among the patients presenting after
distally. delay, and also defined as undergoing “secondary flexor
surgery,” are a group with much more complicated
THE PSEUDO-SHEATH
problems, sometimes as a result of injuries to the other
After implantation, the silicone rod holds the adjacent structures of the digits and, sometimes, as a result of the
tissues apart. Microscopic studies show that the pseudo- unaided healing process within a digit in the presence
sheath is not simply a tube of scar.11 The tissues adjacent of an inactive flexor system. The problems in these cases
to the rod organize over a few days into a mesothelium- are not simply those of being unable to get the tendon
like layer. In the chicken experiments described by ends together. So, in terms of the pathologies in the
Salisbury and his colleagues, this intima consisted pre- digits themselves, the problems we all face in the rather
dominantly of one layer of flattened fibroblasts with heterogeneous mix of cases that we call “secondary
a surface made irregular by pleats and pores, whereas flexor tendon surgery” are not so different—namely,
the normal tendon sheath has an intima of several flexor tendons that are not intact and flexor tendons that
layers of thicker, cuboidal cells. The intima also con- are stuck in scar tissue, variably associated with divided
tained macrophages, intermediate cells, mast cells, and pulleys, skin deficit on the flexor aspect of palm and
Schwann cells. By 4 to 6 weeks, the deeper tissues have digits, stiff fingers, and injuries to other, adjacent struc-
formed a second layer of loose, well-vascularized con- tures in the fingers, hand, or forearm.
nective tissue and the pseudo-sheath has a basic appear- Whether we should be carrying out single-stage or
ance similar to normal synovial sheath. The collagen in two-stage tendon grafting, or a mixture of both, depend-
the outer layer was of variable thickness and contained ing on the individual case, is a matter of opinion with
collagen, reticulum, and elastic and unmyelinated nerve little hard fact to support either side of the debate. It is,
fibers. The collagen was orientated along the axis of the perhaps, worth remembering that the two-stage graft
implant much as it is orientated along the lines of stress was introduced because of dissatisfaction with the
in a tendon sheath. results of the one-stage procedure, albeit in North
Chapter 28: Staged Tendon Grafts and Soft Tissue Coverage 299
America, which has a largely white population of infection and those who re-rupture the re-repair will
Northern European origin. When the scar tissue between present at a later stage for tendon grafting but also may
the tendon and sheath is fine and diaphanous, we talk be unsuitable for single-stage grafting, for a variety of
of “adhesions” and two-stage grafting seems to be reasons, including those grouped together above under
overkill. When the scar is more dense, we talk not of “bad injury” and “bad patient.”
adhesions but of scarring! This is an inconsistency of A small group of patients presenting with severe and/
surgical thought as either can prevent movement and, or contaminated injuries, sometimes with missing seg-
perhaps, it might be better to stage the grafting in all ments of the flexor tendons, are deemed unsuitable for
cases, because a failure of secondary flexor tendon primary repair. This subject is discussed in Chapter 9 by
surgery is usually a handicap for life and can even lead Professor Tang. While we endeavor to carry out primary
the patient to demand amputation. repairs now in most of these patients while carrying out
I almost always use two-stage grafting as I was brought the other procedures necessary to their overall hand
up at a time and place where this was believed to give reconstruction, then mobilize them as early as possible,
the best results. Sometimes, it seems that this is overkill, there are some cases where primary repair is impossible.
particularly when the sheath is not badly scarred. Whenever possible in such cases, we insert tendon rods
However, most of my cases for tendon grafting are into the flexor sheaths to maintain these until the flexor
patients for whom primary surgery failed and, as a tendons can be reconstituted at a later date.
group, are “bad patients,” as defined earlier. Although Most other situations in which the surgeon has to
not the reason for doing two-stage grafting when I consider the need to graft arise in clinic in preparation
started, I have come to realize that this technique may, for exploration of digits with various deficits of move-
particularly, suit these cases and my practice. More gen- ment on elective surgical lists, whether after delayed
erally, it is also the case that no one has worked out how presentation or after problems following primary
to identify the “bad patient,” whether in northern surgery. In clinic, the latter group of patients have to be
Europe, or elsewhere. told that the surgeon cannot predict whether the need
Two-stage graft surgery can be unrealistic to the eco- at surgery will simply be to free the (intact) tendon from
nomic needs of many patients in many parts of the scarring and then move it as early as possible to prevent
world and the circumstances of hand practice elsewhere readhesion, with 2 to 4 weeks off work, or the tendon
push surgeons more toward single-stage grafting. Prag- will be found to have gapped or be so scarred that
matism in this respect, and one’s early teaching and releasing it intact from the scarring will prove impossi-
experience, is probably the major determinant of the ble. If grafted immediately, this will require a 2- to
preferences of different surgeons for single or two-stage 3-month period without use of this hand while the graft
grafting! Despite the preference for single-stage grafting heals fully at each end. The dilemma for the patient,
of many senior surgeons, who may have great skill in given this information and, often, having just had a long
this, and the supportive feeling that the particular sup- period off work, is that he or she cannot tell his, or her,
pleness of the hands of certain peoples, compared to the employer how long the period off work after surgery will
hand of those of northern European origin, allows be until after the event. Under these circumstances,
single-stage grafting to be effective more often, there will many, if given the option of staged grafting, will prefer
be circumstances where this expedient may be so to have a rod inserted, buddy strap the finger to the
unlikely to give a good result that the two-stage graft adjacent one for use for a few months, and choose
should be considered by even the most ardent supporter an opportune time from the point of view of his or
of the one-stage graft. her employment to have a graft inserted and the subse-
Previously unemphasized reasons for staging grafting quent 2 to 3 months of one-handed life. The second
have become evident in my practice over the past 20 stage can be carried out at any time after the hand has
years. Some patients present with ruptures of primary become supple, giving the patient a wide choice of the
repairs and undergo immediate exploration with a view timing of the second operation. That the second stage
to re-repair.13 If it is found at surgery that re-repair is not is inevitably being planned with a minimum of 3 to 4
possible, we routinely put a tendon rod into the finger, months’ notice is often convenient to the work situation
with the rod being replaced by a graft when the finger in Europe.
has settled. At this point in time, the finger is often Where it is obvious in clinic that there is either a pulley
unsuited to a single-stage tendon graft procedure or skin deficit on the palmar aspect of the finger, or both,
because of its swollen condition, this being the third I also advise two-stage grafting because (1) I believe it is
traumatic episode for this finger (exploration of the easier to deal with the deficit(s) surgically without having
rupture following after the causative incident and the the reconstructions of pulleys and/or skin mobilized
primary repair) in a short period of time. Others who aggressively in the early postoperative period, as is neces-
rupture a primary repair and cannot undergo immediate sary to maintain movement of a tendon graft, and (2) it
re-repair for reasons such as skin breakdown and is easier to rehabilitate the tendon graft after the second
operation without restrictions to protect reconstructions intact tendons and intact pulleys after surgical dissec-
of pulley and/or skin deficiencies. tion is impossible (Figure 28-1). The second is finding
a gapped tendon with scar in the tendon gap after a
THE CLINICAL PRINCIPLES OF TWO-STAGE previous primary repair. The tendon is now several mil-
TENDON GRAFTING limeters too long, and tenolysis is likely to be followed
by re-adhesion as the tendon will be moving less than
Detail of the First Stage optimally during rehabilitation. It is usually the case
This often begins as the exploration of a digit with a that these tendons are considerably scarred within the
deficit(s) of movement on an elective surgical list. tendon sheath, possibly because the gapped tendon has
Simple statements, such as “tenolysis” and “tendon moved inadequately for most of period of rehabilitation
graft” that we put on our operating lists are often a gross after the primary surgery.
simplification of the surgery needed and reinforce an If a tendon is so frayed after tenolysis that I do not
underestimation of the problem. Whether secondary think it will survive rehabilitation, I replace it with a
surgery is being carried out after delayed primary pre- rod, with a view to two-stage tendon grafting. In this
sentation or for failed primary surgery, all of the tissues circumstance, I do not use special regimens, such as the
on the palmar side of the finger may be scarred to some Strickland frayed tendon regimen, as this places thera-
degree and each layer may require treatment. In respect pists in the uncomfortable position of using a regimen
of the management of the sheath and tendon, the sepa- with which they are less familiar with tendons that may
ration of sheath and tendons by surgical dissection snap under their care. This may make their rehabilita-
requires meticulous technique, time, and considerable tion too cautious in a group of patients in whom this is
concentration, and can be tediously slow. Great care is likely to be counterproductive and lead to further stuck
required to try to achieve an end point of intact tendons tendons.
and intact pulleys whenever possible. Where this dissec- Under all three of these circumstances, I insert a
tion ends otherwise, both tendons are usually removed tendon rod. The distal end of the tendon of the FDS or
in preparation for tendon grafting. If the flexor digito- flexor digitorum profundus (FDP) that will motor the
rum superficialis (FDS) tendon is intact and functional, graft is held to physiological length by suturing it, with
this is normally left in situ with a view to replacing a nonabsorbable 2-0 or 3-0 suture, to either the deep
the profundus tendon with a graft passed through the transverse ligament in the palm or the ligamentous
chiasma of the FDS, or a decision is made to leave the structures of the flexor aspect of the wrist. My preference
finger with proximal interphalangeal (PIP) flexion only, is to use the palmaris longus whenever possible as the
in which case a hyperextending distal interphalangeal graft, as it is easier to suture than the smaller plantaris,
(DIP) joint may need distal flexor tendon tenodesis or and to graft from the distal phalanx back to the palm,
joint fusion. as this only requires harvest of the palmaris tendon in
Two situations will make tendon grafting inevitable. its extramuscular part. Only occasionally have I found
The first is where the tendon is found to be so severely it necessary to graft back to the wrist. A silicone rod of
scarred to the sheath that achieving an end point of approximately the diameter of one of the patient’s flexor
tendons is passed through the sheath from the distal
end of the proximal motor tendon to the distal phalanx.
These rods are manufactured in round and oval shape:
either works equally well. We use sizes 3 or 4 most com-
monly. A new and useful alternative is the “Universal
Tendon Spacer,” which is a flexible silicon rod whose
diameter changes along its length. This rod is moved
through the tendon sheath until the part of appropriate
diameter fits comfortably within the sheath; then the
two ends are cut off (Figure 28-2). The distal end of
the rod is cut obliquely and passed behind the FDP
stump distally, to maintain a pocket to aid attachment
of the distal end of the tendon graft to the distal phalanx
at the second operation. The rod is then sutured with
4-0 nylon to the FDP stump, and to the A4 pulley if
suture to the FDP stump is thought to be too weak
to hold the rod in position during subsequent finger
Figure 28-1 A flexor tenolysis showing such dense movements until the second stage. The free proximal
scarring that excision of the flexor tendons leaving a end of the rod is not sutured and should reach slightly
functional pulley system is impossible. proximal to the sutured distal end of the motor tendon
Subcutaneous scarring
Sheath scarring
Figure 28-2 A Universal Tendon Spacer passed through Figure 28-3 The undersurface of the skin and
the tendon sheath until the part of appropriate diameter fits subcutaneous fat of a typical case of flexor tenolysis,
comfortably within the sheath, then the two ends will be showing the scarring of the subcutaneous fat which causes
cut off. a longitudinal skin deficiency.
in the palm or wrist. The hand is then closed. The first

stage of a staged tendon graft procedure requires no
protection postoperatively. The hand is mobilized early
without protective splinting and the patient usually
returns to work within 2 to 3 weeks. Adjunctive proce-
dures, such as pulley reconstructions and skin replace-
ment, are also carried out at this stage (see later).
Usually between 3 and 6 months is an adequate
delay before carrying out the second-stage tendon graft-
ing procedure. Impatience to complete the second stage
by the patient or the surgeon is counterproductive as the
final result is generally much better if the healing process
of the first, and larger, operation is completely over.
Correction of Skin Deficiencies at the A

First Stage
Scarring of the skin and subcutaneous soft tissues at the
time of primary injury may cause longitudinal skin
shortening in the finger or thumb. In fact, during dis-
section of the digit to reach the tendon sheath, if one
examines the undersurface of the subcutaneous fat, one
will see that this almost never escapes some scar deposi-
tion with resultant tightening of the overlying skin
(Figure 28-3). I routinely open these cases using a mid-
lateral incision to allow this incision to be extended
into the distal palm as a V (Figure 28-4). This allows
one to advance the V of skin from the palm into the
finger to compensate for the subcutaneous scarring B
in the finger. We first reported use of this technique
Figure 28-4 A, Marking of the typical skin excisions used
for reconstruction of skin deficits of the palmar aspect
by the author for secondary exploration of the digital flexors.
of the fingers.14 This advancement of palmar skin is
These include distal palmar V incisions. B, These allow
usually sufficient to deal with skin shortage where the advancement of the distal palmar skin into the digits to
skin injury has been a simple cut. We usually do not counter the typical skin shortage due to the subcutaneous
close the V as a Y but allow it to epithelialize under a scarring shown in Figure 28-3, with the palmar wounds
moist antiseptic dressing done twice daily by the patient being allowed to heal by secondary intention under moist
during the first few postoperative weeks of mobilization antiseptic dressings during early postoperative mobilization.
A B
C
D
Figure 28-5 A, A case with more extensive shortage of

skin, for which the palmar V incision is inadequate. B, The
same incision was made initially, then the flap was split
at the PIP joint level (shown by the white line). C, A cross
finger flap was inset into the split. D and E, The finger
was mobilized normally postoperatively after the cross
finger flap pedicle was divided.
in the manner described after the McCash open palm of skin deficiency. The finger is opened through a mid-
technique in Dupuytren’s surgery. Preoperatively, it is lateral incision on the same side as the intended donor
usually obvious from the nature of the primary injury finger for the cross finger flap (Figure 28-5B). The mobi-
and/or the appearance of the finger whether more sig- lized skin is split at the PIP level, and a cross finger flap
nificant skin shortage is present and more skin will have is incorporated into the gap (Figure 28-5C–E).
to be incorporated onto the palmar aspect of the finger Cases with greater skin deficiency need more exten-
to achieve full extension (Figure 28-5A). Use of a cross sive flap reconstruction. There are many options of free
finger flap is a simple way of incorporating more skin and distant pedicled flaps available. Most will swell sig-
onto the palmar aspect of the finger for moderate cases nificantly and require secondary thinning of the flap
later. Guimberteau (2001) described a simple means of 4 pulley reconstructions Design of two
resurfacing the whole palmar aspect of a finger using a over a rod bipedicle flaps
distal ulnar artery pedicled fasciocutaneous flap from
the distal part of the ulnar aspect of the flexor surface
of the forearm.15 Unlike distally based radial artery–
based forearm flaps, the ulnar artery can be dissected
free into the middle of the palm, so the flap reaches the
tip of the finger comfortably.
Skin deficit in the palm with flexor tendon exposure
can often be reconstructed using local flaps, which have Excision of unstable skin
the advantage of avoiding the swelling and subsequent A (recurrent breakdown)
unnatural wobbling mobility which is common after
distant flap reconstruction of the palm. A longitudinal
exposure of a flexor tendon in the palm can be closed
quickly and simply using local bipedicled flaps. We first
reported this technique as a means of closing the gap in
the palm after harvesting a Zancolli reverse digital artery
flap for finger tip reconstruction.16 Two bipedicle flaps
are designed, one on either side of the defect (Figure
28-6A). The common digital neurovascular structures
are retained in the flaps by dissecting under the skin
bridges at a deep level, immediately adjacent to the
tendons and their sheaths. At the lateral margin of each
palmar flap, only the skin is incised and the fibers in
the subcutaneous fat broken by blunt scissor dissection B
to create a much more superficial wound. The palmar
flaps then slide in to close the deep defect (Figure
28-6B) and the superficial lateral wounds epithelialize
under moist antiseptic dressings done by the patient
during the first few postoperative weeks of mobiliza-
tion, as in the McCash Open Palm Technique for
Dupuytren’s surgery (Figure 28-6C). We have used the
same principle to close longitudinal skin defects on the
palmar surface of the fingers exposing the flexor tendons
and their sheath.17
For round, or near-round, defects of the palm, large
triangular flaps are useful. This technique was first
described by Mathes and his colleagues in 1988 for
closure of defects on the sole of the foot.18 One, or more,
skin triangles are designed and incised adjacent to the C
defect (Figure 28-7A). The fibers immediately below
the skin incisions are released by pressing down on the Figure 28-6 A, A patient presenting for secondary flexor
subcutaneous fat with a scalpel, then the deeper fat is surgery with a longitudinal defect of the palm and exposure
mobilized by blunt scissor dissection. The blood supply of the flexor tendons in the mid-palm. The poor quality
palmar skin has been excised. B, Bipedicle flaps have been
of each flap is from small arterial branches coming up
advanced centrally to close the mid-palmar defect. C, Late
through the underlying pulp from the underlying neu- view showing excellent healing of the palm with palmar skin.
rovascular bundles. While a very small flap may have This case also illustrates multiple pulley reconstructions over
insufficient blood supply beneath the triangle of skin, a silicone rod.
big flaps are entirely safe. These flaps will slide freely in
any direction after being released in this way (Figure
28-7B). Several flaps may be designed, each sliding in a
different direction, or a very big one right across the technique,19-21 or using fascial flaps with skin graft, or
palm may be used. fascial flaps carrying a skin island vascularized by the
Skin deficiency exposing flexor tendons in zone 5 underlying fascia.22-24 These reconstructions may be
can be easily reconstructed in most cases with local based on either the radial or the ulnar artery in the distal
flaps from the forearm, using the V-Y fasciocutaneous forearm.
A B
Figure 28-7 A, A patient presenting for secondary flexor surgery with a near-round skin deficiency in the distal palm. A
palmar triangle flap has been designed and dissected prior to movement laterally into the defect. B, Late view showing
excellent healing of the palm with palmar skin.
Correction of Pulley Deficiencies at the space but leaves concerns in respect of their strength,
First Stage unless elaborate bone fixation techniques are used. We
Single-stage tendon grafting in conjunction with pulley mostly have a need for pulley reconstruction when we
reconstruction requires that the pulleys be strong explore a flexor secondarily and come across a severe
enough to resist the tendon forces when mobilization “mess” of scarring (see Figure 28-1). Sometimes, the
is started immediately. The most important pulley defi- last cut of the tenolysis, or the removal of a completely
cits requiring reconstruction are those of the A2 at the welded-in flexor, destroys what was left of a weakened
base of the finger and the A1 at the base of the thumb. pulley and, sometimes, it is simply impossible to undo
By careful preservation of the sheath in the middle part the scar tissue. For us, this is a situation that demands
of the digit to avoid distal digital bowstringing, it is use of a two-stage tendon graft. The tendons being
usually unnecessary to reconstruct an A4 pulley (see removed from the finger or, if these are too poor, the
Chapter 10 regarding distal bowstringing). Commonly, more proximal part of the tendon of the muscle not
palmaris longus tendon, the proximal tendon of which- intended for use later as the motor for the graft can be
ever of the flexor muscles will not be used to motor the used to reconstruct the pulleys. The tendon is split lon-
tendon graft, or the extensor retinaculum, is used as the gitudinally and opened out, then turned through 90°
new pulley at the base of the digit. Whichever material (Figure 28-8A). This provides enough material to make
is used, it is passed around the repaired flexor tendons, as many pulleys as one wants (Figure 28-8B). Because
or flexor tendon graft, and the proximal phalanx, and there will be no force on them for 3 to 6 months, the
under the extensor tendon two or three times, then new pulleys can be simply sutured to the remnant edges
sutured to itself. Bearing in mind that many cases under- of the sheath, to which they will be strongly bound by
going flexor surgery have poor results because the exten- the time they have to hold a tendon against the skele-
sor tendons, bathed in fibrin in the edema of the injury, ton. This technique avoids harvesting of tendons that
tether to the underlying skeleton and overlying skin to may be required for the second stage or the use of exten-
a greater degree than do the flexor tendons in their sor retinaculum, which leaves an obvious scar on the
sheaths, and are restricting even passive finger flexion,25 very visible dorsum of the wrist.
I have reservations about use of techniques of pulley
reconstruction that require passage of tendon, or exten- Correction of Joint Deficiencies at
sor retinaculum, around the phalanges and through the the First Stage
extensor compartment. Attachment of new pulleys to The deepest problems at exploration of these fingers,
the sides of the phalanx avoids invading the extensor and the most likely to give rise to a recurrence of loss
Rod under Split FDS

to the distal phalanx, it is advisable to pass a temporary
preserved suture through the proximal end of the graft and attach
A3 and A4 it to the tissues in the palmar, or wrist, incision to prevent
pulleys
the tendon graft being pulled out of the sheath repeat-
edly during the distal suturing activities. Numerous
methods of attachment of the distal end of the graft to
the distal phalanx have been described: we mostly use
the technique we described in 1996, which dispenses
with the use of a button on the nail of the digit26 and is
simple, effective, and cheap. The proximal end of the
New pulley graft is woven into the tendon of the motor using Pul-
vertaft’s technique, with the tension of the new muscu-
lotendinous unit being set in the conventional manner
by reference to the finger cascade when the hand is
A
resting on the operating table with the wrist in the neutral
position. After the second stage, the graft is mobilized
by the modification of the early active mobilization
technique we use for primary flexor tendon repairs.27,28
We use exactly the same regimen of immediate mobi-
lization after tendon grafting as we do after primary
repair (see Chapter 13B, Box 13[B]-1), which simplifies
things for everyone in the unit. Mobilization is started
the day after the second stage and continues for the
same period, although it could be argued that this
regimen could be relaxed as the suture techniques are
stronger than those of primary flexor tendon surgery.
OUTCOMES AND PROGNOSIS
It is my impression, after using two-stage tendon graft-
B
ing for many years, that the results are better than previ-
Figure 28-8 A, A pulley reconstruction over a silicone rod ously with a one-stage procedure. The inclusion of the
using the proximal (FDS) tendon, which will not be the extra step of insertion of the rod converts the situation
eventual motor of the tendon graft. B, Another case using normally found in secondary surgery in respect of
the same material to entirely replace the pulley system of a moving a repair in a scarred environment to one that is
finger. more like that found in primary flexor tendon surgery,
as intended by the pioneers of this technique. Conse-
quently, these cases are assessed by us using the more
of extension, are the ligaments of the underlying joints. rigorous methods of assessing primary flexor tendon
In general, this has little bearing on whether one grafts surgery, rather than those of earlier times, which accepted
in a single stage or two stages, except that the degree of a much poorer expectation from secondary surgery. It is
dissection of the interphalangeal joints usually reflects my belief that all flexor tendon grafting should now be
the degree of general scarring of the fingers. A consider- assessed in this way to identify any difference from
able dissection of the PIP joint, particularly, will also primary surgery and emphasize the disparity, should
give rise to more inflammation and scarring in the post- such exist. Where disparity exists, it should be inter-
operative period and increase the likelihood of failure preted as a need to improve on surgery and rehabilita-
of the one-stage procedure. tion and not an acceptance, as in the past, that the cases
are more “difficult.”
Details of the Second Stage Failure of staged flexor tendon grafting may occur at
At the second operation, it is only necessary to expose either of the two stages. Protrusion of the rod, always
the rod at its two ends through small skin incisions to through the skin of the distal part of the finger and
allow removal of the 4-0 nylon sutures attaching the rod not the palm, where it is better covered, is a very rare
to the stump of the profundus tendon distally, then experience in our practice, except where there has been
remove the rod and attach the graft distally and proxi- an infection, which has also been a rare occurrence,
mally. The harvested tendon graft is sutured to the proxi- perhaps because all are given 5 days of antibiotic cover-
mal end of the rod and pulled distally through the new age after insertion of the rod. More common, but also
pseudo-sheath. Before working distally to attach the graft uncommon, has been movement of the rod from the
finger proximally into the forearm. This has occurred in ranges of movement due to extensor tendon tethering
three patients, each of whom required secondary flexor and joint dorsal capsule tightening, (2) rupture of the
tendon grafting after rupture of a primary repair. All repairs (which is rare as they are stronger than those
three patients were of slightly “manic” personality, with after primary surgery), and (3) adhesion of the graft to
the fault of overactivity rather than underactivity in the its surrounds, which is not common but more likely
pursuit of their rehabilitation. One presumes that, in than rupture of one of the two repairs. The management
pursuit of either their daily activities or their therapy, of each of these crises is exactly as after their occurrence
the rod was, in some way, pulled proximally and the following primary surgery or one-stage grafting, except
suture attachment distally in the finger gave way. Why that the patient may be influenced to choose options of
all three rods were coiled in the forearm and the mecha- treatment more accepting of the disability and less
nism of this occurring are mysteries. inclined to further surgery because of the passage of
Failures after the second stage are exactly like failure time with adaptation of the hand to his, or her, needs
of one-stage flexor tendon grafting and include (1) poor and the repeated failure of one’s surgery.
References
1. Hunter JM, Singer DI, Macklin EJ: Staged flexor tendon recon- 14. Moiemen NS, Elliot D: Palmar V-Y reconstruction of proxi-
struction using passive and active tendon implants. In Hunter mal defects of the volar aspect of the digits, Br J Plast Surg
JM, Schneider LH, Mackin EJ, et al, editors: Rehabilitation of 47:35–41, 1994.
the Hand: Surgery and Therapy, ed 3, St Louis, 1990, CY Mosby, 15. Guimberteau JC: New Ideas in Hand Flexor Tendon Surgery,
Ch 34:427. Aquitaine, 2001, Domaine Forestier, pp 135–143.
2. Mayer L, Ransohoff N: Reconstruction of the digital tendon 16. Moiemen NS, Elliot D: A modification of the Zancolli reverse
sheath: A contribution to the physiological method of repair digital artery flap, J Hand Surg (Br) 19:142–146, 1994.
of damaged finger tendons, J Bone Joint Surg (Am) 18:607– 17. Yii NW, Elliot D: Bipedicle flap reconstruction of longitudinal
616, 1936. palmar skin and soft tissue defects of the digits, J Hand Surg
3. Bassett CAL, Carroll RE: Formation of a tendon sheath by (Br) 27:122–128, 2002.
silicone-rod implants, J Bone Joint Surg (Am) 45:884–885, 18. Colen LB, Replogle SL, Mathes SJ: The V-Y plantar flap for
1963. reconstruction of the forefoot, Plast Reconstr Surg 81:220–228,
4. Hunter JM: Artificial tendons. Early development and appli- 1988.
cation, Am J Surg 109:325–338, 1965. 19. Bardsley AF, Soutar DS, Elliot D, et al: Reducing morbidity in
5. Hunter JM, Aulicino PL: Salvage of the scarred tendon systems the radial forearm flap donor site, Plast Reconstr Surg 86:287–
utilizing the Hunter tendon implant. In Flynn JE, editor: 292, 1990.
Tendon Surgery in the Hand, ed 3, Baltimore, 1981, Williams 20. Elliot D, Bainbridge LC: Ulnar fasciocutaneous flap of the
and Wilkins. wrist, J Hand Surg (Br) 13:311–312, 1988.
6. Hunter JM, Blackmore S, Callahan AD: Flexor tendon salvage 21. Elliot D, Bardsley AF, Batchelor AG, et al: Direct closure of
and functional redemption using the Hunter tendon implant the radial forearm flap donor defect, Br J Plast Surg 41:358–
and the superficialis finger operation, J Hand Ther 2:107–113, 360, 1988.
1989. 22. Becker C, Gilbert A: Le lambeau cubital, Ann Chir Main
7. Hunter JM, Jaeger SH: Tendon implants. In AAOS Symposium 7:136–142, 1988.
on Tendon Surgery of the Hand, St Louis, 1975, CV Mosby. 23. Elliot D, Lloyd M, Hazari A, et al: Relief of the pain of
8. Hunter JM, Jaeger SH: Tendon implants: primary and second- neuromas-in-continuity and scarred median and ulnar nerves
ary usage, Orthop Clin North Am 8:473–489, 1977. in the distal forearm and wrist by neurolysis, wrapping in
9. Hunter JM, Jaeger SH: Flexor tendon implants and prosthe- vascularized forearm fascial flaps and adjunctive procedures,
ses. In Rubin LR, editor: Biomaterials in Reconstructive Surgery, J Hand Surg (Br) 35:575–582, 2010.
St Louis, 1983, CV Mosby. 24. Yii NW, Niranjan NS: Fascial flaps based on perforators for
10. Hunter JM, Jaeger SH, Singer DI, et al: Tendon reconstruction reconstruction of defects in the distal forearm, Br J Plast Surg
with implants. In Tubiana R, editor: The Hand, Vol 3, 52:534–540, 1999.
Philadelphia, 1988, WB Saunders, pp 255–279. 25. Kulkarni M, Harris SB, Elliot D: The significance of extensor
11. Salisbury RE, Levine NS, McKeel DW, et al: Tendon sheath tendon tethering and dorsal joint capsule tightening after
reconstruction with artificial implants: A study of ultrastruc- injury to the hand, J Hand Surg (Br) 31:52–60, 2006.
ture. In Hunter JM, Schneider LH, editors: AAOS Symposium 26. Sood MK, Elliot D: A new technique of attachment of flexor
in Tendon Surgery in the Hand, St Louis, 1975, CV Mosby, tendons to the distal phalanx without a button tie-over,
Chapter 6:59–65. J Hand Surg (Br) 21:629–632, 1996.
12. Harris SB, Harris D, Foster AJ, et al: The aetiology of acute 27. Elliot D, Moiemen NC, Flemming AFS, et al: The rupture
rupture of flexor tendon repairs in zones 1 and 2 of the fingers rate of acute flexor tendon repairs mobilised by a controlled
during early mobilization, J Hand Surg (Br) 24:275–280, active motion regimen, J Hand Surg (Br) 19:607–612,
1999. 1994.
13. Dowd MB, Figus A, Harris SB, et al: The results of immediate 28. Elliot D: Primary flexor tendon repair: operative repair, pulley
re-repair of zone 1 and 2 primary flexor tendon repairs which management and rehabilitation, J Hand Surg (Br) 27:507–
rupture, J Hand Surg (Br) 31:507–513, 2006. 513, 2002.
CHAPTER
29
TWO-STAGE RECONSTRUCTION
WITH THE MODIFIED
PANEVA-HOLEVICH TECHNIQUE
Alexandros E. Beris, MD, Marios G. Lykissas, MD, and
Ioannis Kostas-Agnantis, MD
OUTLINE In 1972, Kessler4 reported a combination of these

techniques using the pedicle tendon transfer to replace
Flexor tendon reconstruction in zone 2 with the the rod. This method was later known as “modified
Hunter technique is an established approach to restore Paneva-Holevich method.” This combination presents
digital flexion and to overcome adhesions in the fibro- several technical advantages and resolves some prob-
osseous canal. Paneva-Holevich modification of the lems emerging from the Hunter technique.11 The graft
Hunter technique refers to forming a pseudo-sheath used (FDS) is an intrasynovial donor tendon and has
around a silicone rod and a loop between the flexor better morphological, functional, and healing character-
digitorum profundus and the flexor digitorum super- istics than extrasynovial tendons.12-14 In the past two
ficialis in the first stage, and the use of the formed decades, we used modified Paneva-Holevich method in
pedicle graft through the pseudo-sheath in the second the patients who were indicated for staged tendon
stage. This combination presents several technical reconstruction in the digits. We found that this tech-
advantages and resolves problems emerging from the nique has some unique advantages. The size of the FDS
Hunter technique. We describe the indications, opera- is similar to the silicone rod that is used in the first stage
tive technique, postoperative care, outcomes, and for stimulation of pseudo-sheath formation. In addi-
complications of this method for the flexor tendon tion, during the second stage we found it very easy to
reconstruction in zone 2 based on our clinical experi- locate the loop between FDP and FDS that is usually
ence over the past decades. situated at the level of the lumbrical muscles. There have
been no donor site morbidity. This operation is associ-
In 1965, Paneva-Holevich1 published a small series of ated with a lower rate of post-reconstruction tendon
flexor tendon injuries in which the proximal part of the ruptures, because there is only one suture site at the
flexor digitorum superficialis (FDS) was used as a pedicle second stage instead of two for a free tendon graft as
graft for flexor digitorum profundus (FDP) tendon with the Hunter technique.
reconstruction. In 1969, Paneva-Holevich reported two-
INDICATIONS
stage tendon reconstruction using this method in 34
digits.2 She called her new method “two-stage teno- The indications for the modified Paneva-Holevich are
plasty.” This surgery was later known as the “Paneva- the same as for the Hunter technique. Candidates
Holevich procedure.” James Hunter,3 the pioneer of for a modified Paneva-Holevich technique must have
staged tendon reconstruction, first described the use of suffered injuries of both flexor tendons to the affected
a silicone rod as a “space saver” followed by free tendon digit with serious scarring and a nonfunctional flexor
grafting for the management of patients with poor prog- apparatus. More specifically, indications include (1)
nosis (Boyes grades 2 to 5) in 1971. The philosophy was flexor tendon reconstruction in Boyes 2 to 5 injuries
simple: a flexible silicone-Dacron–reinforced gliding in zone 2 with considerable scarring of the tendon
implant for the formation of a pseudo-sheath as the first bed; (2) finger replantation with damage to the fibro
stage of profundus tendon reconstruction, followed by osseous canal; and (3) failed previous flexor tendon
grafting an autogenous tendon into the pseudo-sheath reconstruction.11
in the second stage. This method was used rather popu- In cases where FDS of the injured finger is intact this
larly in later years.5-9 technique cannot be used, since a distal interphalangeal
307
(DIP) tenodesis or arthrodesis is the treatment of is chosen corresponding to the diameter of the FDS
choice.11 A relative contraindication is scarring in the tendon (usually No. 3 to 5). The implant is inserted
palm that may compromise the anatomic integrity of and its distal insertion is secured with direct sutures to
the FDS. the profundus stump and is reinforced with pull-out
This procedure greatly facilitates staged flexor tendon suture to the distal phalanx. The proximal part of
reconstruction in children with minor modifications in the silicone rod is cut to the lumbrical level and is left
the rehabilitation program.15 Indications and contrain- free underneath the FDS-FDP loop after checking its
dications of a modified Paneva-Holevich in children are free motion.
the same as in adults. We usually reconstruct at least A1, A2, and A4 pulleys
using pieces of the removed tendons (see Figure 29-2).
The technique used for pulley reconstruction is suturing
OPERATIVE TECHNIQUE
these pieces of flexors to the lateral sides of the fibro-
The surgical technique includes two stages with a osseous canal. Pulley reconstruction should follow
minimum of a 3-month time interval.11 In both stages, silicone rod insertion in order to accurately match the
the use of magnifying loupes is mandatory. selected implant. Any necessary secondary procedures,
such as nerve repair, interphalangeal (IP) or metacarpo-
Stage 1 phalangeal (MCP) joint arthrolysis, and web space
The flexor tendons are exposed through a Bruner inci- plasty, are performed at this point, and the skin is closed
sion, which gives excellent access. Complete removal of without tension.
the cicatrix follows and special care is taken to preserve
as many pulleys as possible. The injured FDP tendon is Stage 2
excised proximally at the level of the lumbrical muscles. The stage 2 surgery is done after an interval of 3 months
Distally, a 1-cm FDP stump at the base of the distal and consists of three steps: (1) a mid-palmar inverted L
phalanx is preserved for anchoring of the silicone rod incision for loop retrieval; (2) an antebrachial incision
during the first stage and the tendon graft during the for transsection of the FDS at the musculotendinous
second stage. junction; and (3) an angular incision over the DIP joint
A second incision is made in the palm (inverted L) for graft retraction and anchoring the graft (FDS) to the
and is center near thenar for index and middle finger distal phalanx (Figures 29-3 to 29-5).
and near hypothenar for the ring and small finger
(Figure 29-1). The FDS and FDP tendon ends of the
injured finger are retrieved, freed of adhesions, and
sutured together with a loop at the lumbrical level in
an end-to-end fashion (Figure 29-2). A silicone rod
Silicone rod
Reconstructed
A1, A2, and A4
pulleys
Flexor Flexor
digitorum digitorum
profundus superficialis
(FDP) (FDS)
Figure 29-2 Formation of a loop between FDS and FDP

Figure 29-1 A Bruner incision in the digit and an L incision tendon, reconstruction of A1, A2, and A4 pulleys, and
in the palm for the FDS-FDP loop junction. silicone rod placement in stage 1.
Chapter 29: Two-Stage Reconstruction With the Modified Paneva-Holevich Technique 309
Figure 29-3 An L incision in the palm for retrieval of

the loop and rod. A longitudinal incision is made in the
antebrachium for proximal transection of the FDS, and an Figure 29-5 The FDS tendon is retrieved from the wrist.
angular incision made at the DIP joint level for rod removal The area of the healed FDS-FDP junction is indicated with an
and advancement of the grafted FDS tendon. arrow.
A mid-palmar incision is used to identify the proxi-

mal end of the silicone rod and to retrieve the FDS-FDP
loop. The loop is identified easily because of its volume.
Flexor Trimming of the loop may be necessary in rare cases.
digitorum
A longitudinal antebrachial incision is used to iden-
superficialis
(FDS) tify the FDS tendon to the same finger. The tendon is
cut at the musculotendinous junction after a measure-
ment is done for the needed length. The cut FDS is then
pulled out to the palmar incision through the carpal
tunnel (see Figure 29-5). The FDS stump is sutured to
the proximal end of the silicone rod.
A third angular incision is made over the DIP joint
and the silicone rod with the graft sutured to its end is
gently retracted through the pseudo-sheath (Figure
29-6). The silicone rod is then discharged and the
tension of the graft is estimated by temporary stabiliza-
tion with a hypodermic needle through the skin of the
Flexor distal phalanx. The desired tension is adjusted so that
digitorum
profundus the reconstructed finger is kept in slightly more flexion
(FDP) than the adjacent fingers in flexion and extension of the
wrist. Then, the graft is secured to the profundus stump
in the distal phalanx with three or four interrupted 3-0
Figure 29-4 The loop site between FDS and FDP has nonabsorbable sutures. To avoid nail deformities, pull-
healed. The distal end of the FDS tendon is sutured to the out sutures should exit proximal to the nail matrix on
distal stump of the FDP tendon. the dorsum of the phalanx. In the recent years, we used
OUTCOMES
Between 1992 and 2011, we treated 46 patients (55
digits) with zone 2 injuries using modified Paneva-
Holevich reconstruction. Between 1992 and 2000, we
had 20 patients (22 digits); they were followed for at least
1 year. The mean age of the patients was 24 years (range,
3 to 54 years). The mean total active motion recorded
was 189° of 219° of total passive motion (71% of the
contralateral respective finger) (Figure 29-7).11 Accord-
ing to the Buck-Gramcko scale, overall, an excellent
score was achieved in 50%, good in 32%, fair in 9%, and
poor in 9% of the digits. Using the revised Strickland
scale, 73% of the digits had good or excellent results.
Complications included pulley rupture in 4, nail defor-
mity in 8 (cosmetically unacceptable in one only), trig-
gering at the MCP joint in one, sensitive scar in one, and
deep infection in 2 digits in stage 1. These results are
slightly better than those achieved by Wehbe and others8
with the Hunter method of reconstruction. They reported
Figure 29-6 An angular incision is made over DIP joint and a total active range of digital motion of 176°. Superior
the silicone rod with the FDS graft sutured to its distal end is results were also noted when our findings were com-
retracted through this incision. pared with those of the two of the largest series using the
Hunter method.9,10 The good and excellent results in
these reports were 40% and 42% (La Salle-Strickland
scale), respectively, for zone 2 injuries, compared with
72% in our series (revised Strickland scale).
a small anchor inserted in the palmar aspect of the distal Since 1970s, many authors have reported good and
phalanx, securing the distal part of the graft. excellent results in the majority of their patients by
using the modified Paneva-Holevich technique (Table
POSTOPERATIVE CARE
29-1). Kessler4 had good and excellent results in 83%
A part of the preoperative passive physiotherapy program of his patients by using the Strickland scale. Winspur
to overcome stiffness and achieve maximum joint and colleagues17 obtained good and excellent results in
motion, a postoperative rehabilitation program is also 80% of their patients, by using the Buck-Gramcko scale.
of paramount importance to maintain maximum finger Similarly, in our patients, good and excellent results
joint flexion. Intensive postoperative physiotherapy were recorded in 82% of the digits after surgery using
should follow both stages. the Buck-Gramcko scale and 73% using the modified
Strickland scale.11
Stage 1 We used the modified Paneva-Holevich technique in
At the end of the first stage, the hand should be immo- 9 children (nine digits) with zone 2 injuries between
bilized with a bulky dressing for 48 hours. An intensive 1992 and 2005 and recorded good and excellent results
rehabilitation program consisting of passive MCP and in 8 children (89%) after a mean follow-up of 40
IP joints flexion is initiated 3 days after surgery. The goal months.15 The mean total active motion achieved was
is to achieve and preserve full passive joint flexion and 196° (75% of the contralateral finger) of 237° of total
extension of the reconstructed finger until the second passive motion.
stage is undertaken.
COMPLICATIONS
Stage 2 The staged flexor tendon reconstruction is a demanding
After the second stage operation, a dorsal splint is technique with risks and complications. The complica-
applied to hold the wrist in 30° flexion, the MCP joint tions can appear in both stages of surgery.25
in 70° flexion, and the IP joints in a slightly flexed posi- In stage 1 of the two-stage flexor tendon reconstruc-
tion. An early controlled motion program comprising tion, complications include (1) rod buckling, (2) necro-
passive flexion and active extension is started at day 3.16 sis of the skin, (3) rod migration, (4) rupture of the distal
The splint is removed by 5 weeks and active motion end of silicone rod, (5) synovitis, and (6) infection.
and blocking exercises are initiated to avoid flexion At the second stage, the following complications can
contractures. be noticed: (1) bowstringing, (2) impingement of the
Figure 29-7 Flexion (A) and extension

(B) of a ring finger 3.5 years after tendon
reconstruction with the modified
Paneva-Holevich method.
A B
Table 29-1 Outcomes of the Modified Paneva- Flexion contracture of the DIP joint is one of the most
Holevich Technique commonly described complications that can be treated
Criteria* and with night extension splints.10,11,15,17-24 Silicone rod
Authors Digits Good-Excellent Rate rupture, bowstringing, and rupture of the distal graft
suture are other common complications.
Kessler et al4 6 83%†, Strickland
In stage 1, rod buckling can be prevented by avoiding
Winspur et al17 10 80%† suturing the pulleys under tension, so that silicone rod
Brug et al18 27 52% moves freely. Skin necrosis can be avoided by using a
Bruner incision with angles no less than 45°. We could
Chuinard et al19 16 62.5%, Boyes (modified) prevent rupture of the distal end of the silicone rod by
Paneva-Holevich 39 56%, Boyes (modified) suturing the rod to the distal stump of the FDP and a
et al20 pull-out suture of the silicone rod. In case of rupture of
Alnot et al21 19 73%, total active motion the silicone rod, the volar aspect of the distal phalanx
is opened and the implant is fished out with a retriever.
22
Naam 21 52.4%, Strickland Silicone rod synovitis can be treated effectively with
Brug et al 23
76 55% antibiotics and splinting. In stage 2, bowstringing can
11
be prevented by meticulous and secure reconstructions
Beris et al 22 82%
of A1, A2, and A4 pulleys in stage 1. If the distal graft
15
Darlis et al 9 89% junction is disrupted, the graft should be reattached
Abdul-Kader and 12 75% methods are same for silicone rod rupture. Flexion
Amir24 deformity of the DIP joint can be prevented by placing
less tension of the graft during surgery and dynamic
*Buck-Gramcko method was used unless specified. night splints after stage 2.
†
Calculated based on data provided in the articles.
Infection is an uncommon complication but can be
a serious one that may affect considerably the outcome.
The percentage of infection varies from 2.3% to 25.6%
proximal suture in the fibro-osseous canal, (3) tendon in both stage 1 and 2.8,9,15,25-28 Inadequate treatment may
grafts loose or tight, (4) disruption at the distal or proxi- require removal of the rod and reoperation with the
mal junctions, (5) flexion deformity of the proximal two-stage technique after 5 months. Infection is more
interphalangeal (PIP) and/or DIP joints, which is con- common in stage 1 than in stage 2; this fact may be
sidered to be the most common complication at this attributed to extensive surgical exposure of the digit and
stage, and (6) infection. silicone rod synovitis or both. In our series infection was
Complications after the modified Paneva-Holevich recorded in 2 digits (9%) during stage 1.29 In one
technique occur in 0% to 27% of the digits.10,11,15,17-24 case infection was resolved by closed irrigation and
intravenous antibiotics, while in another case rod because it has already healed by stage 2; and (2) the FDS
removal was necessary. of the little finger sometimes is thin in the wrist area
and cannot be used. This problem can be overcome by
DISCUSSION
reinforcement of the tendon with a PL graft or by using
In 1971, Hunter and Salisbury2 presented the prelimi- the FDS of an adjacent finger.18
nary results after two-stage flexor tendon reconstruction We started using the modified Paneva-Holevich tech-
addressing the problem of functional compromise after nique from 1992. Since 1999, this method has been
flexor tendon injuries in zone 2. Since then, two-stage used for all patients who required staged tendon recon-
flexor tendon reconstruction has been widely accepted, struction. The modified technique has several advan-
presenting different rates of success and complica- tages over the Hunter’s staged reconstruction and is now
tions.26,30,31 In the first stage, the silicone rod is inserted more familiar to us. Some modifications regarding the
to stimulate pseudo-sheath formation with a smooth methods of tendon junction have been described in the
and gliding surface that allows the passage of a free literature, where a Kessler suture or a fish-mouth tech-
tendon graft through it at a second stage.32,33 In further nique was used for the loop junction between the FDS
studies Hunter showed that the fibroosseous canal and the FDP in stage 1 operation,22,23 but three or four
reconstruction in zone 2 allows an unrestricted gliding simple sutures are considered more than enough for the
without adhesions formation.34 loop. The lumbrical muscle belly can be folded over the
In 1982, Paneva-Holevich reported 324 digital flexor FDS-FDP loop, but this may increase the risk for a lum-
tendon reconstruction with her method of pedicle FDS brical plus finger.18,23 Pulley reconstruction can be
tendon grafting, among which in 39 digits with exten- achieved by using the excised tendon material and not
sive scar, she combined her technique (loop between using the PL19 or extensor retinaculum.21
the FDP and the FDS in the first stage and the use Many authors recommended that the distal anchor of
of the formed pedicle graft in the second stage) with the graft during stage 2 should include attachment to
the Hunter silicone rod technique.20 Compared to both the FDP tendon stump and a pull-out suture. Addi-
the Hunter technique, the modified Paneva-Holevich tional strength can be achieved by passing the graft
method is advantageous because (1) there is no need of through an osseous tunnel in the distal phalanx.3,5 We
identifying the motor during the first stage; (2) the currently prefer to pass the graft underneath the distal end
FDS-FDP loop can be identified easily in the palm of the profundus stump and suture to it with transverse
during the second stage; (3) there is no donor site mor- sutures on both sides and an additional suture through
bidity, since no free grafts are harvested; (4) it can be an absorbable anchor to the distal phalanx without a
performed easily in children15; (5) it comprises a pedi- pull-out suture through the nail. If the A5 pulley has been
cled tendon graft with a strong proximal junction that preserved, the proximal end of the profundus stump can
has already healed by stage 2; (6) it uses a tendon graft also be sutured to the distal edge of the A5 pulley.37
(FDS) that is consistent compared with palmaris longus In most cases, the proximal part of the FDP to the
(PL) and plantaris, which are reported to be absent in injured finger is used as a motor. When power of this
20% and 25% of healthy individuals, respectively35; (7) FDP muscle is absent or questionable, the FDS of the
the FDS tendon graft is three times larger than conven- same or adjacent finger can be used as a motor.8 During
tional grafts used in the Hunter technique (mean cross- operation, care should be taken to making proper judge-
sectional area of 10.6 mm compared with the 3.1 mm, ment about which proximal motor tendon is the best
1.6 mm, and 3.2 mm of PL, plantaris, and toe extensors, motor, and either a FDP or a FDS tendon can be the
respectively)3,36; and (8) it uses an intrasynovial graft, motor source.18
which has better morphological, functional, and healing Two-stage flexor tendon reconstruction with combi-
characteristics than extrasynovial grafts.12-14 nation of a silicone rod and a pedicle FDS tendon graft
We have found only two disadvantages with the is an efficient method of restoration of function of the
Paneva-Holevich technique: (1) the difficulty in ten- flexor tendons in zone 2. The combination presents
sioning the graft at the distal anchoring site of the graft. several technical advantages and resolves some prob-
The proximal tendon junction presents no problem lems emerging from the Hunter technique.
References
1. Paneva-Holevich E: Two stage plasty in flexor tendon injuries silicone-Dacron reinforced gliding prosthesis prior to tendon
of the fingers within digital synovial sheath, Acta Chir Plast grafting, J Bone Joint Surg (Am) 53:829–858, 1971.
7:112–124, 1965. 4. Kessler FB: Use of a pedicled tendon transfer with a silicone
2. Paneva-Holevich E: Two-stage tenoplasty in injury of the flexor rod in complicated secondary flexor tendon repairs, Plast
tendons of the hand, J Bone Joint Surg (Am) 51:21–32, 1969. Reconstr Surg 49:439–443, 1972.
3. Hunter JM, Salisbury RE: Flexor-tendon reconstruction in 5. Schneider LH: Flexor tendons-late reconstruction. In Green
severely damaged hands. A two-stage procedure using a DP, Hotchkiss RN, Pederson WC, editors: Green’s Operative
Hand Surgery, ed 4, New York, 1999, Churchill Livingstone, 21. Alnot JY, Mouton P, Bisson P: Longstanding flexor tendon
pp 1898–1941. lesions treated by two-stage tendon graft, Ann Chir Main
6. Soucacos PN: Two-stage flexor tendon reconstruction using Memb Super 15:25–35, 1996.
silicone rods. In Vastamaki M, editor: Current Trends in Hand 22. Naam NH: Staged flexor tendon reconstruction using pedi-
Surgery, Amsterdam, 1995, Elsevier, pp 353–357. cled tendon graft from the flexor digitorum superficialis,
7. Soucacos PN: Secondary flexor tendon reconstruction. In J Hand Surg (Am) 22:323–327, 1997.
Duparc S, editor: Textbook on Techniques in Orthopaedic Surgery 23. Brug E, Wetterkamp D, Neuber M, et al: Secondary recon-
and Traumatology, Paris, 2000, Elsevier SAS, pp 55–340. struction of flexor tendon function of the fingers, Unfallchirurg
8. Wehbé MA, Mawr B, Hunter JM, et al: Two stage flexor-tendon 101:415–425, 1998.
reconstruction, Ten-year experience. J Bone Joint Surg (Am) 24. Abdul-Kader MH, Amin MA: Two-stage reconstruction for
68:752–763, 1986. flexor tendon injuries in zone II using a silicone rod and ped-
9. LaSalle WB, Strickland JW: An evaluation of the two-stage icled sublimis tendon graft, Indian J Plast Surg 43:14–20, 2010.
flexor tendon reconstruction technique, J Hand Surg (Am) 25. Soucacos PN, Beris AE, Malizos KN, et al: Two-stage treatment
8:263–267, 1983. of flexor tendon ruptures: Silicone rod complications analyzed
10. Amadio PC, Wood MB, Cooney WP 3rd, et al: Staged flexor in 109 digits, Acta Orthop Scand (Suppl) 275:48–51, 1997.
tendon reconstruction in the fingers and hand, J Hand Surg 26. Weinstein SL, Sprague BL, Flatt AE: Evaluation of the two-
(Am) 13:559–562, 1988. stage flexor-tendon reconstruction in severely damaged digits,
11. Beris AE, Darlis NA, Korompilias AV, et al: Two-stage flexor J Bone Joint Surg (Am) 58:786–791, 1976.
tendon reconstruction in zone II using a silicone rod and a 27. Frakking TG, Depuydt KP, Kon M, et al: Retrospective outcome
pedicled intrasynovial graft, J Hand Surg (Am) 28:652–660, analysis of staged flexor tendon reconstruction, J Hand Surg
2003. (Br) 25:168–174, 2000.
12. Abrahamsson SO, Gelberman RH, Lohmander SL: Variations 28. Finsen V: Two-stage grafting of digital flexor tendons: A
in cellular proliferation and matrix synthesis in intrasynovial review of 43 patients after 3 to 15 years, Scand J Plast Reconstr
and extrasynovial tendons: An in vitro study in dogs, J Hand Surg Hand Surg 37:159–162, 2003.
Surg (Am) 19:259–265, 1994. 29. Beris AE, Korompilias AV, Lykissas MG, et al: Management
13. Seiler JG 3rd, Chu CR, Amiel D, et al: Autogenous flexor of infection in 2-stage flexor tendon reconstruction. In
tendon grafts. Biologic mechanisms for incorporation, Clin Malizos KN, Soucacos PN, editors: Infections of the Hand and
Orthop Relat Res 345:239–247, 1997. Upper Limb, Athens, 2007, Paschalidis Medical Publications,
14. Leversedge FJ, Zelouf D, Williams C, et al: Flexor tendon pp 271–276.
grafting to the hand: An assessment of the intrasynovial 30. Honner R, Meares A: A review of 100 flexor tendon recon-
donor tendon—a preliminary single-cohort study, J Hand structions with prosthesis, Hand 9:226–231, 1977.
Surg (Am) 25:721–730, 2000. 31. Reill P: Die zweizeitige beugesehnentransplantation, Hand-
15. Darlis NA, Beris AE, Korompilias AV, et al: Two-stage flexor chirurgie 10:215–221, 1978.
tendon reconstruction in zone 2 of the hand in children, 32. Schneider LH: Staged tendon reconstruction, Hand Clin
J Pediatr Orthop 25:382–386, 2005. 1:109–120, 1985.
16. Kleinert HE, Kutz JE, Atasoy E, et al: Primary repair of flexor 33. Schneider LH: Complications in tendon injury and surgery,
tendons, Orthop Clin North Am 4:865–876, 1973. Hand Clin 2:361–371, 1986.
17. Winspur I, Phelps DB, Boswick JA Jr: Staged reconstruction 34. Hunter JM: Staged flexor tendon reconstruction. In Hunter
of flexor tendons with a silicone rod and a “pedicled” subli- JM, Schneider LH, Mackin EJ, et al, editors: Rehabilitation of
mis transfer, Plast Reconstr Surg 61:756–761, 1978. the Hand, St Louis, 1984, CV Mosby, pp 288–313.
18. Brug E, Stedtfeld HW: Experience with a two-staged pedicled 35. Wehbé MA: Tendon graft anatomy and harvesting, Orthop Rev
flexor tendon graft, Hand 11:198–205, 1979. 23:253–256, 1994.
19. Chuinard RG, Dabezies EJ, Mathews RE: Two-stage superficia- 36. Carlson GD, Botte MJ, Josephs MS, et al: Morphologic and
lis tendon reconstruction in severely damaged fingers, J Hand biomechanical comparison of tendons used as free grafts,
Surg (Am) 5:135–143, 1980. J Hand Surg (Am) 18:76–82, 1993.
20. Paneva-Holevich E: Two-stage reconstruction of the flexor 37. Viegas SF: A new modification of two-stage flexor tendon
tendons, Int Orthop 6:133–138, 1982. reconstruction, Tech Hand Up Extrem Surg 10:177–180, 2006.
CHAPTER
30
OUTCOMES OF THE MODIFIED
PANEVA-HOLEVICH
PROCEDURES AND
EARLY POSTOPERATIVE
MOBILIZATION
Nash H. Naam, MD, FACS, and Lori Niemerg, OTR/L, CHT
OUTLINE In 1965, Paneva-Holevich suggested the use of pedi-

cled flexor digitorum superficialis (FDS) tendon as a
Patients with severe flexor tendon injuries associated graft by creating a loop of the flexor digitorum profun-
with scarred digital tendon sheath may require tendon dus (FDP) and flexor digitorum superficialis (FDS) then
grafting. Single-stage flexor tendon reconstruction may reflecting the latter in the second stage as a pedicled
be unfeasible because of the scarred tendon bed; there- tendon graft.1,2 In 1971, Hunter and Salisbury intro-
fore, staged flexor tendon reconstruction is recom- duced the concept of using a silicone-Dacron reinforced
mended. The Paneva-Holevich technique uses the tendon rod to stimulate formation of a new tendon
pedicled flexor digitorum superficialis (FDS) as the sheath before tendon grafting.3 This transforms the
donor graft thereby avoiding harvesting a free tendon scarred tendon bed into a gliding pliable functional
graft. The modified technique incorporates the use of system. In 1972, Kessler reported on the combined use
a Silastic rod in the first stage to promote the formation of Hunter rod and pedicled FDS for staged flexor tendon
of a new tendon sheath and the use of a pedicled FDS reconstruction.4 Since then, several reports of the com-
as the tendon graft in the second stage. This technique bined method have been published.5-9
combines the benefits of the Hunter rod and the use We started performing this procedure in 1983. In
of a pedicled intrasynovial tendon, which may create 1997, we published our experience with the use of this
less adhesion than extrasynovial tendons. This modi- technique in 33 patients.8 Up to 2009, we applied this
fied technique is ideal for the implementation of an technique in 116 patients. Candidates for this type of
early active range of motion (AROM) program since tendon reconstruction included patients who did not
the proximal repair is already healed by the time the have their flexor tendon repaired or those who had their
second stage is performed, but the distal graft repair repairs failed secondary to rupture or adhesions (Figure
to the bony distal phalanx should be strong enough 30-1). Most of these procedures are performed in
to withstand the stresses of the AROM program. The patients with zone 2 flexor tendon injuries. However,
incorporation of an early AROM program with this zone 1 injuries are also amenable to this type of recon-
technique provides a significant advantage in improv- struction. Zone 3 and 4 injures can usually be treated
ing the ultimate outcome of the procedure. with conventional single-stage interposition tendon
grafts unless there is a concomitant damage to the flexor
Flexor tendon reconstruction in the presence of a tendon sheath in zone 2. This procedure is particularly
damaged flexor tendon sheath with destruction of useful in tendon injuries associated with severe crushing
majority of pulley system or serious scar formation is injuries when there are associated fractures, nerve inju-
very challenging to the hand surgeon. The fibrotic ries, and skin defects.5,7,8
tendon gliding bed does not allow smooth excursion of This technique has become our standard technique
the tendon graft, which results in significant adhesions for flexor tendon reconstruction when the tendon bed
and limited range of motion. In these circumstances does not allow one-stage flexor tendon grafting. A dis-
single-stage flexor tendon reconstruction would not be tinct advantage of this procedure is to allow earlier
appropriate and staged tendon reconstruction should active range of motion (AROM), since the proximal
be considered. repair should be completely healed by the time the
314
Chapter 30: Outcomes of the Modified Paneva-Holevich Procedures and Early Postoperative Mobilization 315
Figure 30-1 Loss of active flexion of the index finger after Figure 30-3 The FDS and FDP tendons are seen at the
an old injury of both flexor tendons. base of the finger. Note the scarring of the flexor tendon
sheath.
Figure 30-2 Stage 1: severely scarred flexor tendon Figure 30-4 The flexor tendons remnants have been
sheath. Some of the pulleys are still intact. excised. Note the proximal ends of FDS and FDP tendon are
ready for the repair.
second stage is performed if a tendon graft, instead of should be performed at this stage utilizing pieces of the
tendon transfer, is used. A strong distal repair, preferably excised flexor tendons. Any nerve grafting or flexion
attaching the tendon to the bony distal phalanx, would contracture release can be done at this stage. The largest
allow the graft to withstand the forces of early AROM possible Hunter rod is then inserted. The Hunter rod
without fears of rupture. Actually, Paneva-Holevich rec- should not touch the gloves as this may produce inflam-
ommended starting active motion of the involved digit matory reaction secondary to the contact with the talc
in the first postoperative week and reported no increase powder. The distal end of the rod is sutured to the distal
in the incidence of rupture in her early report of second- stump of the FDP with horizontal mattress sutures of
ary reconstruction of the FDP tendon by FDS transfer 4-0 Prolene or 4-0 fiberwire. It is important to be sure
from the same finger.7 that the sutures include the Dacron tape within the
Hunter rod since the silicone alone has very little
SURGICAL TECHNIQUE holding power. The proximal stump of the rod is left
free in the palm. The FDS and FDP tendons of the
Stage 1 injured finger are exposed at the mid palm level. Their
Through a Bruner zigzag incision, the flexor tendon ends are freshened to healthy margins and then sutured
sheath is exposed. The remnants of the flexor tendons to each other with an end-to-end method (Figures 30-5
are excised (Figures 30-2 to 30-4). Special care should and 30-6).
be taken to preserve all the normal pulleys as much as In making the end-to-end suture, the dorsal epiten-
possible. If the important pulleys or majority of the dinous layer is performed first with a running interlock-
flexor pulley system are destroyed, pulley reconstruction ing 6-0 Prolene suture followed by core suture of 4-0
Box 30-1 Clinical Pearls—Stage 1

 Flexor tendon remnants are excised.
 Pulleys are preserved or reconstructed using the excised
flexor tendons.
 The proximal ends of the FDS and FDP are repaired end-
to-end in the palm.
 Leave the Prolene suture long to facilitate identification
in stage 2.
 The largest possible Hunter rod is inserted. The distal
end is repaired to the FDP stump and the proximal end
is left free in the palm.
 PROM is started 3 to 5 days postoperatively.
Figure 30-5 The proximal ends of the FDS and FDP

tendons have been repaired end-to-end.
Figure 30-7 Stage 2: the site of FDS and FDP tendon

repair and the proximal end of the Hunter rod are exposed in
the palm.
Patients are started on passive range of motion

Figure 30-6 A Hunter rod has been inserted. The A2 pulley (PROM) of the operated digits 3 to 5 days postopera-
has been reconstructed using part of the excised flexor tively, which lasts as long as required to ensure adequate
tendons. passive range of finger motion. PROM is performed to
keep the joints flexible. The patient is instructed to
perform PROM of each joint of the involved digit for 10
Prolene or 4-0 fiberwire in a modified Kessler technique. repetitions 6 to 8 times a day. Unrestricted active motion
The volar epitendinous layer is then completed using exercises of the uninvolved digits are emphasized as well
the 6-0 Prolene. The Prolene suture is left long to facili- (Box 30-1).
tate easier identification of the site of the tendon repair
during the second stage. The wounds are closed and the Stage 2
patient is put in a dorsal splint with the wrist flexed 45°. We recommend allowing at least 12 weeks before pro-
This technique is used mostly for flexor tendon inju- ceeding with the second stage. The scar should be
ries in zones 1 and 2. If the tendon laceration is in zone supple. Excellent PROM is a prerequisite before pro-
3 or 4 and the digital sheath is compromised, because ceeding to stage 2. Through a zigzag incision in the
of either a concomitant injury or extension of scarring palm, the site of FDS-to-FDP tenorrhaphy in the palm
that limits tendon excursion, this technique can be used is exposed and freed of the scar tissue (Figure 30-7). A
as well. This will require placing the end-to-end suturing zigzag incision is made over the distal forearm and the
of the FDS and FDP either distal to the carpal tunnel in FDS tendon of the involved digit is isolated. The tendon
zone 3 injuries or proximal to the carpal tunnel in zone is divided at the musculotendinous junction and then
4 injuries. The FDS tendon may be divided proximal to retrieved in the palm incision as a pedicled graft (Figures
the musculotendinous junction and stripped of any 30-8 and 30-9). The Hunter rod is exposed and the new
muscle tissue. sheath is opened at its proximal end in the palm.
Figure 30-8 The FDS tendon is exposed at the distal

forearm and divided at the musculotendinous junction.
Figure 30-10 The end of the FDS is guided by the Hunter
rod through the new sheath.
Figure 30-9 The FDS tendon is retrieved in the palm Figure 30-11 The FDS pedicled graft has been delivered to
incision. the distal attachment site guided by the Hunter rod.
A distal incision is made at the level of the distal

interphalangeal (DIP) joint. The distal end of the new
sheath is opened and the Hunter rod is exposed and
freed. The proximal end of the rod is sutured to the
proximal end of the FDS graft (Figure 30-10). As the
rod is pulled distally, it guides the FDS graft through
the new sheath (Figure 30-11). After the distal end of
the FDS tendon is pulled beyond the fingertip, tension
of the graft is adjusted. Optimal tension on the graft is
set to allow extension of the finger with the wrist flexed
and flexion of the finger with wrist extension. The
tension should flex the finger should be slightly more
than the normal flexion cascade. The distal end of
the graft is anchored to the volar aspect of the base
of the distal phalanx using 4-0 stainless steel pullout
wire that is tied over a button (Figure 30-12). Extra Figure 30-12 The position of the digit after repair of
horizontal mattress sutures of 4-0 Prolene are inserted the distal end of the graft to the distal phalanx with a
attaching the graft to the distal stump of the FDP. pullout wire.
Box 30-2 Clinical Pearls—Stage 2 by the hand therapist to be of an immense value. Patients
tended to understand the details of the program better
 Allow at least 12 weeks before proceeding with the
and their compliance with the therapy program to be
second stage.
 The second stage should not be performed unless the also better. Patients are seen preoperatively by our certi-
patient gains excellent passive range of motion. fied hand therapist. The therapist discusses with the
 The site of the tenorrhaphy is exposed in the palm. patient the postoperative rehabilitation program to
 An incision is made at the distal forearm and the FDS allow the patient to participate in understanding the
of the involved digit is isolated and divided at the importance of this rehabilitation program and its impact
musculotendinous junction. on the eventual result of the staged flexor tendon recon-
 The tendon graft is retrieved in the palm. struction. Sometimes splints are prefabricated preopera-
 The tendon graft is threaded through the new sheath tively to decrease the time and the difficulty of making
guided by the Hunter rod. custom splints postoperatively. Since virtually all these
 Optimum tension should be adjusted then the tendon
patients are scheduled on an elective basis, preoperative
graft is anchored to the bony distal phalanx with 4-0
teaching by the therapist can be easily incorporated in
stainless steel wire. Extra sutures of 4-0 Prolene can be
placed between the FDP and the tendon graft. the protocol.
 Early active motion starts 3 to 5 days postoperatively. At the first postoperative visit, 3 to 5 days postopera-
tively, the compression dressing is removed and a light
compression dressing is applied along with fingersocks
or 1-inch Coban. A dorsal blocking splint is applied.
Postoperatively, the patients are instructed to perform The wrist is kept in neutral or 20° flexion and the meta-
early AROM exercise 3 to 5 days after surgery, as detailed carpophalangeal joints (MP) in 60° flexion with the IP
in the paragraphs that follow (Box 30-2). joints kept extended. Patients are taught first the place-
and-hold exercise program as well as wrist tenodesis
EARLY MOBILIZATION
exercises. The patient is advanced gradually to AROM
In the past four decades, significant advances in basic exercises within the middle arc of motion and within
and clinical research have improved our understanding the restraints of the dorsal blocking splint. The extremes
of tendon function, physiology, and tendon healing.10-13 of the arc of motion in extension and flexion are to be
These advancements triggered an evolution in the post- avoided in this early phase. Exercises are performed 4
operative rehabilitation after flexor tendon repairs. Suc- times a day.
cessful rehabilitation after flexor tendon repairs has to At 2 weeks, scar mobilization is started. Scar mobili-
provide both protection of the repair and prevention of zation is a manual therapeutic technique that uses
adhesions from limiting the tendon excursion. Studies massage to break down scar tissue. It is performed 4
have documented improved tendon function with early times a day by applying gentle firm pressure over the
controlled mobilization as the forces applied to flexor scar and massaging it in a horizontal, vertical and circu-
tendon repairs provide more rapid recovery of tensile lar motion. A self adhesive Silicone gel sheet is used at
strength with improved tendon excursion and fewer night. The sheet is cut appropriate to the size of the scar
adhesions.14,15 Several studies have documented the and applied directly over the scar. It may be wrapped
superior results of early AROM following flexor tendon with Coban or stockinet. It helps to reduce, flatten, and
repair and reconstruction.13,16-20 smooth the scar.
This technique of flexor tendon reconstruction using At 2 weeks, the AROM is increased. Gentle blocking
the pedicled FDS is ideal for implementation of an exercises may be started. Exercises are repeated 6 to 8
AROM program. The site of the proximal repair is times a day. Sometimes ultrasound is used if adhesions
already healed by the time the second-stage procedure are excessive.
is performed. The strong bony fixation of the graft to the At 4 to 5 weeks, the dorsal blocking splint is dis
bony distal phalanx provides a strong construct allowing continued. A clamshell splint is fabricated supporting
AROM. In our experience we have found that the results the MP joint at 0°, allowing full AROM of the PIP and
of the more recent procedures were significantly better the DIP joints to promote excursion of the flexor
than the older ones essentially because of the AROM tendons. The splint is a hand-based, volar/dorsal splint
program that we adopted in the last 15 years. Smith and maintained with Velcro straps on the ulnar and radial
colleagues17 used early AROM following staged flexor aspects of the hand (Figure 30-13). All the fingers are
tendon reconstruction. In 26 digits in 22 patients, 20 included in the splint, but the thumb is excluded to
digits (77%) achieved good to excellent results. allow full range of motion of the thumb. The splint
may be used all the time or just during exercises. Neu-
Our Protocol romuscular electrical stimulation may be used. The
Early AROM requires a cooperative, focused, and under- patient is advised to avoid any lifting or heavy use of
standing patient. We found that preoperative teaching the hand.
Figure 30-13 Clamshell splint.
A B
Figure 30-14 Postoperative function at 1 year after surgery. A, Flexion. B, Extension.
At 8 weeks, progressive strengthening exercises with classification.21,22 There were no patients in grade 1; 32
the use of putty and/or hand gripper are started. Patients patients in grade 2; 14 patients in grade 3; 19 patients
are gradually weaned from the clamshell splint after in grade 4; and 29 patients in grade 5. Sixty-six patients
obtaining satisfactory AROM. Unrestricted activities are had previous surgery: 36 patients had tendon repairs;
allowed at 8 weeks (Figure 30-14). 25 were primary and 11 were secondary repairs. Eleven
patients had single staged flexor tendon grafts and 19
PERSONAL EXPERIENCE AND OUTCOMES
had flexor tenolysis.
From 1983 to 2009, we treated 116 patients with this During the first stage of the tendon reconstruction,
technique; 94 patients were available for review. The 68 42 patients underwent pulley reconstruction. Pulley
male and 26 female patients ranged in age from 14 to reconstruction was performed using Kleinert and
71 years with an average of 34 years. The index finger Bennett’s method in which the tendon graft is sutured
was involved in 21 patients; long finger in 37; ring finger to the remaining rim of tissue at the site of the pulley.23
in 17; and little finger in 19 patients. Twelve patients Twelve patients had nerve grafting, 5 patients had nerve
had injuries in zone 1; 63 patients in zone 2; 13 patients conduits using polyglycolic acid neurotubes, and 26
in zone 3; and 6 patients in zone 4. Preoperatively, patients had release of flexion contractures of the PIP
patients were evaluated according to modified Boyes joint by excision of the check-rein ligaments.
Table 30-1 Results According to Zone of Injury

Functional Recovery
Zone No. of Patients Excellent Good Fair Poor Excellent + Good, %
1 12 2 9 0 1 92
2 63 20 24 10 9 70
3 13 3 8 0 2 85
4 6 2 2 1 1 67
Total 94 27 43 11 13 74
Table 30-2 Results According to Preoperative Status With the Modified Boyes Grading Method
Functional Recovery
Grade No. of Patients Excellent Good Fair Poor Excellent + Good, %
II 32 9 16 4 3 78
III 14 4 7 1 2 79
IV 19 6 9 2 2 79
V 29 8 11 4 6 66
CHOICE OF PROCEDURE
The postoperative follow-up ranged from 2 to 27
years with an average of 9.5 years. The results were Whenever the FDS is available, this technique has proved
evaluated using the grading system reported by Strick- to be simple and reliable, and the results are reproduc-
land and Glogovac.24 This method measures the active ible. This technique avoids harvesting a donor graft,
degree of PIP and DIP joint flexion minus any extension thereby reducing the morbidity of the site of the donor
lag. Patients who have more than 150° are rated as graft. The FDS being an intrasynovial tendon has advan-
excellent, 125° to 149° as good, 90° to 124° as fair, tages over the use of an extrasynovial tendon. There have
and less than 90° as poor. According to this evaluation, been several studies that found improved function in
27 of our patients were rated as excellent, 43 as good, animal models following tendon grafting using an
11 as fair, and 13 as poor. The results by zone of injury intrasynovial tendon such as the FDS compared to
are listed in Table 30-1. The results according to the extrasynovial tendons such as the palmaris longus or
preoperative status of the finger according to the modi- plantaris.25-28 Gelberman and colleagues25 compared the
fied Boyes grading system are listed in Table 30-2. morphological and functional characteristics of intrasy-
Patient satisfaction was very high; 78% of the patients novial tendons with the extrasynovial tendon grafts in
were satisfied or very satisfied with the procedure. Of the dogs. They found that the intrasynovial tendon grafts
94 patients, 64 were manual laborers; 59 of them heal with minimal adhesions with normal cellularity
returned to their original work activities, 3 retired, and and collagen organization. This provided a smooth
2 had to change their job. gliding surface. The extrasynovial grafts, on the other
Persistent flexion contractures of the PIP or the hand, healed with ingrowth of connective tissue from
DIP joints or both were present in 57 patients. The the digital sheath that obliterated the gliding surface
flexion contracture ranged from 5° to 57° with an and occupied the space between the tendon surface and
average of 14°. surrounding tissues. They concluded that intrasynovial
There were no infections or tendon ruptures in this tendon grafts had significantly improved morphological
group of patients. Fourteen patients required tenolysis; and functional characteristics compared with the extra-
10 improved, but 4 did not improve and 2 of them synovial tendon grafts.
underwent arthrodesis of the PIP joint because of per- An added advantage of this technique is proximity of
sistent flexion deformities. the size of the FDS tendon to that of the FDP compared
with the size of the palmaris longus or plantaris, which FDS-to-FDP repair in the second stage is much easier
is much smaller. Carlson and colleagues29 studied the than trying to isolate the profundus tendon of that digit.
morphological and biomechanical characteristics of the The addition of a long Prolene suture at the site of the
free tendon grafts, comparing palmaris longus, plan- repair actually makes identification of the repair site
taris, and extensor digitorum longus of the toe with the much easier. The use of the largest possible size of
FDP. They found that the average cross-sectional area of Hunter rod takes away the uncertainty of whether the
the FDP was 10.6 mm2 and the cross-sectional areas of FDS tendon graft will fit in the new tendon sheath. We
the palmaris longus, plantaris, and the toe extensors have not had any difficulty with passing the FDS in the
were 3.1 mm2, 1.6 mm2, and 3.2 mm2, respectively.29 tendon sheath. This combined approach of using Hunter
The FDS tendon has a cross-sectional area much closer rod to stimulate the production of a new sheath and the
to the FDP tendon. That is why we recommend using use of the pedicled FDS as a graft takes advantage of the
the largest possible size of Hunter rods during the first benefits of the two techniques. This method of flexor
stage. We used size 6 Hunter rods in 76%, size 5 in 14%, tendon reconstruction provides certain advantages over
and size 4 in 10% of the patients. the classic use of Hunter rod and an extrasynovial
From the technical standpoint this procedure is tendon graft such as the palmaris longus, plantaris, or
straightforward. Even identification of the site of the toe extensors.30-33
References
1. Paneva-Holevich E: Two-stage plasty in flexor tendon injuries 14. Chesney A, Chauhan A, Kattan A, et al: Systematic review of
of fingers within the digital synovial sheath, Acta Chir Plast flexor tendon rehabilitation protocols in zone II of the hand,
7:112–124, 1965. Plast Reconstr Surg 127:1583–1592, 2011.
2. Paneva-Holevich E: Two-stage tenoplasty in injury of the 15. Gelberman RH, Woo SL, Lothringer K, et al: Effects of early
flexor tendons of the hand, J Bone Joint Surg (Am) 51:21–32, intermittent passive mobilization on healing canine flexor
1969. tendons, J Hand Surg (Am) 7:170–175, 1982.
3. Hunter JM, Salisbury RE: Flexor tendon reconstruction in 16. Khan K, Riaz M, Murison MS, et al: Early active mobilization
severely damaged hands: a two-stage procedure using a after second stage flexor tendon grafts, J Hand Surg (Br)
silicone-Dacron reinforced gliding prosthesis prior to tendon 22:372–374, 1997.
grafting, J Bone Joint Surg (Am) 53:829–858, 1971. 17. Smith P, Jones M, Grobbelaar A: Two-stage grafting of flexor
4. Kessler FB: Use of a pedicled tendon transfer with a silicone tendons: results after mobilization by controlled early active
rod in complicated secondary flexor tendon repairs, Plast movement, Scand J Plast Reconstr Surg Hand Surg 38:220–227,
Reconstr Surg 49:439–443, 1972. 2004.
5. Chong JK, Cramer LM, Culf NK: Combined two-stage teno- 18. Braga-Silva J, Kuyven CR: Early active mobilization after
plasty with silicone rods for multiple flexor tendon injuries flexor tendon repairs in zone two, Chir Main 24:165–168,
in “no-man’s land,” J Trauma 12:104–121, 1972. 2005.
6. Winspur I, Phelps DB, Boswick JA: Staged reconstruction of 19. Pettengill KM: The evolution of early mobilization of the
flexor tendons with a silicone rod and a “pedicled” sublimis repaired flexor tendon, J Hand Ther 18:157–168, 2005.
transfer, Plast Reconstr Surg 61:756–761, 1978. 20. Yamazaki H, Kato H, Uchiyama S, et al: Long term results of
7. Paneva-Holevich E: Two-stage tenoplasty: results. In Hunter early active extension and passive flexion mobilization fol-
JM, Schneider LH, Mackin EJ, editors: Tendon Surgery in the lowing one-stage tendon grafting for neglected injuries of the
Hand, St Louis, 1987, CV Mosby, pp 272–281. flexor digitorum profundus in children, J Hand Surg (Eur)
8. Naam NH: Staged flexor tendon reconstruction using pedi- 36:303–307, 2011.
cled tendon graft from the flexor digitorum superficialis, 21. Boyes JH: Flexor tendon grafts in the fingers and thumb: an
J Hand Surg (Am) 22:323–327, 1997. evaluation of end results, J Bone Joint Surg (Am) 32:489–499,
9. Beris AE, Darlis NA, Korompilias AV, et al: Two-stage flexor 1950.
tendon reconstruction in zone II using a silicone rod and a 22. Boyes JH, Stark HH: Flexor tendon grafts in the fingers and
pedicled intrasynovial graft, J Hand Surg (Am) 28:652–660, thumb: a study of factors influencing results in 1000 cases,
2003. J Bone Joint Surg (Am) 53:1332–1342, 1971.
10. Lundborg G: Experimental flexor tendon healing without 23. Kleinert HE, Bennett JB: Digital pulley reconstruction employ-
adhesion formation—a new concept of tendon nutrition and ing the always present rim of the previous pulley, J Hand Surg
intrinsic healing mechanisms. A preliminary report, Hand (Am) 3:297–298, 1978.
8:235–238, 1976. 24. Strickland JW, Glogovac SV: Digital function following flexor
11. Gelberman RH, Vande Berg JS, Lundborg GN, et al: Flexor tendon repair in Zone II: A comparison of immobilization
tendon healing and restoration of the gliding surface: An and controlled passive motion techniques, J Hand Surg (Am)
ultrastructural study in dogs, J Bone Joint Surg (Am) 65:70–80, 5:537–543, 1980.
1983. 25. Gelberman RH, Seiler JG III, Rosenberg AE, et al: Intercalary
12. Boyer MI, Strickland JW, Engles D, et al: Flexor tendon repair flexor tendon grafts: A morphological study of intrasynovial
and rehabilitation: state of the art in 2002, Instr Course Lect and extrasynovial donor tendons, Scand J Plast Reconstr Surg
52:137–161, 2003. Hand Surg 26:257–264, 1992.
13. Tang JB: Indications, methods, postoperative motion and 26. Seiler JG III, Gelberman RH, Williams CS, et al: Autogenous
outcome evaluation of primary flexor tendon repairs in Zone flexor-tendon grafts: A biomechanical and morphological
2, J Hand Surg (Eur) 32:118–129, 2007. study in dogs, J Bone Joint Surg (Am) 75:1004–1014, 1993.
27. Abrahamsson SO, Gelberman RH, Lohmander SL: Variations 30. Brug E, Stedtfeld HW: Experience with a two-stage pedicled
in cellular proliferation and matrix synthesis in intrasynovial flexor tendon graft, Hand 11:198–205, 1979.
and extrasynovial tendons: An in vitro study in dogs, J Hand 31. LaSalle WB, Strickland JW: An evaluation of the two-stage
Surg (Am) 19:259–265, 1994. flexor tendon reconstruction technique, J Hand Surg (Am)
28. Leversedge FJ, Zelouf D, Williams C, et al: Flexor tendon 8:263–267, 1983.
grafting to the hand: an assessment of the intrasynovial donor 32. Amadio PC, Wood MB, Cooney WP 3rd, et al: Staged flexor
tendon: A preliminary single-cohort study, J Hand Surg (Am) tendon reconstruction in the fingers and hand, J Hand Surg
25:721–730, 2000. (Am) 13:559–562, 1988.
29. Carlson GD, Botte MJ, Josephs MS, et al: Morphologic and 33. Wehbe MA, Mawr B, Hunter JM, et al: Two-stage flexor-
biomechanical comparison of tendons used as free grafts, tendon reconstruction. Ten-year experience, J Bone Joint Surg
J Hand Surg (Am) 18:76–82, 1993. (Am) 68:752–763, 1986.
CHAPTER
31
VASCULARIZED TENDON
TRANSFERS FOR
RECONSTRUCTION
A Tendon Vascularity and
Gliding, Island and Free
Vascularized Transfers
OUTLINE be insufficient collagen production. Instead, vascular

connections develop through adhesion between the
This chapter presents several new approaches to flexor tendon and peripheral tissues. The adhesion diminishes
tendon reconstruction for salvage tendon surgery. The the sliding capacity of the tendons and limits functional
use of an island tendon, vascularized by the mesoten- recovery of the tendon.
don, with all its gliding surfaces intact, provides new Potenza introduced the essential roles of adhesions
methods to deal with adhesions and has the added for tendon healing in early 1960s.1 Since then, investiga-
merit of being a one-stage procedure. The procedure tors sought to lessen functional impact of adhesion
can be done as a local pedicled flap, as a free vascular- formation and optimize the sliding capacities of the
ized composite tissue transfer from the foot, or as a tendon. Few attempts were made to understand why
vascularized transplant from a cadaver donor. These tendons need vascular or pseudo-vascular connections.
types of vascularized tendon, or tendon and flap, trans- Indeed, some researchers tended to minimize the role
fers had multiple applications; the author achieved of vascularization. The efforts have led to less research
rather favorable functional results in the patients. aimed at providing vascular supplies to the tendon for
These procedures are expected to offer reconstructive many years because it seemed pointless to carry out
options for the cases involving damages to multiple research on this subject if tendons are very slightly vas-
structures together with flexor tendons. cularized and receive sufficient nourishment from the
synovial fluid.2
From the outset, surgical principles concerning the Major past effort was done to diminish adhesion by
reconstruction of finger flexor tendons have centered on limiting the contact between the grafted tendon and the
the tendon as a simple force transmission belt connect- recipient site. Catgut, polyester, and silicone interposi-
ing the muscular structure. Muscles create the forces that tions were introduced and showed their efficacy but to
move articulated structures of bones, and the tendon is the detriment of tendon solidity; rupture due to insuf-
bent by this force around the joints during motion of ficient healing or necrosis is a major complication. The
the extremities. Consequently, this very mechanical fact that some damaged tendons need adhesions in
concept led to the development of techniques mainly order to heal was acknowledged, as was its detrimental
aiming at rebuilding this “transmission belt” as solidly effect on sliding and functional outcome. For decades,
as possible. The tendon is considered as mostly avascu- research was aimed at decreasing the adhesion. Yet two
lar; mechanically, the tendon simulates a transmission antagonistic aspects have to be reconciled: healing with
belt. poor sliding and with the risk of rupture.
From the 1940s, many researchers have accumulated Different avascular tendon grafts, such as the pal-
evidence of poor tendon healing capacity. The major maris longus, the plantaris, and others, have been used
reason for poor tendon healing is believed to thus far.3 The two-stage techniques became popular to
323
treat the cases with serious scar during secondary the subcutaneous tissues and led to new concepts and
repairs or reconstruction. Two-stage tenoplasty by James to new surgical procedures.10
Hunter4 and Paneva Holevitch5 needs to be completed
with multiple operations. In these operations, a silicone ANATOMICAL STUDIES AND SURGICAL BASIS
rod capable of recreating the conditions of a synovial
sheath is inserted first. A tendon is then grafted or trans- Microvideo Observations of Tendon
ferred in a second stage. Despite all the precautions, Structures in Zones 3, 4, and 5
functional results were sometimes mediocre because, We have performed 95 video observations in vivo with
apart from Hunter’s series, which found 80% good functional analysis, either directly under the skin or
results, other teams only approached 50% success rates. close to tendons, muscle, and nerve sheaths during
A good skin condition is required before surgery. The human surgical dissection using light microscopy (at
two-stage technique necessitates at least 6 months, thus magnification ×25).
discouraging patients and surgeons owing to the time This gliding or sliding tissue structure, traditionally
factor and to the difficulty in obtaining good functional called “connective,” “areolar,” or “loose tissue and
result. Moreover, in the mid to long term, the outcome paratenon around the tendons,” has for long been con-
becomes even less satisfactory sometimes, with some sidered to be packing tissue that fills spaces. In fact, this
fingers in flexion deformities. tissue plays a mechanical role, allowing movements
In fact, these techniques obey a certain mechanical between the structures it connects, preserving mobility
logic. The tendon acts as a force transmission cord; its and independence between organs, in particular,
motion should require optimization of smooth gliding between tendons and skin. This tissue is important
surface in the first stage of the operation. An attempt for the nutrition of the structures embedded in it
was made to solve the biological problem by trying to and acts as a frame for blood and lymph vessels
create sliding conditions with a synovial pseudo-sheath. (Figure 31[A]-1).
Although this principle may represent enormous prog- Mechanically, it diminishes friction while facilitating
ress compared to the past, the biological realities and deformability and adaptability. The fibrous tissue,
requirements are not respected. The results of the pro- known as the paratendon, surrounds the tendon. It is
cedures and the difficulties encountered led some sur- composed of multidirectional filaments, intertwining
geons to question very foundations of avascular nature and creating partitions that enclose microvacuolar
and believed mechanical role of the tendon. shapes (Figure 31[A]-2). We term this the Multimicro-
In the staged tendon reconstruction, the tendon is vacuolar Collagenous Dynamic Absorbing System
not vascularized and placed in a more or less sclerotic (MVCAS) to emphasize its function. This system is situ-
recipient site. It is not always possible to achieve both ated between the tendon and its neighboring tissue and
healing and gliding of the repaired tendon at the same favors optimal sliding. The tendon is able to travel far
time. Past investigations demonstrated that the tendon and fast without any hindrance, and without inducing
is a vascularized structure and has vascularity distribut- movement in any other neighboring tissue, thus account-
ing both inside and outside the tendon, as well as ing for the absence of any dynamic repercussions of
having a very specific lymphatic drainage system.6-9 The movement on the skin surface. When the flexor tendon
current techniques remain completely alien to these moves, its movement is barely discernible in the palm.
biological realities and ignore, or at least exclude, neces- In the light of above new information obtained, the
sity of vascular supplies to the grafted tendon during time has come to confirm some anatomical truths
surgical reconstruction. Therefore, better knowledge of about this tissue. The notion of multilayered sliding
the intricate physiology of the tendon and the condi- between completely anatomically separate tissues—
tions favoring optimum function are necessary to obtain sliding thanks to what many believe to be an elastic
better outcome of the surgery. process—is likely to be revised in the light of these
For many decades, terms such as hierarchical tissue observations. Continuous matter and microvacuolar
distribution, stratification, and virtual space between struc- framework should be noted between the tendon and
tures have been taken for granted, yet the real basis for surrounding structures.11,12 Scanning electron micro
them needs to be questioned. Their scientific under scopy demolished the existence of different super
pinnings were limited to the notion of virtual space imposed layers because they were never observed.
or the existence of loose connective tissue, but their Furthermore, the elementary laws of mechanics and rhe-
biomechanical foundations were more than vague. In ology presented the problem in terms of global dynam-
the past 50 years, research focused on the microscopic ics where continuous matter composed of millions of
findings of these structures while the global concept of vacuoles, each measuring a few microns to a few milli-
the structures has not been addressed. As we have exam- meters in size, is organized in dispersed branching
ined these tissues more closely, new hypotheses and fractal patterns (Figure 31[A]-3). The sides of the vacu-
findings have emerged concerning the organization of oles, which are intertwined, are composed of collagen
Chapter 31A: Tendon Vascularity and Gliding, Island and Free Vascularized Transfers 325
A A
B B
Figure 31(A)-1 A, Traction on the paratenon that shows Figure 31(A)-3 Multifibrillar framework, microvacuoles
tendon surface and fibrous tissue. B, Fiber networks inside inside the sliding system. Illustrates the microvacuole filled
the sliding system between the tendons. with components (e.g., glycosaminoglycan and framed by
collagen types I and III).
fibers. This approach to tendon physiology also sup-

poses a completely different way of perceiving the
problem of reconstruction. These observations demon-
strating the real histological continuity between the
paratenon, the common carpal sheath, and the flexor
tendons illustrate the perfect vascularization of this
functional ensemble. The observations introduce a new
concept: the sliding unit, composed of the tendon and
its surrounding sheaths. Further functional detail of this
sliding unit includes (1) a tendon only has optimal
functional value when it is surrounded by its original
sliding sheath and its vascular heritage; (2) a tendon is
adherent only when it is artificially separated from its
own sliding sheath, or when the harmony between the
tendon and the sheath has been interrupted; and (3) a
tendon is only one of the elements involved in the
Figure 31(A)-2 Histological and collagenous continuity
between the epitenon and sliding system. transmission of force through the sliding unit.
A B
C D
Figure 31(A)-4 A and B, Sliding unit composed of flexor tendon, common carpal sheath (zone 3), and mesotendon
(branches of the ulnar artery inside). C and D, Movement of the MCVAS during tendon gliding.
For zones 3, 4, and 5, the author set out to define a of elastic traction (grade 3) and those with all possible
different role for the tendon in the production and complicating factors such as major soft-tissue damage,
transmission of a force. The tendon is not purely a joint stiffness, poor vascularization, and trophic changes
transmission belt acting in the carpal sheath surrounded (grade 4).
by a virtual space, nor is it a tissue that is avascular or The theoretical bases for this technique are that the
only very slightly vascularized. The tendon is nourished tendon can be conceived as vascularized and that the
by its own vascular system. Due to existence of the tendon is an element of a highly complex sliding and
MVCAS, the tendon is extensively linked to its sur- functional unit in association with its surrounding
rounding structures in these areas, including sheath in sheaths (Figure 31[A]-4).
zone 4. The MVCAS lies above the tendon and exerts a In developing this technique, the author sought to
major role of tendon vascularization with peritendinous answer following basic questions: (1) Which sliding
tissues. structures should be used to replace zone 1 and 2
tendons? The mesotendon and its vascular branches
Basic Principles for Our Methods provide good vascularization of the flexor tendon and
of Tendon Reconstruction the sliding carpal sheath both extrinsically and intrinsi-
The idea is to transfer en bloc a digital flexion unit cally. The structure thus transferred is a real sliding struc-
composed of the flexor tendon with the sheaths from ture which already exists naturally in zones 3, 4, and 5.
zones 3, 4, and 5 to zones 1 and 2 at a single stage. The (2) How will the replacement flexion structure be vas-
author uses this technique for the reconstruction of cularized? Vascularization is ensured by a preretinacular
finger flexor tendons with Boyes grade 3 and 4 presenta- mesotendon with branches arising from the ulnar artery.
tions.13,14 These patients include those with restricted At the inferior third of the wrist, just before the flexor
passive motion in the proximal interphalangeal (PIP) retinaculum or the annular ligament, the latter has
or distal interphalangeal (DIP) joints even after a period two or three branches of around 1 mm in diameter.
These branches pass through the common carpal sheath the FCU tendon. The ulnar artery is dissected, and all
toward the superficial flexor tendons, especially those its branches are carefully separated and divided. First,
of the middle, the ring, and the little fingers, through a the cutaneous branches between the ulnar artery and the
fine transparent mesotendon acting as a mesentery con- skin are carefully isolated. The branches emerge from
necting the tendons. This vascular supply to the flexor the volar aspect of the pedicle and are major compo-
system and the common carpal sheath is distal to the nents of the ulnar forearm flap. These branches should
tendon–muscle junction, thus allowing harvesting of be divided only when skin transfer is not required. The
retrograde island transfers of purely tendinous struc- ulnar pedicle is then separated from the ulnar nerve on
tures without muscles. (3) How will the sliding unit be its dorsal aspect along its whole length from the lower
positioned in zone 2? For reversed vascularized tendon third of the forearm to Guyon’s canal. On the posterior
transfer, only the ulnar artery–based pedicle is suitable aspect of the artery, the branches to the ulna are then
owing to its distally based palmar point of rotation and identified. The branches on the anterolateral side emerg-
to its branch transmission at the level of the tendon. ing just proximal to the Guyon’s canal are those supply-
Since there are many clinical circumstances and forms ing the common carpal sheath and the flexor sliding
of tissue destruction, this surgical technique has been system. These small branches emerge from the ulnar
developed over time to include a wide range of variants artery and go into the common carpal sheath and the
(Figure 31[A]-5). multi-microvacuolar absorbing system. The vascular
branches and fibrous tissues act as a mesentery, i.e.,
Anatomical Features of the Ulnar mesotendon, a mobile structure 2 cm long.
Artery–Based Pedicle Flap A mesotendinous structure composed of the FDS
In the distal forearm, the ulnar artery runs parallel to tendon of the ring finger is then raised with the carpal
the nerve between the flexor carpi ulnaris (FCU) tendon sheath and its vascular connections from the ulnar
laterally and the flexor digitorum superficialis (FDS) artery (Figure 31[A]-7). These connections, usually
tendons of the fourth and fifth fingers medially. Covered comprising two or three small branches on the antero-
only by skin, subcutaneous fat, and the superficial fascia, lateral side and measuring on average 0.2 to 0.5 mm
this artery is relatively superficial in the lower and in diameter, are found just proximal to the proximal
middle compartments. However, in the upper compart- edge of the flexor retinaculum. At the level of the A1
ment, the cutaneovascular relationships are less clear pulley, the FDS tendon is transected proximal to the
and the raising of a reverse island flap is thus more decussation after forceful traction on the tendon, avoid-
problematic. Cutaneous vascularization is ensured by a ing laceration of the vinculum longum of the flexor
series of two to four small pedicles linked to the main digitorum profundus (FDP) tendon. The ulnar artery is
pedicle through the fascia. The vessels are about 1 cm then ligated proximally. All the other branches of the
long and 1 to 3 mm in diameter. Since the small pedi- ulnar artery to the deep arch division are ligated to
cles lie 15 to 25 mm apart, each flap usually contains at obtain a rotation point at the level of the deep branch.
least two pedicles of good quality. In all our patients, The MVCAS surrounding the tendon is kept in place,
the anatomic presentation was constant, both topo- thus ensuring a real vascular connective link around the
graphically and with regard to vascular distribution tendon. A composite mesotendinous unit of 20 cm long
(Figure 31[A]-6). The anterior compartment of the is then raised.
forearm is drained by two venous systems, the venae The sliding unit is transferred to the distal part of the
comitantes of the ulnar artery and the superficial system, hand to provide a complete flexor tendon unit from the
whose veins are of larger diameter. Both systems have finger tip to the wrist. The transferred tendon unit is laid
abundant anastomotic networks, which make it easy to into the zone 2 and is passed under the A2 and A3
raise both free and pedicle flaps. pulleys. These pulleys must be carefully preserved or
reconstructed if necessary, since the tendon transfer
OPERATIVE PROCEDURES exposes them to much greater force than a simple
tendon graft does. The pulley system often presents a
Vascularized FDS Tendon Graft Based on the difficult problem. We prefer to use the remaining parts
Ulnar Artery: Essential Procedures of pulleys. Sometimes, the preserved pulleys are too
The basic procedure consists of the transfer of the FDS narrow and require careful dilatation. It is better to
tendon of the ring finger to repair tendon defects of the rebuild a pulley than to keep one if the transfer and its
other fingers. Preoperative evaluation includes Allen and blood supply are compromised.
Doppler tests to ascertain that the radial artery provides The distal junction of the grafted tendon is achieved
adequate blood supply to the hand. Angiography of the by inserting the graft tendon into the distal phalanx
arm is also advisable. A bayonet-shaped incision is first with a “barbed wire” suture. The proximal junction with
traced and then made on the medial side of the forearm, the distal stump of the relevant FDP tendon is per-
the axis of the incision overlying the lateral border of formed using Pulvertaft repair. The tension on the suture
Middle Ring
Flexor
digitorum
superficialis
(FDS)
tendon
Ulnar
artery
Ulnar
Flexor digitorum artery
superficialis (FDS)
of the ring finger
A B
Flexor digitorum
superficialis (FDS)
tendon
Ulnar
artery
C D
Figure 31(A)-5 Transfer of a sliding flexion unit composed of a flexor tendon and surrounding sheath as a reverse island
pedicle graft. A, Identification of mesotendon around the FDS tendon of the ring finger. B, Section of FDS tendon of the ring
finger and ulnar artery. C, Insertion of the grafted tendon into the middle finger. D, Completion of the transfer and tendon
junction placed outside zone 2.
Radial rotation
Flexor digitorum point
superficialis
6 cm
Skin
Ulnar Ulna
artery Ulnar rotation Ulnar straight
A B point line continuity
C D
Figure 31(A)-6 A, Various vascular branches emerging from the ulnar artery proximal to entrance to Guyon’s canal. B, The
ulnar artery forearm flap has a very distal rotation point, the graft can be used to repair the distal part of the hand. Radial
forearm flap does not have a distal rotation point, not fitting distal finger repair. C, Vascular branches running from the ulnar
artery to the FDS tendon. D, Mesotendon and its vascular connections to the ulnar artery act as a mesentery.
should be slightly overcorrected in comparison with the Delay between injury and reconstruction seems to cause
other fingers. The whole procedure takes about 3 hours: progressive narrowing of the pulleys. The pulleys may
1 hour for finger dissection and preparation, 1 hour be widened by mechanical manipulations, avoiding
for raising the transfer and 1 hour for insertion and rupture, but this maneuver is not easy. Otherwise, surgi-
closure. cal pulley reconstruction is mandatory. Our functional
On completion of the procedure, a dynamic Kleinert results obtained to date have been good and very often
splint is applied to allow early movement, which is excellent. Under good patient conditions, the results are
indicated in the cases with flexor tendons or pulleys much better than with a tenodesis or an arthrodesis.
reconstruction but without skin problems and where
mobilization can intervene early. Combined Island FDS Tendon and Palmaris
Longus Tendon Transfer for Tendon and
FDS Tendon Transfer to Reconstruct the FDP Pulley Reconstruction
Tendon With an Intact FDS in Another Finger For a long time we used the Weilby procedure for pulley
This procedure was first attempted after much reflection reconstruction. However, the idea arose of using the
and with good experience of the basic procedure palmaris longus as another vascularized tendon on the
obtained in 30 cases. There is no fundamental difference same mesotendon as the FDS. The palmaris longus is
in the dissection and the donor elevation. The most transferred together with the FDS. Like the Weilby pro-
difficult part is to respect the FDS tendon in the recipi- cedure, we use this method with a periosteum wedge
ent site and the chiasma of Camper. Because the two suture as cross lacing from A1 to A4 pulleys. Before
tendons are squeezed together, the presence of the A1 suturing, the smooth sliding of the transferred tendon
and A2 pulleys sometimes make the procedure difficult. has to be checked.
C
D
Figure 31(A)-7 A, The mesotendon and branches of the ulnar artery to the FDS tendon and sectioning the FDS proximal to
the Camper’s chiasma. B, After tendinomuscular section and before ulnar artery section. C, The flexion sliding unit is created.
D, The unit is moved distally and the sliding unit is grafted to the recipient finger.
Composite Flexor Tendon and Skin flap can be rotated for 180° and positioned on the
Flap Transfer digital surface, but the tendon can be placed at its physi-
Combined transfer of vascularized flexor tendon and ological orientation due to flexibility of mesotendon.
skin flap allows surgeons to treat skin problem and to The skin is closed tension free, providing good healing
reconstruct the tendon at the same time (Figure 31[A]- without skin disunion or necrosis. This is of fundamen-
8). In the lower third of the forearm, the ulnar artery tal importance for achieving a good functional result.
sends branches not only to the FDS tendons but also to Based on author’s experience, the operation is reli-
the skin. These branches are easily identified, being able, with almost complete absence of complications.
close to the mesotendon branches and constantly of The anatomy of ulnar artery is constant, with at least
excellent caliber, allowing simultaneous composite one good-sized artery found in all the patients. The flap
transfer of the skin and tendon.13-15 Slight upward trac- has 360° mobility around a rotation point in the palm,
tion on the internal edge of the flap reveals the small which makes the entire skin surface of the hand acces-
vertical vessels arising from the ulnar artery to the skin. sible. This is not the case with the radial forearm flap.
After identifying the skin flap pedicle, the flap is dis- Tissue quality is excellent, being fine, fat free, and virtu-
sected (Figure 31[A]-9). ally hairless. There are no serious consequences at the
The second step is dissection of the ulnar artery and donor site. The scar on the forearm is usually very fine
identifying the mesotendon branches. Generally, the and not hypertrophic. The technique allows for further
skin flap lies proximal to the mesotendon. However, developments such as sensory innervation by means of
thanks to the flexibility of these cutaneous branches, the the medial cutaneous branches of the ulnar nerve.
Figure 31(A)-8 Transfer of a sliding flexion unit composed of a flexor tendon and a skin flap. A, Mesotendon and skin
branches identification. B, Section of FDS tendon to the ring finger and ulnar artery. The tendon and ulnar artery flap are
isolated. C, Tendon junction outside of the zone 2 and digital skin coverage with the flap.
This procedure is indicated in cases with significant underneath and achieve early motion. Skin of this sort
contracture of the skin on the palmar aspect of the digits inevitably breaks down or necroses, compromising
after multiple surgical procedures. A plain skin graft the functional result, so it should be replaced (Figure
cannot solve this problem. In some cases where the 31[A]-10). The solution is to perform a safe skin flap
overlying skin is extremely scarred and of poor quality, transfer together with tendon reconstruction, thereby
it would be impossible to replace the flexor tendon making early motion possible.
A B
C D
Figure 31(A)-9 Rising of the composite flexor tendon and skin flap island transfer for tendon repair and digital palmar
resurfacing. A, Outline of the skin flap incision based on the lateral edge of the FCU tendon. B, Identification of the fascia
connection to the tendon before cutting the ulnar pedicle. C, Owing to plasticity and distal rotation point of the ulnar pedicle,
the graft can be easily placed to the finger. D, Skin resurfacing is completed in the same time of the tendon reconstruction.
The wide variety of composite flap transfer is made This statement remains true. The influences of aspects
possible by the ulnar artery at the lower third of the of the patient’s life such as their psychological profile,
forearm, which offer a solution to a large number of smoking, socioeconomic status, and desire for future
clinical cases and meet varied surgical reconstructive employability have an impact on functional outcome.
requirements. For example, it is possible to perform a All of these factors must be taken into consideration in
double skin flap with one or two flexor tendon transfers, determining the aim of reconstruction, in choosing
or a skin flap with a flexor tendon for reconstruction these procedures and result evaluation.
and a palmaris longus as an island transfer for pulley Many systems of evaluation have been proposed. We
repair. It is also possible to add a bone transfer at the use the modified Strickland’s criteria.17 Nevertheless,
same time (Figure 31[A]-11). the arithmetical addition of degrees between extension
and flexion compared with the hypothetical maximum
amplitude, while not distinguishing between metacar-
RESULTS AND DISCUSSION
pophalangeal (MCP) joint and PIP or DIP joints, would
It is almost impossible to evaluate the results of tendon seem debatable for this sort of salvage situation. A
reconstruction operations by any statistical method. There significant alteration of MCP joint movement only
are so many variables; e.g., the type and extent of the rarely occurs. Clearly in such cases, the principal aim
injury, the age of the patient, the accompanying injuries is to restore effective and useful function, including
of nerves and vascular structures and the procedures grip, and especially to achieve recovery of good PIP
used—that only general conceptions, based on experience, joint movement. For heavily damaged fingers, too many
can be used. Tendons in the fingers are the most difficult unfavorable factors are present and it is not possible
to repair. achieve a full recovery. The patient should be informed
Joseph H. Boyes16 of incapability of full recovery preoperatively. More
A B
C D
Figure 31(A)-10 A and C, Results of two cases of palmar skin contracture and loss of flexor tendon function. B and D, Skin
resurfacing with a composite flexor transfer and skin flap.
importance should also be given to preoperative skin mobilization inducing pain and inflammation and
condition. requiring dressing. We now prefer to add a skin flap in
We treated 75 patients with Boyes grade 3 and 4 order to reinforce cicatrization, even if slight revision
injuries, all previously operated on at least twice. Our under local anesthesia may be required several months
strategy was determined by the skin quality primarily. later.
Since mobilization is early (3 days postoperatively), it
is mandatory to avoid skin dehiscence or necrosis. In Group 2
these circumstances, we use a composite skin and flexor We began to have this group of patient 10 years after
tendon transfer. group 1. With the experience gained, the technique was
Our patients were divided into three groups: (1) 18 extended, to be indicated in young subjects, such as
patients, including 13 grade 3 and 5 grade 4 patients in rugby players. Nevertheless, the technique is extremely
whom FDS tendon transfers were used; (2) 17 patients intricate and is indicated only in young subjects capable
in whom only the FDP tendon was injured with intact of following stringent rehabilitation. We had 17 cases:
FDS tendon were repaired by islanded FDS transfer; and 7 excellent (41%), 7 good (41%) and 3 poor, including
(3) 40 grade 4 patients, needing flap transfers due to 2 who preferred not to have joint arthrodesis after inter-
either major skin retraction, due to presence of a skin vention. A useful range of motion was obtained in 80%
defect or skin stiffness together with vascular or nerve of cases (Figure 31[A]-13).
problems. Four cases (23. 5%) required tenolysis, which revealed
the excellent state of the transferred tendon. Any adher-
Group 1 ences found were always located around the tendinous
There were 5 excellent (4 grade 3, 1 grade 4, 27.8%); 7 anastomoses. After tenolysis, 4 fingers obtained 2 excel-
good (6 grade 3, 1 grade 4, 38.9%); 4 medium (2 grade lent and 2 good results.
3, 2 grade 4, 22.3%); and 2 poor (1 grade 3, 1 grade 4,
11.1%) results (Figure 31[A]-12). Improvement was Group 3
achieved in 66.5% of patients. The fair and poor results Forty patients were analyzed. There were 1 excellent
were mainly due to healing problems during early (2.5%), 26 good (65%), 5 fair (12.5%), and 8 poor
Figure 31(A)-11 Several types of combined

transfers of multiple tissues. A, Transfer of multiple
flexor tendons. B, Transfer of double flexor tendons
and double skin flaps. C, Combined skin flap,
island FDS tendon transfer, and grafting palmaris
longus (PL) tendon for flexor pulley reconstruction.
D, Composite skin flap, flexor tendon, and bone
transfer. We called above types of combined transfer
as “ulnar trail.”
Two flexor tendons Skin flap
Flexor digitorum
superficialis (FDS)
tendon Skin flap
Palmaris
longus (PL)
tendon
Skin flap
Bone
(20%) results (Figure 31[A]-14). The results show that Overall, 42 patients (66.6%) achieved an excellent,
67.5% of these extreme salvage flexor tendon situations good result compared to an average of 55% in series
were greatly improved. The technique also produces where similar cases are operated using the two-stage
favorable trophic changes. Finger skin becomes more procedure with or without a silicone rod. However, in
supple and sensitive, joints are less stiff and are mechan- this particular field, precise evaluation of results is a real
ically active, and flexion is improved. challenge, and in many previous publications results
GROUP 1: 18 CASES
Poor
11.1%
Excellent
Fair 27.75%
22.25%
Good
38.9%
B
A
Figure 31(A)-12 Functional results of the flexion system transfer.
GROUP 2: 17 CASES
Excellent
41%
Poor
18%
Good
41%
B
A
Figure 31(A)-13 Results of the flexion system transfers for cases of the FDP tendon disruption with an intact FDS.
GROUP 3: 40 CASES
Excellent
2.5%
Poor
20%
Fair Good
12.5% 65%
B
A
Figure 31(A)-14 Results of combined flexor tendon–pulley and skin flap transfer.
have been evaluated by different methods, rendering the patient’s own will and the skills of the therapist.
true comparison difficult, if not misleading. What is Smoking appeared to be a major factor to worsen the
sure is this new technique seems to give better func- outcomes.
tional performance and reduces time lost from work. Regrettably, in the earlier years, we did not perform
The new technique using a mesovascular tendon vascularized flexor tendon grafting during a tenolysis,
transfer unit, which is now our standard procedure for when the tendons were found continuous but of poor
Boyes grade 3 or 4 cases, is likely to set the trend for quality. Some tendons ruptured one day after surgery.
flexor tendon surgery because the requisite tendon It is also regrettable that such procedures were not
reconstruction can be carried out in one operation. performed in patients with poor tendon conditions
Compared with other techniques, the advantages of this such as dehiscence. From 1996, the author changed
technique are as follows. It makes use of a living tendon the approach, and now performs composite skin and
islanded on a thin mesotendon with vascular branches, tendon transfers more often. It led to good results. The
providing a perfect blood supply to all areas both extrin- composite skin flap allows surgery to be done under
sic and intrinsic. It thus avoids adhesions and improves good conditions and facilitates immediate rehabilita-
the vascularity of the surrounding tissues. Since the graft tion, which is a major advantage. Sometimes a later
is a vascularized flexor tendon, rather than a simple tenolysis may still be required. However, the psychologi-
avascular graft, it retains its flexibility, pliability, and cal impact is very positive in our patients. Rehabilitation
resistance and allows the correct tension to be achieved. can be begun immediately after surgery.
The MVCAS and the carpal sheath retain the unrestricted
FUTURE CHALLENGES: PROCEDURES
gliding movement of the tendon. The grafted tendon is
USING OTHER GRAFT SOURCES
approximately 18 to 20 cm, which can be used to recon-
struct flexor tendon defect from the pulp to the carpal Our experience in the more recent years using vascular-
area. All the damaged pulleys have to be reconstructed ized flexor tendon autotransplants from the toes and
because the traction exerted by this type of tendon is homotransplants (allografts) suggests some applicable
greater. The vascular supplies to the tendon are anatomi- procedures. In the author’s unit, the transfer of flexor
cally constant. Because of the very distal rotation point mechanism of the second toe was performed in six patients
and the plasticity and versatility of the mesotendon, the to repair the digital flexor tendons, sheath, and palmar
flap transfer is performed in the same way as a classic plates in a single operation. On the donor site, the
reverse-flow radial or ulnar forearm flap. tendon is approached through a plantar incision from
It should be noted that the radial forearm flap does the medial side of the second toe to the mid plantar
not allow transfer of the common carpal sheath and the area. The plantar fat is retracted and the plantar aponeu-
flexor tendon because the radial artery supplies them rosis is transected, exposing the second toe flexor system
only at the myotendinous level and its point of rotation and its vascular network. Attention should be paid to
is too proximal. The composite flap and tendon transfer several anatomical points: (1) The flexor sheath of the
described here are confined to the ulnar vascular system. second toe is shorter than the second, third and fourth
The main disadvantage is the need to transect the digital flexor sheaths in the hand by 15% on average,
ulnar artery. However, in our experience of 629 cases of while it is longer than the fifth digital flexor sheath (by
a variety of ulnar artery–based flaps, no serious long- 5%); (2) the metatarsophalangeal (MTP) plate is wider
term effects such as paresthesia or functional deficits and thicker than the MCP joint plate; and (3) the A3
have been encountered. pulley is more developed in the toe flexor sheath.
These procedures described in this chapter have now The vascular type is identified and the composite
become routine practice in the author’s unit. Our experi- tendon flap is harvested from distal to proximal. The
ence indicates that they are safe, technically feasible, and vascular supply of the toe flexor system depends on the
above all provide practical solutions to problems that medial collateral digital artery, which is a terminal
often led to amputations or arthrodesis in the past. Only branch of the first common plantar digital artery, a
one patient requested an amputation since he was branch of the medial plantar artery. Venous drainage is
unable to carry plasterboard panels owing to a problem from its comitantes veins.
with his index finger. There are two different anatomic types. In type I,
Nevertheless, the functional outcome of our patients which is present in 50% of the cases, the second toe
has not improved in the past 15 years. The good or medial collateral artery arises directly from the first
excellent rates are still the same as they were then. common plantar digital artery, giving a long vascular
Factors influencing the outcome go far beyond the pedicle. In type II (i.e., the other 50% of cases), the
purely technical or surgical. Such concerns exist as to second toe medial collateral artery arises from the
skin tissue quality of the patient, whether pain or edema medial branch of the medial plantar artery beneath
is present, and the duration of the postoperative edema- the big toe flexor tendon and has a short vascular
tous phase. Other factors affecting the outcomes are pedicle. Dissection is performed under the periosteum,
FDS
Vascular pedicle
Type I FDP
A B
C D
Figure 31(A)-15 Free vascularized transfer of flexor tendon system from the big toe. A, Lack of flexion of the index finger.
B, Flexor tendons and pulleys harvested from the toe. C, Flexor tendons and pulleys transferred into the index finger.
D, Flexion of the finger 1 year after surgery.
elevating the whole flexor toe system with the two technique. The tendons are sutured with adequate
tendons, flexor pulleys and the three plantar plates with tension, the digits in a cascade position. The second toe
their vascular supply. The flexor tendons are transected free flexor tendon flap is the only one-step procedure
as far as required for the tendon defect in the hand and for reconstructing complex digital flexor tendon defects
the vascular pedicle is freed as far as possible depending anatomically, dynamically, and functionally.
on the anatomical type. Finally, the skin of the donor Six patients underwent above operations. All started
site is closed directly. physiotherapy the day after the operation with the
The freed tendon flap is then deployed over the recip- Duran protocol. Four had recovery to good (2 grade 3,
ient digit. Some surgical adjustments may be required 2 grade 4, 66.6%), 1 fair (1 grade 4, 16.6%), and 1 poor
to adapt the flap to its recipient site. For example, lateral (1 grade 4, 16.6%). No patients complained about the
resection of the MTP plate may be needed to narrow it, foot scar (Figure 31[A]-15).
or full circumferential incision of the flexor tube on the Vascularized tendon homograft (allograft) provides
cruciform pulleys to lengthen it and to fix the A2 and another source of donor tendon.18,19 Introduction of
A4 pulleys exactly in their most functional positions. cyclosporine in 1980 changed the indications and
The digital sheath is secured laterally to the fibrous improved success rates in tissue allograft with the use of
bundles by two continuous non-absorbable sutures. The low, nontoxic maintenance doses for the relatively weak
annular pulleys should be fixed in their anatomical antigenic response organs. The author’s team performed
position. The distal stump of the FDP tendon is secured a vascularized tendon allograft in patients based on the
with a Kleinert suture and protected with a barbed previous experience of vascularized tissue transfers.20
wire for 4 weeks. Meanwhile, the proximal FDS and To harvest the tendon, the arm is placed in abduction
FDP tendon stumps are repaired with the Pulvertaft to facilitate cooperation with other surgical teams. A
tourniquet is applied to the upper arm just before aorta

clamping. While the heart, liver, and kidney are removed
by other surgical teams, the author’s team harvested the
flexor tendon from the forearm. Above procedures may
take more than 2 hours.
The ulnar artery and its branches nourishing the
tendon are identified in the forearm. The FDS of the ring
finger is dissected at the tendon–muscle junction. All
the branches of the ulnar artery nourishing the tendon
as well as adjacent mesotendon are carefully preserved. A
The superficial palmar arcade is then clamped and tran-
sected distally to the third common palmar digital artery,
preserving the two collateral arteries inside the donor.
The functional unit composed of the FDS and FDP
tendons and all the pulleys is then separated from the
phalanges through a medial approach. Dissection is per-
formed under the periosteum over the phalanges, but
the flexor sheath is not opened. The radial side of the
ring finger is similarly dissected. Upon completion of
above dissections, the only remaining link between the
structure to be transplanted and the donor’s hand is the
ulnar artery. The tourniquet is then released. The super- B
ficial veins of the forearm are used for venous drainage.
The ulnar artery is ligated proximal to its branches sup-
plying the harvested skin. The transplant is placed in a
sterile plastic container filled with serum at 4°C.
The donor tendon is brought to the recipient patient
to repair tendon defects in the digits. The proximal parts
of the grafted FDS and FDP tendons are passed under
the superficial palmar arch of the recipient hand and is
sutured to the distal end of the recipient tendons with C
a Pulvertaft method. The ulnar artery of the donor is
connected to that of the recipient with an end-to-side Figure 31(A)-16 Free vascularized flexor tendon
anastomosis. The superficial veins of the donor are also allografting. A, Loss of flexion of the ring finger before surgery.
B, Harvested allograft. C, Finger flexion 1 year postoperatively.
anastomosed with recipient anterior forearm veins.
Total ischemia time is 3 hours.
SUMMARY
In these patients, the swelling abated little by little
after surgery, and good functional results were obtained The use of vascularized tendon grafts nourished by ulnar
4 months later. One patient had a passive flexion of 80° artery through mesotendon, with all gliding surfaces
in the PIP joint without extension defect, and passive intact, provides new methods to reduce adhesions and
flexion of 55° in the DIP joint with an extension deficit has the added merit of being a one-stage procedure.
of 35° (Figure 31[A]-16). The average total active These types of vascularized tendons or tendon and flap
flexion almost equaled the range of passive motion. This transfers are indicated in secondary reconstruction and
finger is now very functional and fully adapted. The can be expected to offer effective options for tendon
merit of the procedures is to reconstruct all the pulleys, reconstruction. Transfer of vascularized flexor tendon
to keep the digital sheath intact, and to avoid adhesion system from the toes or homotransplants of the digital
formation. flexor tendon are additional sources of tendon grafts.
References
1. Potenza AD: Critical evaluation of flexor-tendon healing and 3. Littler JW: Free tendon grafts in secondary flexor tendon
adhesion formation within artificial digital sheaths, J Bone repair, Am J Surg 74;315–321, 1947.
Joint Surg (Am) 45:1217–1233, 1963. 4. Hunter JM: Tendon salvage and the active tendon implant: A
2. Lundborg G, Holm S, Myrhage R: The role of the synovial perspective, Hand Clin 1:181–186, 1985.
fluid and tendon sheath for flexor tendon nutrition. An exper- 5. Paneva-Holevitch E: Résultats du traitement des lésions mul-
imental tracer study on diffusional pathways in dogs, Scand tiples des tendons fléchisseurs des doigts par greffe effectuée
J Plast Reconstr Surg 14:99–107, 1980. en deux temps, Rev Chir Orthop Repar 58:481–487, 1972.
6. Zbrodowski A, Gajisin S, Grodecki J: The anatomy of the flexor tendon salvage surgery, Plast Reconstr Surg 92:888–903,
digitopalmar arches, J Bone Joint Surg (Br) 63:108–113, 1993.
1981. 14. Guimberteau JC, Goin JL, Panconi B, et al: The reverse ulnar
7. Verdan CE: Half a century of flexor-tendon surgery. Current artery forearm island flap in hand surgery; 54 cases, Plast
status and changing philosophies, J Bone Joint Surg (Am) Reconstr Surg 81:925–932, 1988.
54:472–491, 1972. 15. Guimberteau JC, Panconi B: Recalcitrant non-union of the
8. Smith JW: Peripheral nerve surgery—retrospective and con- scaphoid treated with a vascularized bone graft based on the
temporary techniques, Clin Plast Surg 13:249–254, 1986. ulnar artery, J Bone Joint Surg (Am) 72:88–97, 1990.
9. Schatzker J, Branemark PI: Intravital observations on the 16. Boyles JH: Flexor-tendon grafts in the fingers and thumb: an
microvascular anatomy and microcirculation of the tendon, evaluation of end results, J Bone Joint Surg (Am) 32:489–499,
Acta Orthop Scand (Suppl) 126:1–23, 1969. 1950.
10. Guimberteau JC: New Ideas in Hand Surgery; Island Vascular- 17. Strickland JW: Results of flexor tendon surgery in zone II,
ized Flexor Tendon Transfers, the Sliding System. France, 2002, Hand Clin 1:167–179, 1985.
Aquitaine Domaine Forestier, p 210. 18. Cavadas PC, Mir X: Single-stage reconstruction of the flexor
11. Guimberteau JC, Sentucq-Rigall J, Panconi B, et al: Introduc- mechanism of the fingers with a free vascularized tendon flap:
tion to the knowledge of subcutaneous sliding system in Case report, J Reconstr Microsurg 22:37–40, 2006.
humans, Ann Chir Plast Esthet 50:19–34, 2005. 19. Peacock EE Jr: Homologous composite tissue grafts of the
12. Guimberteau JC, Bakhach J: Subcutaneous tissue function: digital flexor mechanism in human beings, Transplant Bull
the multimicrovacuolar absorbing sliding system in hand and 7:418–421, 1960.
plastic surgery. In Siemonov MZ, editor: Tissue Surgery, Berlin, 20. Guimberteau JC, Baudet J, Panconi B, et al: Human allotrans-
2006, Springer, pp 41–54. plant of a digital flexion system vascularized on the ulnar
13. Guimberteau JC, Panconi B, Boileau R: Mesovascularized pedicle: A preliminary report and 1-year follow-up of two
island flexor tendon: new concepts and techniques for cases, Plast Reconstr Surg 89:1135–1147, 1992.
B Physiotherapy After Vascularized
Tendon Transfers
Serge Rouzaud
OUTLINE PHYSIOTHERAPY AFTER SURGERY
As is the case with all physiotherapy following repair Timing

of the flexor tendon, the return of satisfactory active Postoperative physiotherapy starts early after surgery, so
motion amplitudes, in flexion as well as in extension, as to limit or at least modulate tendon adhesions due
requires a specific physiotherapy program. The therapy to scar healing. Physiotherapy must be careful and effi-
must be modified in different postoperative periods cient. This requires perfect knowledge of the kind of
with emphasis of different exercises. This chapter surgery, the methods of tendon repair, and the pulleys
describes specific day-by-day therapy regimens that are that may have been rebuilt. The physiotherapist must
used in the cases of vascularised tendon transfer. Such have a thorough knowledge of physiopathology of the
therapy must respect not only the recipient digit and tendon so as to ensure the quality of the work.2 The
its vascular anastomoses, but also the donor digit, so physiotherapist should ensure sufficient therapy to
that function of the donor and recipient digits is improve the results but avoid being too aggressive,
restored as much as possible. which could cause disruption or diastasis at tendon
junctions that hampers the result.
Physiotherapists are confronted with new surgical
methods of flexor tendon reconstruction with vascular- Three Phases of Physiotherapy After Surgery
ized tendon transfers.1 This technique provides a last The surgical technique consists of the transfer of a vas-
resort solution to salvage a nonfunctional finger. At this cularized sliding unit to favor intrinsic healing. The
stage, the patient has had a long history of time- proximal and distal tendon junctions are situated in
consuming treatment, which has often not only kept the zones 1, 3, or 4, which are deemed “safe” and may
patient from professional activities but also greatly shorten the period of putting the tendon in rest position
reduced the ability to perform day-to-day tasks. This last and favor active flexion exercise. The protocol that we
resort solution is proposed at the end of a long treat- have made for vascularized tendon transfer comprises
ment, often after amputation of the finger has been three stages: days 0 to 21, days 21 to 45, and after day
evoked; therefore, it can represent hope for the patient. 45, governed by the periods of tendon healing. Days 0
Nevertheless, the risk of lassitude and diminished will- to 21 represent the most important stage. In this stage,
ingness to participate in the treatment is great. The the therapy determines the final result by limiting adhe-
medical team should therefore encourage and support sions arising from extrinsic healing and favoring intrin-
the patient in this ultimate stage of the treatment. sic healing.
Splinting and Joint Positions

PREOPERATIVE PHYSIOTHERAPY
Within the first 72 hours after surgery, a modified Klein-
Physiotherapy starts before surgery for the patients with ert splint is applied (Figure 31[B]-1). The wrist is set at
complex hand trauma. The therapy is usually applied to the neutral position, metacarpophalangeal (MCP) joints
a finger with serious limitation in passive extension and are set in 60° flexion, and the interphalangeal (IP)
flexion. The presurgery phase is important to improve joints are set at flexion between 0° and 10°.3 The trac-
the quality of local tissues and restore passive joint tion is anchored in distal part of the nail distally and
motion as much as possible. The improvement in the runs under a pulley, which allows a flexion of three
quality of tissues and joint suppleness obtained in this digital joints (MCP and proximal and distal [PIP and
phase will reduce “surgical aggression” and create a DIP] joints). The friction forces against the pulley are
proper local status, which would favor improvement of limited by a nylon thread tethered to a rubber band
hand motion and therefore outcomes of the surgery. below the pulley. The tension of the rubber band must
340
Chapter 31B: Physiotherapy After Vascularized Tendon Transfers 341
60°
0°
Figure 31(B)-1 Modified Kleinert splint with a palmar

pulley.
Figure 31(B)-3 Passive flexion with the rubber band force.
Methods of Physiotherapy
In the first phase we aim to reach following goals at day
21: (1) passive flexion of the MCP, PIP, and DIP joints
back to normal, (2) normal extension of the IP joints
or at least limited to a 20° flexion, and (3) active flexion
from 0° to 60° on the PIP joint and from 0° to 20° on
the DIP joint.
In this phase, we perform daily physiotherapy: (1)
Prevention of edema. Edema is a factor favoring tendon
adhesions and articular ligament retractions. Measures
to prevent edema must start as soon as possible after
surgery, such as elevation of the upper limb and mobi-
lization of adjacent digits.5,6 (2) Passive mobilization.
Passive mobilization keeps the joints mobile, and these
Figure 31(B)-2 Active extension against the rubber band. exercises also allow differential FDS and FDP tendon
motion in case the FDP is rebuilt with an intact FDS
tendon. It is important to maintain the MCP joints in
extension while the IP joints are flexed (Figure 31[B]-4).
be as weak as possible, yet still able to bring the finger (3) Active mobilization. Surgeons and physiotherapists
into full flexion (see Figure 31[B]-1). The wrist at should decide together whether to undertake active
neutral position allows the proximal tendon junction motion according to strength and quality of tendon
site to move and glide, favoring forming gliding surfaces junctions. The Pulvertaft method of proximal junction
between the tendon and surrounding tissues. and distal reinsertion by pull-out technique appear to
Once the splint is applied, the patient carries out 10 be reliable in strength. Protected active flexion was
active extensions an hour, with a passive return to advocated by Rouvillois7 and Bellemère.8 The place-and-
flexion by tension of the rubber band, and 10 active hold is exercised and the amplitude of active digital
flexions of the wrist with return to extension as far as flexion is gradually increased. Place-and-hold exercises
the splint allows, so as to favor gliding of the different are less aggressive and are often easily achieved by the
tissues and to disrupt adhesions (Figure 31[B]-2 and patient. This exercise may avoid resistance during move-
31[B]-3). The active extension should not be forcefully ment. When a tendon is transferred to a finger with an
against the splint.4 The patient relaxes during active intact FDS, differential motion of two tendons needs to
extension to reduce resistance. Edema and dressings are be practiced (Figure 31[B]-5). Between day 8 and day
reduced to lower resistance to extension. 15, the tendon is weak and the exercises are fewer.
This exercise does not stimulate FDP tendon gliding on

the FDS, but the FDS tendon is not present in most
instances of this type of tendon reconstruction. The dif-
ferential motion should be exercised every day.
It is noteworthy that development of flexion contrac-
ture of the joint after these surgical reconstructions,
especially at the DIP joint, is very likely under rubber
band traction. Lack of extension of the finger up to
about 60° may be observed very early, which is difficult
to correct if not taken care of. When a flexion contrac-
ture of more than 20° is present in the PIP and/or the
DIP joints, we modify the splint as early as day 15 after
surgery. The rubber band is temporarily withdrawn and
a Velcro strap is made setting the finger in an intrinsic
plus position. The strap is gradually tightened by the
patient to increase joint extension. The rubber band is
Figure 31(B)-4 Passive PIP joint flexion of the finger with
the transferred tendon. re-positioned every hour to achieve a series of 10 active
extensions with passive return to flexion. Between day
21 and day 45, the splint is removed during the day time
and the joint is gradually allowed to actively move, but
the splint is kept at night. If active flexion of the finger
can be easily achieved by day 21, we apply the splint
only for 8 more days, but the pull-out suture is kept for
another 10 days.
During the therapy period, passive motion is per-
formed every day. Ample passive motion amplitudes are
always emphasized. The finger extension is also sought,
and usually increases at week 5 or 6 after surgery. Intrin-
sic muscle weakness or contracture may develop and
electric stimulation helps prevent such problems.
After removal of the splinting, exercise of active finger
flexion should be increased. The place-and-hold exercise
is gradually given way and active movement, with no
resistance, is encouraged. During active movement, the
rebuilt pulleys are to be protected. Elastoplast strapping
Figure 31(B)-5 Place-and-hold IP joint flexion with MP can be used to protect the pulley with no risk to the
joint extension. vascularization. Protection to the pulleys is required
until the end of 2 months after surgery. The active flexion
of the donor finger is exercised. Electrical stimulation to
Reconstructed pulleys must be protected during the FDP tendon of the donor finger help build the
active finger flexion by positioning the fingers of the strength of digital flexion, we do so as early as week 5.
physiotherapist correctly over these pulleys to reduce After day 45, active exercises are increased and the
the tension.9 The protection with Elastoplast rings is patient is urged to start all daily activities. To favor the
risky because of precarious skin healing. Their tourni- recruitment of neuromuscular activity, electrical stimu-
quet effect may damage vascular supply of the flap. lation to the FDP muscle to which the grafted tendon
The donor finger, usually the ring finger, must be is sutured is added if there are difficulties in active
included into active flexion exercises. Removal of the flexion of the repaired finger. The site of electrical stimu-
FDS may cause adhesions of the intact FDP tendon of lation must be as specific as possible, entailing adequate
this finger, which should be avoided. If extension deficit setting of skin electrodes. Exercises that enhance func-
of the donor finger is present, a Velcro strap is installed tion of wrist and hand as a whole also begin at this time.
to place the finger in intrinsic plus position to correct
the extension deficit. Late Therapy of Extension Deficits
The tendon motion by means of tenodesis effect is a Development of extension deficits is not uncommon,
useful method.10 Active wrist extension favors passive despite all the measures used in the earlier periods to
flexion of the fingers and vice versa. The patient should prevent finger flexion contractures. In the late stage, it is
be relaxed to reach maximum efficiency during exercise. often necessary to apply a dynamic extension splint
Chapter 31B: Physiotherapy After Vascularized Tendon Transfers 343
use of the hand should be encouraged in the intervals

when the splint is removed, so as to render function and
use of the hand, which has already been insufficiently
used for several months or even several years.
In some cases, above measures may not effectively
correct the deficit in extension of the PIP and/or DIP
joints. We then use a series of plaster casts between
physiotherapy sessions. Tubular splint may also be
applied. This technique was originally developed for the
treatment of irreducible flexion contracture accompany-
ing untreated PIP joint sprains. It is extended to the
treatment of irreducible flexion contracture, regardless
of the cause.
Figure 31(B)-6 The strap is gradually tightened by the
patient as the tissues allow more extension. Additional Methods
During physiotherapy, classic techniques of circulatory
(Figure 31[B]-6). Such a splint should be adapted to massages and scar softening must be an integral part
the affected joints (usually the IP joints). The splint is of our work to fight edema and pain, which favor pre-
mainly worn at night, as well as during day periods of venting adhesions and joint stiffness. Deep pressure
two hours in the morning and two hours in the after- massage is an excellent adjuvant for the treatment of
noon if the flexion contracture is difficult to correct. The skin adhesions and scarring. Silicone gels are advised
splint is kept till obtaining a good-quality extension. when scars are hypertrophic.
Frequently, this splint should be worn for 4 to 6 months. It should also be emphasized that during the process
However, the splint must not be worn continuously of physiotherapy, we, physiotherapist and patient, must
during the daytime (which some patients are inclined be patient, and active and regular physiotherapy must
to do because the splint is better tolerated when they not be limited to the sessions directed by the
move than at night when they are at rest). Instead, active therapist.
References
1. Guimberteau JC, Panconi B, Boileau R: Mesovascularized 6. Aoki M, Manske PR, Pruitt DL, et al: Work of flexion after
island flexor tendon: new concepts and techniques for flexor tendon repair with various suture methods, J Hand Surg (Br)
tendon salvage surgery, Plast Reconstr Surg 92:888–903, 20:310–313, 1995.
1993. 7. Tubiana R: Considerations anatomo-pathologiques et
2. Caffinière JY, Simmons BP: Physiologie de la flexion des biologiques. In Tubiana R, editor: Traité de Chirurgie de la
doigts. In Tubiana R, editor: Traité de Chirurgie de la Main. Main. Tome 3, Paris, 1986, Masson, pp 49–61.
Tome 1, Paris, 1980, Masson, pp 339–411. 8. Rouvillois A, Sifre G, Hu W, et al: Mobilisation en flexion
3. Kleinert HE: Réparations primitives des tendons fléchisseurs. active protégée associée à la technique de Kleinert, Ann
In Tubiana R, editor: Traité de Chirurgie de la Main. Tome 3, Kinésithér 19:123–138, 1992.
Paris, 1986, Masson, pp 198–205. 9. Bellemère P, Chaise F, Friol JP, et al: Résultats de la mobilisa-
4. Van Alphen JC, Oepkes CT, Bos KE: Activity of the extrinsic tion active précoce après réparation premiers des tendons
finger flexors during mobilization in the Kleinert splint, fléchisseurs, La Main 3:221–234, 1998.
J Hand Surg (Am) 21:77–84, 1996. 10. Zhao C, Amadio PC, Momose T, et al: Effect of synergistic
5. Thomas D, Moutet F, Guinard D, et al: Mobilisation posto- wrist motion on adhesion formation after repair of partial
pératoire immédiate des tendons fléchisseurs, Ann Kinésithér flexor digitorum profondus tendon lacerations in a canine
27:338–347, 2000. model, J Bone Joint Surg (Am) 80:78–84, 2002.
CHAPTER
32
EXTENSOR TENDON INJURIES—
PRIMARY MANAGEMENT
Brandon E. Earp, MD, and Philip E. Blazar, MD
OUTLINE proximal to a juncturae can be masked on examination

by the ability to extend the injured digit at the MCP
Acute extensor tendon injuries to the hand and wrist joint through an intact juncturae to an adjacent tendon.
have typically received less attention than their flexor (3) Because of the superficial location of the extensors
counterparts. The anatomy of the extensors is para partial and complete injuries can and do occur with
doxically more complex and the management of inju seemingly minor lacerations. (4) Injuries may be ini
ries is more varied and corresponds to the anatomical tially compensated for by the duplications and intercon
zone of injury. In this chapter, the anatomy, identifica nections of the extensor mechanism but a clinically
tion, and management of injury based on anatomical significant deformity can develop with time. (5) A high
zone are reviewed. Surgical and nonsurgical treatment percentage of these injuries have associated bone, skin,
of these injuries is discussed, including the indica or joint injury.1
tions. The role of early mobilization after injury and A major component of the care of tendon injuries is
repair is described. rehabilitation with controlled early motion. While
exceptions exist, the vast majority of flexor tendon inju
The extensor tendon system of the wrist, hand, and ries are currently treated with early motion. In the exten
fingers is surprisingly complex. The six extensor com sor system, the biomechanical characteristics of repair
partments of the wrist and the intrinsic muscles of the do not as routinely allow for the same degree of early
hand comprise 23 musculotendinous units. Open and mobilization. In general, the biomechanical strength of
closed injuries to these structures are more common utilized repairs is dependent on the zone of injury.
than injuries to the flexor structures and range from very Hence the most important factors in determining the
subtle, seemingly minor traumas to overt complex inju treatment of extensor tendon injuries include the ana
ries with failure and/or loss of multiple tissue types. tomical zone, the chronicity of the injury, and any
Failure to diagnose and treat these injuries, including pathology of the adjacent tissues (principally skin,
those in the superficially subtle categories, can lead to bone, and joints).
significant loss of motion and function. The remainder of this chapter will discuss extensor
The zones of injury have been assigned beginning tendon injuries, repair, and rehabilitation based on ana
distally with odd numbered zones located over the tomical zone.
respective distal interphalangeal (DIP), proximal inter
ZONE 1—DIP JOINT
phalangeal (PIP), metacarpophalangeal (MCP), and
wrist joints, while the even numbered zones are located The relatively complex anatomy of the extensor hood
over the underlying intervening osseous structures (see becomes much simpler distally as the terminal tendon
Chapter 1, Figure 1-7). The detailed anatomy of these is the only structure that extends the distal joint. In
tendons is discussed in Chapter 1. addition, the terminal tendon is a surprisingly delicate
A few general anatomical points are critical to be structure when handled surgically, particularly after
aware of when evaluating patients with potential inju trauma. Disruption of the terminal tendon at this level
ries to the extensor mechanism. (1) Variations in exten is commonly referred to as a “mallet” finger because
sor anatomy are common, such as extensor digiti minimi of the characteristic flexion deformity (Figure 32-1).
(EDM) duplication, absence of extensor digitorum com Closed injuries are the most routinely seen variant and
munis (EDC) to the small finger. (2) The juncturae occur from multiple mechanisms ranging from injury
tendinum (see Chapter 1, Figure 1-7) connect the EDC in sports with a ball striking the tip of the digit to
tendons of the ulnar four digits and are more common “trivial” injuries such as tucking in bed sheets. The ulnar
and more substantial (tendon like) on the ulnar part digits are more commonly affected and males with this
of the hand. An injury to the extensor mechanism injury tend to have it a younger age than women. Injury
347
348 Section 4: Extensor Tendon Repair and Reconstruction
recommended to asses for fracture and joint sub

luxation. Management of the injury is based on the
category of injury (i.e., closed versus open, acute versus
chronic, etc.).
Closed mallet injuries without a fracture are managed
by observation, immobilization, or surgery. Nonsurgical
treatment is most commonly used in the treatment of
closed mallet injuries and is used for the vast majority,
including those with fractures that involve one third of
the articular surface or less. Joint subluxation is typically
not seen until approximately 50% of the articular surface
is involved. Controversy exists over the type of immobi
lization, length of immobilization, and the need to
include the PIP joint. The principle of immobilization
Figure 32-1 Clinical presentation of mallet injury with is to maintain the DIP joint in extension to approximate
flexion deformity at the DIP joint.
the injured structures and allow for healing. Constant
immobilization is maintained for 6 to 8 weeks but care
must be exercised as dorsal skin compromise occurs,
particularly if the DIP joint is positioned in hyperexten
sion. A recent randomized trial suggests that digit-based
cast treatment leads to a lower rate of skin problems and
improved patient compliance.5 Some authors advocate
restarting the period of immobilization if the DIP
becomes flexed at any point during the treatment cycle.
The same protocol is typically recommended for patients
who present subacutely up to at least 8 weeks from
injury.
Some residual deformity (extensor lag) in the inter
mediate and long term is common but rarely function
Figure 32-2 Radiograph of bony mallet injury with distal ally limiting.6,7 Furthermore, the apparent extensor lag
phalangeal intra-articular fracture. may improve over an extended period of time of up to
1 year.8
Mallet fractures are also typically managed with a
is thought to occur from any activity that results in similar protocol of closed treatment. The most accepted
forced flexion of the tip of a digit. Variations include indication for surgery is joint subluxation; however,
closed, open with or without tissue loss, and mallet some advocate surgical treatment for large fragments in
fractures (Figure 32-2); it is not infrequent for these the absence of subluxation. Techniques include open
injuries to present late after trauma. Mallet fractures reduction and internal fixation with small screws,
involving large portions of the articular surface can lead K-wires, or a pull-out suture/wire. Pinning of the DIP
to joint subluxation.2 Injuries older than 4 weeks have joint in extension is commonly considered, particularly
been classified as “chronic.”3 in the situation where the fixation is not rigid. A closed
The resulting deformity ranges from a small extensor technique of extension block pinning, where the DIP
lag to a lag equivalent to full passive DIP flexion. In joint is brought into full flexion and a K-wire is intro
some patients the deformity seems to progress over a duced into the middle phalanx and then the joint is
few hours or days, suggesting that partial injuries may extended. The previously inserted K-wire serves to block
become worse with further trauma or with routine use. extension of the fractured fragment while allowing
Mallet finger injuries may lead to a swan-neck deformity extension of the remainder of the distal phalanx, reduc
(flexion of the DIP and PIP hyperextension) through ing the fracture. The two distal phalangeal fragments are
overpull of the extensors at the PIP joint. This is more then pinned to each other and/or the DIP joint is pinned
common in individuals with PIP joint volar plate laxity in a neutral position. The K-wires are left in about 6
and illustrates the concept that a tendon imbalance at weeks, until clinical union.9
one interphalangeal (IP) joint may lead to an opposite Open mallet injuries are commonly associated with
deformity in the adjacent IP joint.4 loss of skin and/or tendon substance as well as a trau
Diagnosis and categorization of a mallet injury matic arthrotomy requiring débridement. Even if there
are based on the posture of the digit and typically is no loss of tissue, the soft tissue injury can be expected
straightforward. Radiographs of the injured digit are to be more severe than with a closed injury. While many
Chapter 32: Extensor Tendon Injuries—Primary Management 349
A B
Figure 32-3 A, Open mallet injury with soft tissue loss including skin and tendon. Note the transarticular K-wire. B, Local
advancement flap coverage of the defect.
open extensor injuries are treated with suture repair of

ZONE 2—MIDDLE PHALANX
the tendon, the nature of the tendon at this level makes
a biomechanically strong repair challenging. Many sur In contrast to zone 1 injuries, zone 2 injuries typically
geons choose to add K-wire fixation as an internal splint occur from a laceration. Injuries at this anatomical level
or to incorporate the skin in a tenodermodesis repair. are more likely to be partial with some intact tendon
With a tenodermodesis repair a suture or sutures are and therefore some active extension. Despite the differ
placed through the dorsal skin and tendon and the ence of only a few millimeters distance anatomically
repair includes both skin and tendon with the same from zone 1, these injuries are seen much less frequently.
suture. The tenodermodesis stitch is left in for 6 weeks In the scenario where only one lateral band is lacerated
in contrast to standard skin sutures so a less reactive (50% of the tendon or more is intact), the injury can be
nonabsorbable material such as polypropylene suture is treated with a short course of immobilization. Injuries
used.10 with an apparent extensor lag or loss of DIP joint exten
In open injuries with tendon or skin loss, wound sion strength should be treated with a longer period of
management needs to be considered. Local advance immobilization or with primary repair. Primary repair
ment flaps can make up for small defects and skin grafts is the preferred treatment for complete lacerations of the
can also be helpful in select situations (Figure 32-3). extensor in this area (Figure 32-4). As these injuries
There are also indications for heterodigital flaps for loss are less common there are no studies that specifically
of larger amounts of skin. Free tendon grafts are also compare the surgical techniques for repair at this level.
occasionally needed to reconstruct the extensor mecha The options used range from technically simple sutures
nism. While these more severe injuries are likely to (figure-of-eight or horizontal mattress) to more complex
include more loss of motion at the DIP joint due to their such as the Silfverskiöld or an interlocking horizontal
more severe trauma, it is important to maintain PIP mattress. Tenodermodesis has also been used in this
joint mobility so the overall impact on the total digital zone. Many authors chose to use a supplemental K-wire
motion is minimized. across the DIP joint with the joint in extension to protect
Rehabilitation for all mallet injuries focuses on main the repair, particularly if there is loss of skin or tendon
taining DIP joint extension without even momentary substance.
exception for the first 6 weeks in the vast majority of Immobilization and rehabilitation are largely similar
cases, regardless of treatment. During that time PIP and to the more common zone 1 injuries. Six weeks of
MCP joints and adjacent digit mobilization as well as immobilization of the DIP joint in extension with
techniques to prevent skin complications are encour mobilization of the PIP joint is maintained. Typically
aged. If a splint is used, the skin is inspected daily; the this is in a splint or cast. Active flexion is permitted at
thumb and countertops or other external aids are used 6 weeks but part time splinting at night is continued for
to maintain the DIP joint in extension when the ortho an additional 4 to 6 weeks.
sis is removed. Cast treatment obviates the need for skin
ZONE 3—PIP JOINT
inspection except at the intervals of cast change. After
the period of absolute immobilization most protocols Zone 3 injuries occur in both open and closed manners.
typically require an additional period of approximately However, closed injuries are frequently underappre
the same length of night-time extension splinting. ciated by patients and medical professionals. The
they also occur at the PIP joint so vigilance is necessary.

In the absence of purulence or overt signs of infection,
surgical repair of the central slip is indicated. For inju
ries without adequate distal tendon for direct repair,
suture anchor repairs are described. Biomechanically
suture anchor repair appears similar to suture repairs.12
Acute closed isolated central slip injuries are managed
nonoperatively. Extension splinting or casting of the PIP
joint is prescribed with the PIP joint in full extension
and the DIP “free” or capable of full flexion. Immobili
zation is maintained for 6 weeks and is followed by a
period of night-time splinting in extension typically of
an additional 6 weeks. Active and passive DIP joint
A flexion is performed throughout the treatment to mobi
lize the lateral bands dorsally or at least prevent them
from subluxating volarly. The goal of treatment is to
prevent the secondary deformity (volar subluxation of
the lateral bands and DIP joint hyperextension) from
developing. For closed injuries with displaced avulsion
fractures and/or PIP joint subluxation/dislocation, open
treatment is indicated. Reconstruction of the central slip
insertion into the dorsal base of the middle phalanx is
performed. Depending on the fragment size and quality,
constructs using screws, K-wires, suture anchors or
tension band may be used. Joint instability may require
pinning the PIP joint in extension.
Subacute presentations are a frequent problem. This
occurs as the injuries are commonly underappreciated
B
and because attenuation of the central slip and the
Figure 32-4 A, Complete zone 2 tendon injury of the resultant boutonniere deformity can develop over
middle finger in a patient who sustained a laceration on weeks. In this situation, the goal of treatment is to
glass to the dorsum of two fingers. B, Zone 3 injury with prevent development or worsening of the deformity.
open PIP joint of the index finger in the same patient. Splinting of the PIP joint in extension while leaving the
DIP joint free to move is therefore indicated when an
injury to the central slip is suspected. Failure of initial
management of a central slip injury with development
functional morbidity of the resultant boutonniere of a boutonniere deformity is a controversial area. Many
deformity is more limiting than the deformity of a authors will consider splinting in the subacute period
neglected mallet finger in most cases. Therefore, vigi but surgical reconstruction is indicated in select cases
lance is necessary to prevent the sequelae of this type of where nonsurgical treatment fails. Favored reconstruc
injury. With closed injuries, patients present with swell tive techniques are more complex than reattaching the
ing at the PIP joint, decreased PIP joint extension retracted central tendon such as mobilization of a com
strength against resistance and a subtle PIP joint exten ponent of the lateral band or a tendon graft such as a
sion lag. The Elson test is the physical examination slip of flexor digitorum superficialis (FDS) left attached
maneuver that is felt to be the most specific for an early to the base of the middle phalanx. Boutonniere recon
closed central slip injury.11 The test is performed with struction is discussed in more detail in Chapter 36.
the PIP joint flexed 90° and the patient extends the IP Rehabilitation after central slip injury has tradition
joints against resistance. A positive test shows increased ally included immobilization of the PIP joint for 6
DIP extension than the contralateral or adjacent DIP weeks with concomitant DIP joint motion. Loss of PIP
joint. joint flexion has been a concern, particularly for open
With an acute presentation, treatment depends on injuries and some authors have advocated for earlier
whether the injury is open or closed. For open injuries, range of motion (ROM). Pratt and colleagues13 described
an arthrotomy and irrigation and débridement of the a postoperative protocol that included 3 weeks of
joint are indicated (see Figure 32-4). These injuries immobilization followed by 3 weeks of protected
occur from a variety of mechanisms and while human motion with a dynamic extension splint. No patient in
mouth injuries are more common at the MCP joint, her series had an extension deficit over 15°.
ZONE 4—PROXIMAL PHALANX

Zone 4 injuries are similar to zone 2 in many ways,
although in zone 4 the anatomy is more complex. A
majority of the injuries seen at this level are open and
partial lacerations are the norm. Examination of a
patient with an injury at this level includes evaluation
for an extensor lag at the PIP joint or weakness of active
extension. In the absence of an extensor lag with the
ability to extend against resistance nonsurgical treat
ment is recommended. This includes PIP joint exten
sion splinting and early protected motion. Many injuries
in this zone occur in the setting of an open fracture.
Treatment of an associated skeletal injury may influence
the choice of closed versus open treatment and the tech
nique of rehabilitation. The “dorsal combined injuries” Figure 32-5 Open zone 5 “fight bite” injury involving the
involving an unstable open fracture and a tendon lac tendon and joint.
eration are a distinct pattern of injury. Rigid internal
fixation of the fracture is typically advocated with repair
of the extensor tendon. Larger defects of the extensor When tendon repair in this area is performed, proxi
mechanism can be bridged with tendon graft. Great mal tendon retraction is rarely an issue, as the intact
care is taken during either repair or graft reconstruction sagittal bands and juncturae tendinea prevent signifi
to ensure proper length balance of the central band cant migration. Common suture techniques include the
and lateral band, as imbalance in the length would modified Kessler, modified Bunnell, mattress, and
induce loss of finger extension. Extensor adherence over figure-of-eight. Care should be taken to avoid excessive
the proximal phalanx may occur, which can lead to shortening of the tendon during repair, which can lead
decreased digital flexion, with possible need for later to loss of flexion. Rehabilitation protocols are varied in
tenolysis and joint release. this region17,18 and include immobilization for 3 to 4
Patients with an extensor lag and/or lack of extension weeks with the wrist extended 45° and the MCP joints
against resistance have an indication for exploration in approximately 15° to 20° of flexion, followed by
and likely repair. Once again a variety of tendon repair mobilization.19-21 Alternate rehabilitation with a pro
techniques are used. Frequently repair is followed by 4 tected early motion protocol such as immediate con
to 5 weeks of immobilization, with subsequent therapy. trolled active motion (ICAM) has been shown to be
Recent biomechanical data have shown that repairs effective, especially in long and ring fingers, which allow
using the Becker and interlocking horizontal mattress for the best support of the digital “yoke.”22-26
techniques are stronger than some more traditional Open sagittal band injuries should be repaired to
techniques.14,15 This has led some authors to advocate prevent subluxation of the extensor tendon away from
beginning range of motion at 3 weeks postrepair.16 the side of injury. Displacement of the extensor tendon
from its central location may be associated with an
ZONE 5—MCP JOINT
extensor lag or, in extreme cases, the inability to extend
Injuries to the extensor mechanism in zone 5 occur over across the MCP joint from a maximally flexed position.
the MCP joint, and are frequently open injuries. A high Intrinsic contracture can result if left untreated. Closed
prevalence of these open injuries occur due to human sagittal band injuries are frequently associated with
teeth; it is critical to identify patients with these “fight inflammatory systemic conditions, or related to blunt
bites” and aggressively treat them with operative irriga trauma. Rupture of the sagittal fibers most often occurs
tion and débridement of the MCP joint as well as repair on the radial side of the middle finger, with ulnar dis
of the tendon, if indicated (Figure 32-5). Due to the placement of the extensor. Management of acute closed
common positioning of the digits in flexion when the sagittal band injuries includes immobilization in exten
injury occurs, and the positioning of the digits in exten sion for 4 weeks, followed by a range of motion proto
sion during the examination of the wound in the clini col.27,28 If closed treatment is unsuccessful, surgical
cal setting, an injury that extends to the joint may be management includes repair of the torn sagittal band if
missed, as the affected portion of the tendon is now the tissues permit. A variant of this injury is the “boxer’s
much more proximally located. A high index of sus knuckle,” which occurs via a direct blow to the extensor
picion is appropriate when evaluating open injuries mechanism over the MCP joint, leading to injury of
in this zone. Bite wounds here should be irrigated, both the extensor mechanism and underlying joint
débrided, and left open. capsule.29 Reconstruction using a juncture or a slip of
the extensor tendon routed around a lateral band or the

radial collateral ligament is used for patients requiring
reinforcement of the native tissues. Chronic radial sagit
tal band injuries may require release of the ulnar sagittal
band and centralization of the extensor.
ZONE 6—DORSUM OF THE HAND
Zone 6 injuries over the dorsum of the hand are less
common, but are often associated with significant
trauma, including fractures and major soft tissue inju
ries. The extensor in this zone is more oval or circular
in cross section and more amenable to core suture repair
with 3-0 or 4-0 nonabsorbable suture (similar to those
for flexor tendon injuries). Early dynamic splinting
or ICAM protocols are often appropriate for these
patients; however, they may also be treated with immo Figure 32-6 Open zone 7 injury with multiple tendons and
bilization for 4 weeks after surgical repair, followed by nerve transections.
a standard mobilization. Complex injuries may neces
sitate extended rehabilitation due to other affected
tissue structures such as bone or skin. Patients with
complex injuries may benefit from acute tendon recon the tendon repair is located in the area of the extensor
struction performed in combination with free tissue retinaculum, a small section can be resected or a length
transfer for soft tissue coverage.30 Extensor adherence ening of the retinaculum can be performed to prevent
to surrounding structures may lead to either extensor bowstringing. The wrist is typically immobilized in 40°
lag or poor flexion from resultant joint contractures. extension, with the MCP joints held in neutral to slight
Uninjured digits in the hand can be similarly affected flexion for 3 to 4 weeks. Early motion of the IP joints
from lack of mobilization with joint contractures and of the fingers is typically possible without undue stress
tendon adhesions. Evans and Burkhalter31 describe early on the repairs.
motion protocols for injuries at this level involving The most common closed tendon injury at the wrist
dynamic extension splints. They report full extension in is an extensor pollicis longus (EPL) rupture. Most fre
over 90% of their patients and no tendon ruptures. quently occurring after closed treatment of a minimally
Newport and colleagues have analyzed several studies or nondisplaced distal radius fracture, the etiology is
that compare static immobilization to early controlled thought to be secondary to ischemia in that region of
movement for uncomplicated injuries in zones 5 to 8 the tendon. The tendon ends are typically frayed, pre
and found that 54 to 95% good or excellent results cluding end-to-end repair, thus reconstruction with
were obtained with immobilization versus at least extensor indicis proprius (EIP) transfer or an interposi
90% good or excellent results for the early controlled tion tendon graft are typically performed.35
motion.32 Five millimeters of tendon excursion is suffi Lacerations over the forearm may to injury of both
cient to prevent adherence of the repaired extensor, tendons and nerves. Nerve repairs should be performed
which is correlated with range of motion at the various at the time of tendon repair. With multiple tendon inju
joints.33,34 ries, repair of all of the divided structures is recom
mended (Figure 32-7). If the injury precludes direct
ZONES 7, 8, AND 9—WRIST, DISTAL, AND
repair of all structures, repair to allow independent wrist
PROXIMAL FOREARM
and thumb extension is the most important, and com
Zone 7 and more proximal extensor injuries are less bined extension of the digits is desired. Injuries at the
common. Appropriate identification of the proximal musculotendinous junction are challenging due to poor
ends of the transected extensor tendons in these areas strength of the repair in the muscle. Often a tendinous
can be difficult. Knowledge of local anatomy including portion can be found extending within the muscle belly
the compartments, location of the muscle bellies, and to a quite proximal extent and can be incorporated for
caliber of the tendons aids with identification (Figure increased repair strength. Rehabilitation is similar to
32-6). The proximal ends may also be retracted due zone 7 but may need to be modified based on the
to muscle contraction, which may require extending mechanical strength of the repair in zone 8.
the proximal dissection. The distal ends are rather easy Zone 9 injuries are those in more proximal forearm
to identify, as a gentle tug on the tendon stump will and result from sharp lacerations. Muscle, tendon, and/
elicit the expected distal movement. The tendons are or nerves, especially the posterior interosseous nerve
repaired using a strong nonabsorbable core suture. If (PIN), are often simultaneously injured. Any nerve
SUMMARY
Extensor tendon injuries are one of the common inju
ries in the hand. Careful attention to the anatomical
details of the zone of injury and complicated mechani
cal balance of the extensor system will determine
whether surgical or nonsurgical treatment is indicated.
As each component of extensor tendon over the fingers
tolerate little loss of tendon substances, in repairing the
extensor tendon, care should be taken to ensure minimal
shortening of the tendon substance to maintain intri
cate mechanical balance of the extensor apparatus.
Though strength of repair is not as important as for
flexor tendons, a mechanically reliable repair method
should be considered. Extensor tendons injured at the
Figure 32-7 Forearm laceration involving multiple tendon distal parts of the fingers, such as over the DIP or PIP
injuries in zones 7 and 8. joint areas may develop joint deformities easily, leading
to chronic mallet finger or boutonniere deformities.
Correct splinting or surgical intervention at acute stage
is important to prevent development of these deformi
injuries should be identified and repaired at the surgery. ties. In many surgical cases, postoperative early motion
The muscle bellies are repaired, frequently with a figure- protocols help restore digital range of motion and
of-eight suture. Fascia can be used to augment the return patients to occupational and daily activities more
muscle repair. Above elbow immobilization is applied rapidly. Adhesions may develop, especially over the
when the injured muscles originate from the humeral fingers or at the extensor retinaculum, which may
epicondyles. require secondary tenolysis.
References
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Acad Orthop Surg 13:336–344, 2005. splinting in extensor tendons repairs zones III to VI: func
7. Okafor B, Mbubaeqbu C, Munshi I, et al: Mallet deformity tional outcome at three months, Tech Hand Up Extrem Surg
of the finger: five-year follow-up of conservative treatment, 12:7–11, 2008.
J Bone Joint Surg (Am) 79:544–547, 1997. 17. Chester DL, Beale S, Beveridge L, et al: A prospective, con
8. Pike J, Mulpuri K, Metzger M, et al: Blinded, prospective, trolled, randomized trial comparing early active extension
randomized clinical trial comparing volar, dorsal, and custom with passive extension using a dynamic splint in the rehabili
thermoplastic splinting in treatment of acute mallet finger, tation of repaired extensor tendons, J Hand Surg (Br) 27:283–
J Hand Surg (Am) 35:580–588, 2010. 288, 2002.
9. Hofmeister EP, Mazurek MT, Shin AY, et al: Extension block 18. Crosby CA, Wehbe MA: Early protected motion after extensor
pinning for large mallet fractures, J Hand Surg (Am) 28:453– tendon repair, J Hand Surg (Am) 24:1061–1070, 1999.
459, 2003. 19. Newport ML: Extensor tendon injuries in the hand, J Am Acad
10. Kardestuncer T, Bae DS, Waters PM: The results of tenoder Orthop Surg 5:59–66, 1997.
modesis for severe chronic mallet finger deformity in chil 20. Newport ML: Zone I-V extensor tendon repair, Tech Hand Up
dren, J Pediatr Orthop 28:81–85, 2008. Extrem Surg 2:50–55, 1998.
11. Rubin J, Bozentka DJ, Bora FW: Diagnosis of closed central 21. Rayan GM, Murray D: Classification and treatment of
slip injuries. A cadaveric analysis of non-invasive tests, J Hand closed sagittal band injuries, J Hand Surg (Am) 19:590–594,
Surg (Br) 21:614–616, 1996. 1994.
22. Howell, JW, Merritt WH, Robinson SJ: Immediate controlled 29. Hame SL, Melone CP Jr: Boxer’s knuckle. Traumatic dis
active motion following zone 4-7 extensor tendon repair, ruption of the extensor hood, Hand Clin 16:375–380,
J Hand Ther 18:182–190, 2005. 2000.
23. Ip WY, Chow SP: Results of dynamic splintage following 30. Scheker LR, Langley SJ, Martin DL, et al: Primary extensor
extensor tendon repair, J Hand Surg (Br) 22:283–287, 1997. tendon reconstruction in dorsal hand defects requiring free
24. Khandwala AR, Webb J, Harris SB, et al: A comparison of flaps, J Hand Surg (Br) 18:568–575, 1993.
dynamic extension splinting and controlled active mobiliza 31. Evans RB, Burkhalter WE: A study of the dynamic anatomy
tion of complete divisions of extensor tendons in zones 5 and of extensor tendons and implications for treatment, J Hand
6, J Hand Surg (Br) 25:140–146, 2000. Surg (Am) 11:774–779, 1986.
25. Matzon JL, Bozentka DJ: Extensor tendon injuries, J Hand 32. Newport ML, Tucker RL: New perspectives on extensor tendon
Surg (Am) 35:854–861, 2010. repair and implications for rehabilitation, J Hand Ther
26. Mowlavi A, Burns M, Brown RE: Dynamic versus static splint 18:175–181, 2005.
ing of simple zone v and zone vi extensor tendon repairs: A 33. Elliot D, McGrouther DA: The excursions of the long extensor
prospective, randomized, controlled study, Plast Reconstr Surg tendons of the hand, J Hand Surg (Br) 11:77–80, 1986.
115:482–487, 2005. 34. Sharma JV, Liang NJ, Owen JR, et al: Analysis of relative
27. Catalano LW 3rd, Gupta S, Ragland R 3rd, et al: Closed treat motion splint in the treatment of zone VI extensor tendon
ment of nonrheumatoid extensor tendon dislocations at the injuries, J Hand Surg (Am) 31:1118–1122, 2006.
metacarpophalangeal joint, J Hand Surg (Am) 31:242–245, 35. Hirasawa Y, Katsumi Y, Akiyoshi T, et al: Clinical and micro
2006. angiographic studies on rupture of the EPL tendon after distal
28. Purcell T, Eadie PA, Murugan S, et al: Static splinting of exten radial fractures, J Hand Surg (Br) 15:51–57, 1990.
sor tendon repairs, J Hand Surg (Br) 25:180–182, 2000.
CHAPTER
33
SAGITTAL BAND INJURIES—
PRIMARY AND SECONDARY
MANAGEMENT
Kristen E. Fleager, MD, Monina Copuaco, OTR, CHT, and
James Chang, MD
OUTLINE side of the index finger and ulnar side of the small finger
differ, in that they do not blend with the DTML. The
Sagittal band injuries have many potential etiologies, insertion of the sagittal band is dorsal and tendinous,
although rheumatic disease and trauma are the most and glides with the extensor system as the digits move.
common. Open acute injuries with a suspicion of sag- The fibers superficial to the extensor digitorum com-
ittal band laceration should be expeditiously explored. munis (EDC) tendon are thinner than the deep fibers,
There is evidence to suggest that closed acute injuries especially in the central digits. The radial component of
(less than 3 weeks) may do well with conservative the sagittal band is typically thinner and longer than the
management consisting of immobilization followed ulnar component, explaining the predilection for radial-
by protected motion. Patients who fail nonoperative sided injury.
management or have chronic injuries (3 weeks or The primary functions of the sagittal band are to help
longer) may be appropriate surgical candidates for extend the proximal phalanx and to stabilize the exten-
primary repair. If there is not sufficient tissue for sor tendon in the midline over the dorsal aspect of the
primary repair, a reconstructive approach using local MCP joint.3 The force displacing the tendon in the ulnar
tendon tissue should be undertaken. direction is greatest in full extension, decreases from 0
to 60 degrees, and then increases again from 60° to 90°
Subluxation or dislocation of the extensor tendon at the of flexion.4 Significantly higher forces are required to
metacarpophalangeal (MCP) joint is typically seen in prevent additional displacement of an already ulnarly
patients with rheumatoid arthritis but may also be seen displaced tendon, and it tends to displace further with
with trauma, congenital laxity of the sagittal band, infec- additional MCP flexion.
tion, and iatrogenic injury. Spontaneous sagittal band The long finger is most frequently involved5, likely
disruption has also been reported.1 A sagittal band because the tendon to the long finger sits on top of the
injury will often present with pain and swelling near the transverse fibers with a relatively loose fibrous attach-
MCP joint, with associated subluxation, or catching. The ment, and the long finger extensor hood attaches
radial sagittal band is typically damaged, with resultant more distally from the joint than that of the adjacent
ulnar deviation of the involved finger. The long finger tendons.6 In addition, the cross-sectional shape of the
is most frequently involved. Treatment options are mul- extensor tendon of the long finger over the MP joint is
tiple and include splinting, realignment with direct rounder and less anchored than that of the other exten-
repair, and various forms of tendon reconstruction. sor tendons at that level.7 The injury is most often
located on the radial side, with subsequent displace-
ANATOMY AND BIOMECHANICS
ment of the extensor tendon in an ulnar direction.
The sagittal band is one component of the extensor reti- Young and Rayan8 studied the anatomy and biome-
nacular system, which forms a cylindrical tube with the chanics of the sagittal band in 48 cadaveric digits and
palmar plate (Figures 33-1 and 33-2). This tube sur- concluded the following: (1) extensor tendon instability
rounds the metacarpal head and MCP joint.2 In the following sagittal band disruption is most common in
central digits, the origin of the sagittal band is palmar the long finger and least common in the small finger;
and blends with the palmar plate, flexor tendon sheath, (2) ulnar instability of the extensor tendon is due to
proximal annular pulley, and deep transverse metacar- partial or complete radial sagittal band disruption, (3)
pal ligaments (DTML). The sagittal bands on the radial the degree of extensor tendon instability is determined
355
Sagittal band Central slip

Transverse
retinacular
ligament
PIP Oblique MP
retinacular
DIP ligament
Dorsal volar
interosseus
Triangular Lateral Sagittal
ligament band band
DIP
PIP
Central slip Lumbrical
extension MP
Figure 33-1 Depiction of sagittal bands and surrounding structures.
Radial Ulnar
1
3
2
4
5
Figure 33-2 Cadaver dissection demonstrating sagittal

bands (arrows) and surrounding extensor retinacular system.
B
by the extent of sagittal band disruption, (4) proximal Figure 33-3 A, The extensor apparatus at the level of
rather than distal sagittal band compromise contributes the MCP joint (transverse section): (1) extensor tendon;
to extensor tendon instability, (5) great forces are (2) superficial layer of sagittal band; (3) deep layer of the
inflicted on the sagittal band while the MCP joint is in sagittal band; (4) loose connective tissue between the
full extension or less frequently in full flexion, which sagittal band and dorsal capsule; (5) dorsal capsule. In the
spontaneous type of dislocation, the thin superficial layer of
may be the mechanism of its injury, and (6) wrist flexion
the sagittal band is ruptured just radial to the extensor
contributes to extensor tendon instability after sagittal
tendon (arrow), and the extensor tendon is detached from
band disruption and may exacerbate the severity of its the radial and palmar connection with the deep layer of the
injury. sagittal band. B, In the traumatic type of dislocation, both
Ishizuki reported on differences in anatomical intra- layers of the sagittal band are ruptured usually at a site
operative findings, depending on if the injury was spon- several millimeters radial to the extensor tendon (arrow).
taneous or traumatic (Figure 33-3).1 Spontaneous
dislocations involve rupture of the superficial layer of
the sagittal band just radial to the extensor tendon,
while traumatic dislocations rupture both layers of the
Chapter 33: Sagittal Band Injuries—Primary and Secondary Management 357
I II III
Figure 33-5 Three types of sagittal band injury: type I,
mild injury with no instability; type II, moderate injury with
extensor tendon subluxation; and type III, severe injury with
tendon dislocation.
CLASSIFICATION
Figure 33-4 Severe ulnar drift of the fingers in a patient
with rheumatoid arthritis. Rayan and Murray12 described three clinical types of
sagittal band injuries. Type I injury is a contusion
without tearing of the retinaculum, and demonstrates
sagittal band several millimeters radial to the extensor no instability. Type II is a moderate injury with extensor
tendon. tendon subluxation, while type III is a severe injury with
tendon dislocation (Figure 33-5). Subluxation was
CAUSES
defined as “lateral displacement with painful snapping
The causes of sagittal band injuries are multiple, and of the extensor tendon with its border reaching beyond
include degenerative disease, trauma, congenital, infec- the mid-line, but remaining in contact with the condyle
tion, and iatrogenic injury.9,10 Rheumatoid arthritis is during full MP joint flexion.” Dislocation was defined
the most common cause of subluxation or dislocation as “displacement of the tendon in the groove between
of the extensor tendon at the MP joint. It is most fre- the two metacarpal heads.”
quently seen in advanced cases with ulnar deviation
DIAGNOSIS
(Figure 33-4) but may also be seen in cases without
severe deformity. Rheumatoid arthritis causes synovitis Diagnosis of a sagittal band injury is primarily based on
of the MCP joint, which then leads to attenuation or clinical findings and can be identified with a thorough
rupture of the sagittal bands. Traumatic injury may review of history and physical examination. Closed
involve a laceration of the hood, direct blow, or forced injuries typically present with pain, swelling, and/or
flexion of the MCP joint. In a closed injury, the finger ecchymosis of the involved MCP joint. Open injuries
is often forced into a flexed and ulnarly deviated posi- will involve a laceration over the MCP joint, typically
tion against a tense extensor muscles, causing a tear in on the radial side. The extensor tendon may dislocate
the radial sagittal fibers. “Boxer’s knuckle,” a direct ulnarward into the intermetacarpal space, and the
impact over the MCP joint with a clenched fist, has also patient may complain of catching, locking, or snapping.
been described as a mechanism of injury. Spontaneous It should be noted, however, that tendon displacement
subluxation secondary to an underlying laxity of the is often be obscured by swelling. Partial ruptures of the
joint capsule may occur during simple activities of daily radial sagittal band will not present with subluxation of
living. The rare case of congenital extensor tendon sub- the extensor tendon. Active extension may produce
luxation involves an ulnar drift of all the fingers, and is ulnar angulation of the MCP joint and supination of the
sometimes part of the entity known as a “windblown finger. With time, the ulnar deviation deformity pre-
hand.”11 vents dorsal relocation of the extensor tendon, and the
Infectious etiologies, such as from a human fight bite, patient may be unable to extend the joint (Box 33-1).
can cause destruction of the joint capsule, extensor
DIFFERENTIAL DIAGNOSIS
tendon and deep fascial spaces. Iatrogenic injury to
the sagittal band, such as during joint replacement or Metacarpal fractures and avulsion injuries may present
MCP joint capsulotomy, may also occur. Such injury with swelling and pain about the MCP joint and should
may be avoided by completing the capsulotomy on the be ruled out. Radiographs may include an anteroposte-
ulnar aspect of the MCP joint, as opposed to the radial rior (AP), lateral, and Brewerton view (AP tangential
side. Chronic myoclonic jerks in a patient with focal view of the metacarpal heads, used to visualize the bony
epilepsy have also been reported to cause extensor origin of the collateral ligaments) (Figure 33-6). Col-
tendon dislocation. lateral ligament injury will demonstrate instability with
Box 33-1 Clinical Pearls: Diagnosis lateral stress when the MCP joint is fully flexed. Pain
will be located deep in the groove between the metacar-
Sagittal band injuries are typically on the radial side, leading
pal heads. Sagittal band injuries, in contrast, will dem-
to ulnar displacement of the extensor tendon.
The long finger is most commonly involved. onstrate instability with the MCP joint in extension and
Possible mechanisms of injury: be associated with more superficial tenderness. Radio-
 Rheumatoid arthritis graphs are essential, which may demonstrate bony
 Finger forced into flexed and ulnarly deviated avulsion. Trigger finger will present with snapping or
position locking, but will be present on the volar aspect of the
 “Boxer’s knuckle”: direct impact over MCP joint with hand. Tenderness will be elicited directly over the A1
clenched fist pulley. Snapping junctura tendinum simulating radial
 Spontaneous: during mild activity such as flicking or
sagittal band rupture has also been reported, and should
snapping be considered.13
 Infection (e.g., fight bite)
 Iatrogenic (e.g., during joint replacement, MCP TREATMENT METHODS
capsulotomy)
 Focal epilepsy Open injuries should be emergently explored, thor-
Congenital cases are rare but may present with an ulnar oughly irrigated, and repaired. Closed injuries have
drift of all of the fingers. multiple treatment options, which include splinting,
Presents with pain, swelling, and/or ecchymosis over realignment with direct repair, and various forms of
MCP joint. Tendon displacement may be obscured by tendon reconstruction. Patients with an acute traumatic
swelling. dislocation may achieve satisfactory results with exten-
Patient complains of snapping, locking, or catching. sion splinting of the MCP joint.14,15 Those who fail con-
Partial ruptures of a sagittal band will not present with servative treatment or who have a chronic dislocation
tendon subluxation. may benefit from surgical intervention. Koniuch and
Do not confuse a sagittal band injury with:
colleagues demonstrated instability in lacerations
 Metacarpal fracture or avulsion injury (rule out with
involving greater than two-thirds of the proximal sagit-
radiograph)
 Collateral ligament injury (will demonstrate instabil- tal band, and recommended surgery for such injuries16
ity with lateral stress when MCP joint fully flexed) (Box 33-2).
 Trigger finger (snapping and tenderness will be Rayan and Murray12 described treatment options
present on volar aspect of hand) based on their classification scheme and the chronicity
 Subluxation of the MCP joint of the injury. Acute (within 3 weeks) sagittal band inju-
 Snapping of the junctura tendinum ries are initially treated with a buddy splint (for type I)
or palmar splint (for types II and III) for 3 weeks, fol-
lowed by protected range of motion 3 times daily for an
3 additional weeks. Buddy splinting is then continued
for 4 additional weeks while completing both active and
Box 33-2 Clinical Pearls: Treatment
Nonsurgical treatment: Closed acute injuries (<3 weeks)

may be treated initially with splinting.
Surgical indications: Chronic injuries (≥3 weeks), patients

who do not respond to nonoperative treatment, open
injuries with lacerations involving greater than two-
thirds length of the sagittal band.
Surgical methods
 If sufficient tissue is present, perform direct repair.
 Reconstructive options are reserved for patients with
60° scarring or deficient tissue.

 Sagittal band reconstructions utilizes local tissues
such as juncturae tendinae or a portion of the exten-
sor tendon.
 “Boxer’s knuckle” injuries are best treated with
Figure 33-6 The Brewerton view is a tangential view of the
primary direct repair of the sagittal band, without
metacarpal heads that is useful in detecting fractures,
capsular repair.
dislocation, or subluxation of the MCP joint.
passive range of motion exercises. Chronic injuries therefore concluded that all acute dislocations less than
(longer than 3 weeks) are treated with buddy splinting 2 weeks old should be initially treated with splinting.
for 6 to 8 weeks. Patients with type II or III injuries, who A buddy splint immobilizes the injured digit to the
do not respond to nonoperative treatment, are then adjacent digit on the side of sagittal band injury (Figure
candidates for surgical intervention. In their series of 28 33-8). It works to minimize abduction forces, and
nonrheumatoid patients, those treated within 3 weeks should fasten proximal to the PIP joint. Both MCP
of injury achieved satisfactory results with nonoperative palmar splints and buddy splints can be used for
treatment. nonoperative treatment, or as part of a postoperative
protocol.
Immobilization Ragland and colleagues18 demonstrated success in
MCP palmar splints should position the joint at a nonoperative treatment of closed sagittal band injuries
neutral abduction-adduction position, and allow no in nonrheumatoid patients with extensor tendon dislo-
more than 20° of active MCP flexion (Figure 33-7). It cations. Patients were treated for 8 weeks with a sagittal
should allow motion at the IP joint, which prevents band bridge splint (Figure 33-9). This splint holds the
stiffness. The splint may also be made in slight deviation MCP joint in 25° to 35° of hyperextension, centralizing
in the direction of the sagittal band injury (typically the extensor tendon while the sagittal band heals. Active
radial), to decrease tension. Inoue and Tamura17 reported motion of the DIP and PIP joints was encouraged.
on six patients seen within 2 weeks with traumatic
or spontaneous dislocations of the extensor tendons. Surgical Options
These patients were treated with a splint that stopped Surgical options are varied, depending on the complex-
MCP flexion at 10° to 20° but allowed active extension. ity of the injury. Simple, acute lacerations involving
The IP joint was left free. All patients had full range greater than two-thirds of the sagittal band or with
of motion and were free of symptoms. The authors associated subluxation may undergo realignment and
A B
C D
Figure 33-7 A–D, A flexion-block splint allows active extension but prevents flexion of the MCP joint past 20°. Motion of
the IP joint prevents stiffness.
Figure 33-8 A buddy splint immobilizes the injured digit to

the adjacent digit on the side of the sagittal band injury. It
should fasten proximal to the PIP joint. B
primary repair with 4-0 braided suture (Figures 33-10

and 33-11). Congenital or spontaneous cases with suf-
ficient tissue may also undergo direct repair. Both Kettle-
camp and Ishiuki have reported good results with a
minimum follow-up of 1 year with direct repair.1,7 The
ulnar sagittal band may also be released to help central-
ize the EDC tendon.
Hame and Melone19 reported on eight professional
athletes with 11 “boxer’s knuckle” injuries who were
treated with centralization of the extensor tendon and
primary sagittal band repair. Seven joints had associated
capsular tears, and these were not repaired. The authors
thought that capsular repair would place excessive
tension on the repair and limit range of motion. Post-
operatively, the joint is immobilized at 60° of flexion C
for 6 weeks. Five months postoperatively, all athletes Figure 33-9 A–C, A sagittal band bridge splint provides
had returned to sports, were symptom free, and had full 25° to 35° more extension of the MCP joint compared to
range of motion. the adjacent digits. It helps maintain the EDC tendon in a
If unable to perform a direct repair of the radial sagit- reduced position.
tal band because of chronicity of injury, scarring, or
deficient tissue, several surgical options are available,
including those described by Wheeldon,20 McCoy,21 and
Carroll.22 A successful surgical repair must meet two Wheeldon20 reported using junctura tendinum to
requirements: (1) the tendon must be accurately aligned reconstruct the radial sagittal band of the long finger.
over the MCP joint to diminish the forces causing dis- The junctura tendinum is separated from its attachment
location to occur, and (2) the repair must be able to to the ring finger tendon and brought over to be sutured
withstand the ulnar forces incurred during flexion of the in the line of the torn aponeurosis, preventing further
joint. dislocation. However, use of the junctura tendinum may
not always be possible because of its irregular location,

inadequate length, or complete absence (Figure 33-12).
McCoy and Winsky21 described using a distal slip of
the extensor tendon to reconstruct the sagittal band. A
4-cm dorsal incision is made along the radial side of the
MCP joint, and skin flaps are reflected. Beginning 1 cm
proximal to the joint, the radial third of the extensor
tendon is stripped back to a point 3 mm proximal to the
level of the articular surface of the metacarpal head. A
suture is placed to prevent additional tearing. The strip
is then looped around the lumbrical tendon and sutured
to itself. Prior to placing the suture, tension is carefully
adjusted with the MCP joint at 95° of flexion. The repair
is tested under direct visualization with flexion and
Figure 33-10 Preoperative view of patient who sustained a
extension of the MCP joint, and tightened as necessary.
dorsal hand laceration with suspicion of ulnar sagittal band Carroll and colleagues22 reported using a distally
injury. based ulnar slip of the EDC to reconstruct the sagittal
band in patients who had previously failed conservative
management. The EDC tendon is first centralized by
releasing the ulnar sagittal band. The ulnar slip of the
EDC is then looped around the radial collateral liga-
ment and carefully tensioned to allow full flexion. The
EDC slip is then sutured to the EDC tendon.
The common themes of the above repairs are: (1)
wide exploration of the sagittal band complex, freeing
the tendon and sagittal band from the underlying
scarred capsule; (2) identification of stout material to
which to anchor the repair; (3) ideally, use of either the
juncturae tedinae or portion of the extensor tendon as
a pedicled tendon graft; (4) release of any tight portion
of the ulnar sagittal band that would cause excessive
ulnar pull; and (5) full range of motion from MCP joint
extension to flexion to test the adequacy of repair.
Postoperatively, the MCP joint is typically immobi-
lized for 4 to 6 weeks. MCP motion is then started with
a goal to regain full flexion. IP motion is started 2 weeks
A
after surgery. Koniuch16 has recommended the use of
dynamic splinting in the postoperative period. Excessive
stiffness of the MCP joint should be avoided at all costs.
INJURIES TO THE THUMB
Much like the other four digits, the radial component
of the thumb at the MCP joint is more critical to exten-
sor pollicis longus (EPL) stabilization than the ulnar
component.23 Subluxation or dislocation of the EPL
tendon is rare but has been reported. Rheumatoid
arthritis is one potential cause secondary to a bouton-
niere deformity of the thumb. A congenital case of bilat-
eral thumb contracture secondary to dislocation of
extensor tendons over the MCP joint of both thumbs
has also been reported.24 Traumatic damage to the dor-
B soradial aspect of the MCP joint, as well as rupture of
Figure 33-11 A, Exploration demonstrates a complete the EPL tendon after a distal radius fracture may also
laceration of the ulnar sagittal band and underlying capsule. lead to EPL ulnar dislocation.25-27 Treatment of an injury
B, Direct repair of the ulnar sagittal band was possible to the thumb sagittal band is similar to that of the
because of the early intervention. remaining digits.
Ulnar Radial
Lumbrical
Tendon slip
(McCoy)
Ulnar Scarred radial

sagittal sagittal band
fibers
Ulnar released
subluxation
RCL
A Injury B Primary suture C Junctura tendinum D Tendon slip E Tendon slip

(Kettlekamp) (Wheeldon) (McCoy) (Carroll)
Figure 33-12 Methods of extensor hood reconstruction. A, Ulnar subluxation of the EDC tendon caused by a torn radial
sagittal band. B, Primary suture of the radial sagittal band centering the EDC tendon. C, The ulnar juncture tendinum is
released from the adjacent tendon and sutured to the palmar radial sagittal band remnant of the deep intermetacarpal
ligament. D, The distal tendon is splinted on the radial side and wrapped around the lumbrical muscle. E, An ulnar, distally
based slip of the EDC is looped around the radial collateral ligament (RCL).
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of the extensor tendons of the hand, Plast Reconstr Surg J Hand Surg (Br) 22:790–792, 1997.
44:142–146, 1969. 26. Cardon LJ, Toh S, Tsubo K: Traumatic boutonniere deformity
22. Carroll C, Moore JR, Weiland AJ: Postraumatic ulnar sub of the thumb, J Hand Surg (Br) 25:505–508, 2000.
luxation fo the extensor tendons: A reconstructive technique, 27. Gong HS, Chung MS, Oh JH, et al: Ulnar subluxation of a
J Hand Surg (Am) 12:227–231, 1987. ruptured EPL tendon at the metacarpophalangeal joint: Case
23. Jaibaji M, Rayan GM, Chung KW: Functional anatomy of the report, J Hand Surg (Am) 34:910–913, 2009.
thumb sagittal band, J Hand Surg (Am) 33:879–884, 2008.
CHAPTER
34
TENDON TRANSFERS FOR
EXTENSOR TENDON
RECONSTRUCTION
Lance M. Brunton, MD, A. Bobby Chhabra, MD, and
Mollie O Manley, MD, MS
OUTLINE distal radioulnar joint (DRUJ). The final and most ulnar
sixth compartment encloses the extensor carpi ulnaris
Upper extremity extensor tendon injuries are often (ECU). This tendon courses through a fibro-osseous
detrimental to overall hand function and may lead to tunnel on the dorsal surface of the distal ulna, creating
significant patient disability. Insufficiency of the wrist, a groove that is often evident on plain radiographs of
thumb, and/or digital extensor tendons may be caused the wrist.
by direct or indirect mechanisms or may be second- Extensor tendons are divided into zones of the hand
arily attributable to systemic disease or radial nerve and forearm, which help to guide treatment. The zones
dysfunction. This chapter will provide an overview of are numbered from 1 to 9 with odd numbered-zones
tendon transfer methods to address extensor tendon largely corresponding to underlying joints. Zone 1 over-
insufficiency, alternatives to tendon transfers for lies the distal interphalangeal joint (DIP) of the four
various clinical scenarios, and guidelines for postop- digits, and zone 9 extends proximal to the musculoten-
erative rehabilitation after reconstructive techniques. dinous junction. The extensor zones of the thumb are
altered because there is one less joint. In the thumb
The extensor muscles of the wrist and hand are con- zone T1 is over the interphalangeal joint (IP) and T3
tained within the dorsal aspect of the forearm and are over the metacarpophalangeal (MCP) joint, whereas in
all innervated by the radial nerve. At the level of the the other digits the MCP joint would correspond to
wrist, the extensor tendons are divided into six com zone 5. The carpal level is T5 for the thumb and zone
partments by tough fibrous septae of the extensor 7 for the other digits.2
retinaculum, numbered from radial to ulnar. The first Injury or dysfunction of an extensor musculotendi-
compartment contains the abductor pollicis longus nous unit may result from direct laceration, acute closed
(APL) and extensor pollicis brevis (EPB). Anatomic rupture, chronic attritional wear, vascular insufficiency,
variation within this compartment includes potential systemic inflammatory disease, or radial nerve denerva-
multiple tendon slips of the APL and a distinctly sepa- tion. There are several clinical scenarios where extensor
rate compartment for the EPB.1 The second compart- tendon injuries cannot be adequately repaired in
ment includes the extensor carpi radialis longus (ECRL) primary fashion and may require tendon transfer recon-
and the extensor carpi radialis brevis (ECRB). The ECRB struction. A classic example is rupture of the EPL tendon
is oriented ulnar to the ECRL. The third compartment in association with nonoperative treatment of a distal
houses the extensor pollicis longus (EPL). This tendon radius fracture. When faced with such a scenario, patient
takes a sharp turn radially after it courses distal to the factors such as comorbidities, accompanying injuries,
ulnar aspect of Lister’s tubercle. Within the fourth com- occupation, and compliance must be taken into account.
partment are the extensor digitorum communis (EDC) Basic principles of tendon transfer surgery remain para-
and the extensor indicis proprius (EIP). The terminal mount for achieving optimal results. The work of Starr
branch of the posterior interosseous nerve (PIN) and among injured military personnel in the early twentieth
accompanying interosseous vessels lie at the floor of this century established a framework for tendon transfer
compartment. The EIP is oriented ulnar to the index surgery and is summarized in Table 34-1.
EDC. The extensor digiti minimi (EDM) is the sole More recent work has demonstrated that sarcomere
tendon within the fifth compartment at the level of the length may be measured in vivo and a single sample
364
Chapter 34: Tendon Transfers for Extensor Tendon Reconstruction 365
Table 34-1 Principles of Tendon Transfer Surgery Traumatic extensor tendon injury may be direct or
Applicable to Extensor Tendon Reconstruction indirect and further classified as acute or chronic. The
Expendable The choice of tendon for transfer acute treatment of these injuries is covered earlier in this
donor should not fully compromise existing textbook. Occasionally, the diagnosis is missed or the
normal function. injury is neglected, especially in the setting of poly-
trauma, altered mental capacity, or in patients with poor
One tendon for Splitting a transferred tendon for
one function separate functions will function only
understanding of a condition or limited access to
to the shortest excursion of the medical resources. The chronicity of the condition often
recipient tendons. alters the type of treatment that can be rendered. Cases
that would ordinarily be treated by direct repair are
Direction A straight line of pull maximizes
instead addressed by delayed reconstruction, and tendon
function of the transfer.
transfer surgery is an indispensible option in these clini-
Similar excursion Donor and recipient excursion cal scenarios.
should be comparable. The first description of extensor attritional rupture
Similar strength Donor and recipient strength should was a case report of two patients by Vaughn-Jackson in
be comparable. One grade of 1948. Both patients had rupture of the ring and small
recipient strength will be lost, even EDC in proximity to the distal end of the ulna; the
for the most successful transfers. “syndrome” of progressive extensor ruptures from ulnar
Joint mobility Tendon transfers will not function in to radial now bears the author’s name.6 Almost a decade
the setting of contracted joints. Near later, another case report demonstrated six patients with
full passive mobility of distal joints attritional extensor ruptures associated with rheumatoid
must be established preoperatively. arthritis (RA). The authors speculated that rupture
resulted from attritional changes caused by localized
Synergy Antagonistic muscles must provide a
stabilizing effect for the recipient.
rheumatoid synovitis.7 In patients with RA, the ECU
tendon subluxates volarly, the wrist deviates radially,
Tenodesis Taking advantage of the tenodesis and the digital extensors course directly over a dorsally
effect of the hand enhances tendon prominent distal ulna.
transfer function; wrist arthrodesis
Radial nerve dysfunction compromises the extension
should be avoided if possible.
capabilities of the wrist and hand. The radial nerve
Tissue Tendon transfers should be delayed essentially innervates the entire dorsal aspect of the
equilibrium until adjacent bone and soft tissue forearm musculature. The radial nerve proper innervates
injuries are healed and mature. the triceps, lateral portion of brachialis, anconeus, bra-
Power versus Weaker motors are used for position chioradialis, and ECRL. At the level of the elbow, the
positional motors and stronger motors for power. radial nerve proper divides into its superficial sensory
branch and the PIN. The PIN innervates the remaining
extensor muscles in the forearm including the ECRB
(with some variability), supinator, APL, EPB, EIP, EDC,
represents the entire muscle.3 Consequently, transferred EDM, and ECU. The radial nerve may be injured directly
musculotendinous units may be set at a sarcomere from a penetrating injury or often indirectly in asso
length specific to the muscle being replaced. Friden4 ciation with humeral shaft fractures. It may also be
astutely recognized that surgeons typically overtighten injured iatrogenically during surgical approaches to the
transfers, thinking they will relax over time, when in arm. Depending on the level and extent of the nerve
reality the sarcomeres are overstretched and only fire at injury, wrist extension, digit extension, and/or thumb
28% of the maximum force of the muscle. This may in extension may be compromised. Lack of active wrist
part account for transfers losing one grade of strength. extension will severely affect power grip of the hand.
Overly tightened transfers become somewhat of a Digit extension is mostly compromised at the level
passive tenodesis.5 of the MCP joints because IP joint extension receives
Wrist kinematics plays a role in tendon transfer. The significant contributions from the median and ulnar-
“dart thrower’s” arc, described as combined wrist exten- innervated intrinsic musculature (lumbricals and inter-
sion and radial deviation through combined wrist ossei) of the hand. A variety of tendon transfers have
flexion and ulnar deviation, is the functional motion for been described to improve function without creating
most activity. It is argued that with some tendon trans- imbalance within the hand. In devising an appropriate
fers, this motion is either not restored or compromised. transfer, available muscles that can substitute for the lost
For example, if the flexor carpi ulnaris (FCU) is sacri- function are considered and the above principles of
ficed for transfer in a patient with radial nerve palsy, the tendon transfer surgery guide the ultimate choice and
dart thrower’s arc may be restricted. technique.
METHODS OF TREATMENT
Traumatic Injury of EPL
Regardless of the mechanism of injury, treatment of an
EPL rupture follows a general algorithm: primary repair
without transposition, primary repair with transposi-
tion, intercalary tendon autograft, tendon transfer, and
thumb IP fusion. Direct repair is clearly the most desir-
able and can be accomplished if tendon retraction is
minimal and the cut ends are healthy. This sometimes
requires a radially directed transposition of the EPL
tendon away from its normal course adjacent to the
ulnar aspect of Lister’s tubercle to achieve increased
length and a more direct line toward the thumb. When
the EPL tendon appears atrophied or degenerative, the
cut ends are debrided until healthy tendon is evident. If
direct repair is impossible even after transposition, an Figure 34-1 EIP-to-EPL transfer. The EPL rupture is
intercalary tendon autograft may be used. The obvious identified. The EIP is identified over the index MCP joint
disadvantages are that autografts are essentially avascu- (ulnar to the common extensor tendon), transected, and
pulled through the proximal incision.
lar and that two repair sites must heal during rehabilita-
tion. The most common available autograft for this
purpose is the palmaris longus (PL), present in approxi-
mately 80%–85% of people. Alternatives include the
long or ring flexor digitorum superficialis (FDS), plan-
taris, or a toe extensor tendon.
Prior to considering a thumb IP arthrodesis as a last
resort, a final option is tendon transfer. In this regard, the
EIP is classically chosen for transfer to the distal cut end
of the EPL. The EIP is a good option for transfer to
the EPL due to its similar line of pull and amplitude.
Prior to harvesting this donor, the patient must demon-
strate independent EIP function by extending only the
index finger while keeping the other digits flexed. Explo-
ration is carried out to identify the ruptured EPL near
the scapho-trapezo-trapezoidal (STT) joint, and once
tendon transfer is deemed appropriate, a transverse inci-
sion is made over the dorsum of the index MCP joint. The
EIP is identified as ulnar to the index EDC and tagged. Figure 34-2 EIP-to-EPL transfer. A tendon passer is used
Another incision is made proximal to the extensor reti- to pass the EIP through the EPL and a Pulvertaft weave is
naculum in the distal forearm, and the EIP is identified created after appropriate tensioning.
as the most distal muscle belly in the fourth compart-
ment. The EIP is confirmed as the tagged tendon in the
distal wound. The tendon is cut distally and brought follow up of 4.3 years.9 In a similar retrospective case
through the more proximal incision (Figure 34-1). The series, the tendon transfer group trended toward less
EIP is tunneled and coapted to the distal EPL stump by extension and decreased strength, so the authors con-
Pulvertaft weave or directly sutured to the extensor cluded that people requiring more dexterity and power,
mechanism at the thumb MCP level (Figures 34-2 and such as musicians or surgeons, should have a free tendon
34-3). The tension should be set in wrist extension so graft.10
that the tip of the thumb touches the tip of the index
finger. With passive wrist flexion, the thumb IP joint Systemic Disease
should fully extend. The thumb is then immobilized for Extensor tendon ruptures are common in the setting of
4 weeks with 0° IP flexion and 20° of wrist extension.8 inflammatory arthropathies such as RA. The reconstruc-
A recent study performed by Schaller and colleagues tive ladder of direct repair, adjacent tendon coaptation,
compared intercalary PL autograft to EIP tendon trans- and tendon transfer is followed. In the setting of RA,
fer for EPL reconstruction. They found no major differ- however, tendon failure by attenuation is rarely ame-
ence in thumb function or complications after a mean nable to direct repair. These patients typically present in
Table 34-2 Common Tendon Transfers for Radial

Nerve Dysfunction
Procedure Wrist MCP Joint Thumb
Boyes PT to FDS (RF) to 1 FDS (MF)
2
(1960) ECRB EDC to EPL
1
2FDS (MF) to FCR to APL
EIP and EPB
Jones PT to FCU to EDC FCR to EPL,

(1921) ECRB/L III-IV, FCR to EPB, and APL
EDC II and EIP
Merle PT to 1
2 FCU to EDC PL to EPB
d’Aubigne ECRB/L and APL
(1946)
1
2 FCU to EPL
Riordan PT to FCU to EDC PL to EPL
(1983) ECRB
Starr (1922) PT to FCR to EDC PL to EPL
and Brand ECRB
(1985)
Tsuge and PT to FCR to EDC PL to EPL
Adachi ECRB
Tenodesis of
APL to BR
Figure 34-3 EIP-to-EPL transfer. Depiction of the finished

transfer.
comparable to the ECRB.12 This transfer is sometimes
performed early after a recognized radial nerve palsy, to
delayed fashion after the tendon ends have retracted and maintain wrist extension, maximize the tenodesis effect,
scarred to adjacent tissue. Once full small joint passive and aid in early retraining, even if later nerve recovery
motion is reestablished, the best option is often tendon restores innervation to the wrist extensor muscles. At
transfer. Briefly, the EIP may be transferred to a ruptured the very least, it may help to prevent wrist flexion con-
EPL and a long/ring FDS transferred to a ruptured EDC. tracture and aid in power grasp with improved wrist
If needed, silicone MCP arthroplasties may be per- positioning. An incision is made on the volar-radial
formed and rehabilitated prior to a tendon transfer.8 aspect of the mid-forearm over the insertion of the PT
tendon. The PT must be harvested with a long strip of
Radial Nerve Dysfunction periosteum and freed proximally to ensure maximum
The most commonly described series of tendon trans- excursion. The tendon is then passed subcutaneously
fers to address a permanent high (or low) radial nerve around the border of the radius superficial to the BR
deficit were adopted in response to injuries suffered by and ECRL. The PT is sutured to the ECRB just distal to
soldiers from the first two world wars. Others have the musculotendinous junction. This connection may
drawn on their early experience and described adapta- be reinforced with a free ECRL tendon graft. The transfer
tions to these procedures with specific goals in mind. is tensioned with the wrist in approximately 45° of
Several of these contributors and their corresponding extension.13
transfers of choice are summarized in Table 34-2. Occasionally, patients with a low radial nerve palsy
(PIN palsy) affecting only the ECU and/or ECRB may
Restoration of Wrist Extension demonstrate excessive radial deviation of the wrist
In high radial nerve deficits, innervation to the ECRL, during active extension. To address this imbalance, the
ECRB, and ECU is lost and active wrist extension is ECRL may be transferred to the ECU or ECRB and effec-
absent.11 The pronator teres (PT) is the most reliable tively increase relative ulnar deviation during wrist
available tendon to address this deficit and is typically extension and subsequently maximize power grasp.
routed to the ECRB for a potentially more centralized
and balanced wrist extension arc. Abrams and col- Restoration of Thumb Extension
leagues confirmed the suitability of the PT by showing The classic tendon transfer to restore thumb extension
that its muscle fiber length and cross-sectional area are is PL to EPL. Comparable excursion is obtained and a
combination of thumb abduction at the MCP joint and musculotendinous junction. The FCR is then tunneled
extension at the IP joint is achieved with the positioning subcutaneously toward the dorsal forearm. The FCR is
of this transfer. It must be first identified that the patient coapted to several of the thickest EDC tendons by Pul-
has a PL tendon, as it is absent in 15% to 20% of the vertaft weave, while the diminutive tendons are sutured
population. This is determined by having the patient to neighboring EDC tendons further distally. Equal ten-
oppose the thumb to the small fingertip while maxi- sioning is difficult, but should be done with the wrist
mally flexing the wrist, at which time it is readily evident and MCP joints in neutral and the FCR under maximal
or palpable. An incision is made on the dorsal aspect of pull (Figure 34-4).
the wrist and the EPL is identified and cut at the mus-
culotendinous junction. The EPL tendon is rerouted
from the third extensor compartment across the ana-
tomic snuff box to pass along the radial border of the
thumb metacarpal. The PL is then identified, freed prox-
imally, and cut at the level of the distal wrist flexion
crease. The tendons are coapted by Pulvertaft weave in
line with the thumb metacarpal. Tensioning of this
transfer should be done with the wrist in neutral and
maximum tension on both ends.13
For patients without a PL, the long or ring FDS is used
and may be brought either around the radius or through
the interosseous membrane (IOM) in the distal forearm.
A slip of the brachioradialis tendon may also be an
adequate motor to substitute for EPL function. A last
option is to include the EPL in the FCU to EDC transfer Extensor
described next. digitorum
Extensor
pollicis communis
Restoration of Digit Extension longus
While the aforementioned transfers for wrist and thumb
extension are consistent among Brand, Jones, and Boyes, Extensor carpi
they all differ in their transfer for restoring digit exten- radialis longus
sion. Brand chose the flexor carpi radialis (FCR) because
of its proximity to the wrist extensors and its adequate Extensor carpi
excursion to power all of the digital extensors simulta- radialis brevis
neously. Critics of the Jones transfer of the flexor carpi
ulnaris (FCU) cite the sacrifice of the most powerful
wrist flexor with ulnar deviation, especially in light of
the more physiological and functional “dart-thrower’s” Flexor carpi
radialis
arc of wrist motion. This transfer should be avoided in
Extensor
a manual laborer who requires wrist ulnar deviation for digitorum
power grasp activities such as hammering. The Boyes communis
transfer uses the ring FDS tendon directed through the
IOM for a straighter line of pull and sufficient excursion. Pronator
A disadvantage to this technique may be increased scar- teres
ring and adhesion formation through the IOM and
therefore some have advocated routing the superficialis
tendon around the radius, especially in adults. The long
finger FDS may compromise power grasp less than the
ring FDS, and its architecture resembles that of the
digital extensors to a closer degree.
The Brand transfer for restoring digit extension uti-
lizes the FCR tendon. An incision is made over the distal
volar forearm between the FCR and PL. The FCR is
identified, cut near its insertion and freed proximally to Brand transfer
allow proper excursion and direction. A second longi- Figure 34-4 Diagram of Brand transfer. (From Trumble TE,
tudinal incision is made in the central dorsal forearm. Rayan GM, Baratz M: Principles of Hand Surgery and Therapy,
The EDC tendons are identified and divided at their ed 2, Philadelphia, 2010, Saunders, page 304).
The original Jones transfer for digit extension utilized

both the FCU and FCR. Today, some surgeons favor the
stronger FCU over the FCR. A volar-ulnar incision is
made in the distal forearm, and the FCU tendon is cut
just proximal to its insertion at the pisiform and freed
proximally. The distal muscle fibers are excised off the
FCU tendon, debulking it for later use. Another incision
may be made more proximally over the FCU muscle
belly for additional untethering of fascial attachments
to increase excursion, but care must be taken to avoid
the innervation of the muscle at its proximal 2 inches.
A third incision is made over the dorsal forearm, through
which the FCU is passed. The FCU is coapted to the EDC
tendons in a similar fashion to the Brand transfer. Some Figure 34-5 Median to radial nerve transfer, shown in a
surgeons avoid including the EDM during transfer for cadaveric forearm. The pledget has been placed under the
two nerve transfers. The distal transfer (left) is a median
fear of overextending the small digit, but it should be
nerve branch to the PL sutured to a radial branch to the
included when a substantial extensor lag exists after the ECRB and the more proximal transfer (right) is a median
other EDC tendons have been secured. The FCU tendon nerve branch to the FCR sutured to the PIN.
should have a straight line of pull from the medial epi-
condyle to the EDC. The transfer should carefully incor-
porate each digital extensor to keep all four MCP joints advantages over nerve autograft because of decreased
extending uniformly. donor site morbidity, pure motor donors, and shorter
Last, the Boyes transfer for digit extension uniquely reinnervation distances. In addition, nerve transfers can
passes the donor FDS musculotendinous units through be accomplished in situations that tendon transfers are
the IOM. A longitudinal incision is made in the radial less advantageous, such as in the presence of significant
distal forearm to approach the volar aspect of the IOM. joint stiffness.16 Distal motor nerve reconstruction is
A transverse incision is made in the distal palm in line more optimal because of dissection and coaptation
with the long and ring fingers. The FDS tendons are away from the zone of injury.17 Furthermore, the brain
identified, divided proximal to Camper’s chiasma, and is better equipped to adapt to nerve rather than tendon
passed subcutaneously to the more proximal incision. transfers. For a high radial nerve palsy, branches of the
Two large windows are made in the IOM proximal to median nerve in the proximal forearm may be sacrificed
the pronator quadratus muscle without violating the without appreciable compromise of other hand/wrist
anterior and posterior interosseous vessels. The muscle function. Redundant branches to the FCR, FDS, and PL
bellies of the FDS are then passed through the IOM. An muscles may be used for nerve transfer to the PIN and/
incision is made on the dorsal forearm and the rerouted or independent nerve branches to the wrist extensors16
donor tendons are delivered to the dorsal surface. The (Figure 34-5). However, one must balance these advan-
long FDS is brought to the radial side of the wrist and tages with the possible risk of injury to uninvolved
interwoven to the EIP and EPL. The ring FDS is taken donor nerves such as the median and ulnar nerves.
ulnarly and sutured to the EDC. This transfer is ten-
REHABILITATION
sioned with the wrist in 20° of extension and FDS under
maximal tension with an assistant keeping the patient’s The principles of tendon rehabilitation are as important
digits and thumb clenched into a fist.13 as the principles of transfer surgery. Traditionally, three
phases of rehabilitation are recognized, each of which
TREATMENT ALTERNATIVES
lasts for approximately 3 weeks. An initial period of
Tendon transfers for radial nerve dysfunction have been immobilization allows early healing and avoids inad-
used reliably for almost 90 years, but these procedures vertent damage to repair sites during the acute inflam-
are not without drawbacks. Tendon transfers are a matory phase. This is followed by early passive range of
balance between restoring function and introducing motion to allow further healing and protection of the
additional dysfunction. An alternative to sacrificing repair site while ensuring adequate tendon gliding, min-
“expendable” tendons that is gaining momentum is the imizing scar adhesions, and preventing joint contrac-
sacrifice of “expendable” nerves. Repair or nerve grafting ture. During this phase, dynamic extension splints may
of proximal lesions has historically poor results because be fabricated to provide more reliable passive mobility
of scar infiltration, large reinnervation distances, and while protecting the repair and restricting the urge to
irreversible loss of target motor endplates after 18 to 24 attempt active motion prematurely. Finally, active range
months.14 Some argue that tendon transfers lead to of motion is initiated and the central nervous system is
unnatural ergonomics.15 Nerve transfer has theoretical trained to fire the transferred musculotendinous unit to
achieve a different function than it is accustomed to overstressing the repair. Another group compared early
performing. Extensor lags are common and may be dynamic splinting to static splinting after ECRL to EPL
treated with static night-time extension splinting. reconstruction; they found better range of motion,
Gradual strengthening and return to vocational and shorter rehabilitation period, shorter time off work, and
avocational activities is pursued as tailored to the indi- better movement of the thumb.19 A systematic review of
vidual patient. rehabilitation protocols after extensor tendon repair
As tendon repair techniques have improved, rehabili- compared immobilization, early controlled mobiliza-
tative protocols have adapted to shorten recovery time. tion, and early active mobilization. While immobiliza-
Some surgeons now recommend immediate active tion has led to comparatively inferior results, the
range of motion in an effort to speed recovery and difference between the other two protocols disappears
decrease the necessity of secondary tenolysis surgery. by 3 months postoperatively.20
Early active extension protocols are started in the first
SUMMARY
few days postoperatively. The postoperative splint is
removed and a custom thermoplastic splint replaces it. The work of early hand surgeons laid the foundation for
The patient is then instructed to start active extension reconstructive alternatives for loss of extensor tendon
out of the splint with increasing frequency as the days function to injury, disease, or nerve impairment. These
and weeks progress. Another form of accelerated reha- techniques are now employed by most well-trained and
bilitation is a dynamic splinting protocol. A device is technically proficient practicing hand specialists. Recent
attached to the splint with a rubber band traction mech- contributions have focused on enhancing tendon repair
anism that passively extends the affected joint. A recent and accelerating rehabilitative efforts to optimize patient
study comparing early active to dynamic splinting pro- outcome. We have summarized the classically described
tocols after EPL reconstruction found no difference at 8 tendon transfers to treat upper extremity extensor dys-
weeks between groups.18 The authors theorized, however, function and challenge the next generation to think of
that patients were not as aggressive in their early active new ways to address these difficult problems with inno-
home exercises for fear of doing something wrong or vative techniques and rehabilitative protocols.
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Scand J Plast Reconstr Surg Hand Surg 41:33–35, 2007. transposition of the extensor carpi radialis longus to the
10. Pillukat T, Prommersberger KJ, van Schoonhoven J: Compari- extensor pollicis longus, In Vivo 23:853–857, 2009.
son of the results between reconstruction of the extensor 20. Talsma E, de Haart M, Beelen A, et al: The effect of mobiliza-
pollicis longus tendon using a free interposition tendon graft tionon repaired extensor tendon injuries of the hand: A
and extensor indicis transposition, Handchir Mikrochir Plast systematic review, Arch Phys Med Rehabil 89:2366–2372,
Chir 40:160–164, 2008. 2008.
CHAPTER
35
SOFT TISSUE COVERAGE FOR
EXTENSOR TENDON
RECONSTRUCTION
Michel Saint-Cyr, MD, FRCS(C)
OUTLINE donor site for local flaps applicable to extensor tendon

coverage. Flap selection will ultimately be dictated by
A myriad of options exist for soft tissue reconstruction the size and location of the defect, donor site availabil-
and coverage of exposed extensor tendons. This can ity, and recipient tissue characteristics.
range from simple skin grafting with or without turn- Goals of this chapter will be to outline initial evalu-
over adipofascial flaps to free flaps in more complex ation and management principles in the presence of
cases. Principles of proper patient and wound evalua- exposed extensor tendons of the upper extremity follow-
tion, radical débridement, early coverage, and rehabili- ing injury. Principles of flap selection and use will
tation are paramount to maximize function. Transfer be discussed to provide stable coverage and expedite
of intrinsic flap (i.e., flap from the injured the hand) rehabilitation and maximize function.
should be considered first to cover local and small area
EVALUATION AND TREATMENT
soft tissue defect. Local or regional flap such as radial
or ulnar forearm flap, dorsal interosseous artery flap, As with any upper extremity–mutilating hand injury,
or lateral arm flap may be considered to cover the ruling out other severe systemic injuries is paramount.
defect in the dorsum of the hand. Anterior thigh flap Before embarking in a complex reconstruction, the
or other vascularized distant flaps should be consid- patient needs to be stabilized and all other life-
ered if the defects are extensive and located over the threatening injuries need to be addressed and resolved.
dorsum of the hand or forearm. Thorough débride- Patient-specific factors such as overall general health
ment is required before embarking on complicated condition, associated comorbidities, profession, socio-
reconstructive procedures, and postoperative motion economic status, age, and compliance to therapy need
of the hand and wrist is important to prevent joint to be considered when selecting the type of reconstruc-
stiffness and tendon adhesions. Despite increased tion. There are also wound-specific factors such as defect
technical requirements and length of operation, free size as well as mechanism of injury, such as crush, pene
flap reconstruction often results in fewer postoperative trating versus blunt trauma, amputation, etc. All wound
complications due to better vascularization, which is factors need to be considered as well as the zone of
important when early postoperative mobilization or injury and availability of local or distant tissue for flap
adjuvant therapy is required. coverage.
WOUND DÉBRIDEMENT
Often, extensor tendon exposure, lacerations, or tendon
loss will require coverage with well-vascularized tissue Early radical débridement, of all nonviable tissue under
to promote proper tendon healing and early mobiliza- tourniquet, control is pivotal prior to any attempt at
tion. Adequate coverage also helps minimize any sub- locoregional or free flap soft tissue reconstruction. The
sequent scarring, in an environment that is already critical step involves débridement of all marginally and
prone to significant adhesions and contracture forma- questionably viable tissue to convert a contaminated
tion. Therefore, it behooves the reconstructive hand wound into a clean wound and thus minimize risks of
surgeon to provide well-vascularized tissue with either subsequent infection. This also allows a clear evaluation
an intrinsic, locoregional, or distant free flap to provide of all injured and missing structures. Early aggressive
stable soft tissue coverage. The dorsal skin of the hand débridement should be performed over traditional
has many qualities that allow flexion and extension of serial débridement whenever possible. Serial débride-
the digits. The increased skin laxity, pliability, and thin- ment can delay final wound closure and make assess-
ness also make the dorsum of the hand an excellent ment of tissue viability difficult, and trigger a cascade of
371
additional tissue loss from desiccation due to prolonged

dressing changes. Early débridement and reconstruction
also help to achieve the ultimate goal of early mobiliza-
tion and return to function, which is critical in the upper
extremity.
The general assessment is done, ideally, in the operat-
ing room under tourniquet control. The upper extremity
is exsanguinated and a tourniquet is elevated and used
to provide a blood-free field, so as to better expose and
identify potentially devitalized tissue. All devitalized
tissue is then débrided and the wound is extirpated very
much like a tumor from the periphery towards the center
and within well-defined natural tissue planes. The
wound bed is resected entirely thus converting it from
a contaminated to a noncontaminated wound. Follow-
ing wound débridement, and once the extensor tendons
have been either grafted or repaired, healthy coverage
can be provided with either an intrinsic, locoregional,
or free flap, as needed. A major prerequisite is adequate
wound débridement to minimize any risk of infection,
wound breakdown, and flap loss. Any initial wound
Figure 35-1 Dorsal hand soft tissue defect following
that cannot be débrided thoroughly is best débrided first-stage radical débridement, under tourniquet control.
serially after 24 or 48 hours. A negative pressure dressing This wound was clean enough to be covered.
can be applied temporarily using a white sponge over
exposed extensor tendons so as to minimize any risk of
desiccation. Note that negative pressure therapy should helps minimize any risk of infection due to the presence
be used sparingly and only as a temporizing measure of residual necrotic tissue (Figure 35-1).
prior to definitive closure, which should be performed
TIMING OF RECONSTRUCTION
ideally within the first week. The upper extremity is
very sensitive to the timing of reconstruction, and any Reconstruction should be attempted as early as possible
prolonged immobilization will have a definite negative once adequate débridement is achieved. Advantages of
impact on final range of motion due to progressive early reconstruction include primary wound closure,
stiffness, joint contracture, and swelling. Early coverage coverage of vital structures, shorter hospitalization
allows patients to enter an aggressive rehabilitation course, avoidance of multiple procedures and multiple
program to maximize their range of motion. painful dressing changes, and early rehabilitation and
Once the wound has been properly débrided, the mobilization. An absolute indication for immediate
tourniquet is released and all nonbleeding and nonvi- primary reconstruction includes exposure of recon-
able tissue is reexcised. Wound edges are inspected for structed or native arteries and veins. Contraindications
bright red bleeding, and the wound is irrigated with a for immediate reconstruction include an unstable
bulb syringe only. Pulse lavage is not used and can lead patient that cannot tolerate a prolonged operative pro-
to extensor tendon friability and additional soft tissue cedure, and patients in whom amputation and pros
trauma. Therefore, we only use triple antibiotic saline thesis would provide a better functional result than
with bulb irrigation. reconstruction.
Choice of extensor tendon coverage, working from If delayed reconstruction is selected or necessary,
distal to proximal, will be based on the level of injury then all joints must be actively or passively mobilized
as well as the availability of nontraumatized soft tissue to maintain motion. Prolonged use of negative pressure
in the proximity of the wound. Clearly, replacing like wound therapy dressings in the hand without passive
with like is the ideal condition. All defects that are and active mobilization is to be condemned as this can
replaced with local tissue of similar color, texture, pli- lead to severe stiffness and fibrosis.
ability, and sensation will provide a better outcome than
non loco-regional flaps. The resulting defect, following SOFT TISSUE COVERAGE AND
radical débridement, will also be much larger than the RECONSTRUCTION
initial wound size. Knowing that stable soft tissue cover-
age can be provided regardless of defect size should be Intrinsic Flaps
impetus for providing aggressive initial débridement. Clearly, if paratenon is available over the exposed exten-
This not only serves to expedite reconstruction but also sor tendon, a simple form of coverage can involve either
Chapter 35: Soft Tissue Coverage for Extensor Tendon Reconstruction 373
a split- or full-thickness skin graft, which is harvested down through paratenon in the opposite direction of
from the either the forearm, the hypothenar region or the elevation of the overlying skin flap. This is taken
groin. Note that skin grafts harvested further from the from mid-axial line to mid-axial line. Care is taken to
defect will be less cosmetically matched compared to not damage any of the dorsal branches of the digital
more local skin graft options. Skin grafts harvested from artery when harvesting this flap. The flap is then turned
the hand or from the forearm would provide better skin over to cover the adjacent digit dorsal defect and provide
match compared to more distant skin grafts such as the good coverage for the exposed extensor tendon. The
proximal forearm, or groin. cross-finger adipofascial flap is covered with a split-
thickness skin graft and the donor site is closed primar-
Turnover and Distally Based Adipofascial Flap ily with its hinged skin flap. The hand is immobilized
If the exposed extensor tendon is devoid of paratenon, for 2 to 3 weeks, preferably 3 weeks, and the division
then a skin graft is not an option. A simple form of and inset of the flap is performed after 2 to 3 weeks,
reconstruction can include a turnover adipofascial flap, with revisions to the donor or recipient site as needed.
which can be used to cover small-to-moderate sized The patient is splinted in a position of function for 3
defects. These are then covered with a split-thickness weeks to minimize any contractures. In compliant
skin graft. Adipofascial flaps can be very useful for resur- patients, the patient can begin light active range of
facing small exposed extensor tendon defects in the motion after the surgery but needs to be very compliant
digits as well as the dorsum of the hand. These can flaps (Figure 35-2).
can be based off of small perforators from the dorsal
metacarpal arteries when covering defects in the hand Metacarpal Artery Island Flaps
or dorsal digital branches when covering dorsal digital The dorsal aspect of the hand represents an invaluable
defects. These can be wide based and are simply turned and expendable donor site for dorsal digital coverage of
over under elevated skin flaps and skin grafted to provide exposed extensor tendons. A sound knowledge of the
well-vascularized coverage over the exposed extensor vascular anatomy of the hand and digits’ dorsal skin has
tendons. Turnover adipofascial flaps need to be widely led to many innovative flap designs for this area. This
based to maximize perforator incorporation into the knowledge is an important prerequisite for the safe
flap, as well as subcutaneous veins. When covering application of these flaps. The blood supply to the
digital defects, the flap is distally based and incorporates dorsal skin of the hand and digits is provided by (1) the
a maximal amount of arterial perforators and subcuta- dorsal metacarpal arteries, which vascularize the proxi-
neous veins for venous outflow. Closure of the skin flaps mal portion of the hand and (2) the dorsal perforating
that have been elevated should not be performed under metacarpal arterial branches from the deep palmar arch,
any tension, so as to minimize any risk of venous con- which supply the distal hand and proximal phalanx.
gestion of the adipofascial turnover flap. These flaps are These two major arterial systems form the basis for
simple to elevate, provide quick and easy coverage direct and reverse dorsal metacarpal artery (DMA) flaps.
options for small defects with exposed tendons, and
offer minimal morbidity to the donor site. First Dorsal Metacarpal Artery Flap
The first dorsal metacarpal artery flap (FDMA flap, i.e.,
Reverse Cross-Finger Flap kite flap), described by Foucher and Braun,1 provides two
Extensor tendon exposure in zones 1 through 4 can be major applications in hand reconstruction: (1) dorsal
covered with reverse cross-finger flaps. The reverse cross- hand wound coverage and (2) thumb reconstruction.
finger flap, first described by Pakiam in 1978, is an In Foucher’s anatomical study of 30 injected cadav-
excellent local flap for soft tissue coverage of exposed eric hands, the FDMA originated from the radial artery
extensor tendons in the dorsal digit. Its vascular supply in 28 of 30 specimens and from the dorsalis superficialis
is provided by the dorsal digital branches of the digital antebrachialis artery in 2 of 30 cases. From there, it
arteries, as well as small subcutaneous veins and venae courses distal to the extensor pollicis longus tendon,
comitantes from the dorsal digital branches. Subcutane- and proximal to the radial artery’s entry between both
ous veins from the cross-finger flap can also be used as heads of the first dorsal interosseous (DIO) muscle. The
venous flow through veins for replants to bridge both FDMA travels parallel to the dorsal surface of the second
recipient and donor veins. The reverse cross-finger flap metacarpal, and superficial to the first DIO muscle
is then covered with either a split- or full-thickness skin fascia, with some fibers occasionally covering the vessel.
graft for definitive coverage. The flap is elevated as The FDMA then continues distally and anastomoses
follows: The adjacent donor digit is used for a cross- at the level of the metacarpal neck with dorsal perfor
finger flap. The mid-axial skin incision is made proximal ating branches from the palmar metacarpal arteries
to the defect, and the skin flap is elevated just above the of the deep palmar arch. These perforator branches
subcutaneous tissue in a direction that is opposite the form the basis of the reverse flow FDMA island flap.
side of the defect. The adipofascial flap is then harvested They anastomose with three different arterial systems:
(1) distally with the dorsal branches of the proper

palmar digital arteries, (2) proximally with branches of
the DMA, and (3) laterally with adjacent DMA perforat-
ing branches (Figure 35-3).
Intact
skin
The FDMA flap is designed over the dorsum of the
island Defect index finger’s proximal phalanx along the mid-radial
and mid-ulnar lines of the finger (see Figure 35-3).
Distal and proximal limits include the proximal inter-
phalangeal (PIP) joint and metacarpophalangeal (MCP)
joint, respectively; however, an extended flap can also
be harvested by including skin from the dorsum of the
middle phalanx. Inclusion of the dorsal skin of the MCP
joint can make dissection of the pedicle safer because
Elevated thin the layer of subcutaneous tissue is very thin at this level.
full-thickness
A lazy S, or Bruner-type incision, is marked from the
A skin flap
head of the second metacarpal bone to the apex of the
first interosseous web space. This design allows for gen-
erous exposure and an en block dissection of the pedicle
without skeletonization and undue risks of vascular
damage.
Elevation of the FDMA flap begins distally by incising
the flap outline over the dorsal proximal phalanx in a
radial to ulnar direction, just above the paratenon layer.
The lazy S, or zigzag incision, is made and the lateral
skin flaps are raised subdermally to develop a subcuta-
neous pedicle. Sensory branches of the radial nerve and
one or more subcutaneous veins are identified proxi-
mally and included in the pedicle. The radial border of
Elevated the second metacarpal bone is then exposed and dissec-
full-thickness tion continues deeper to include the first dorsal inter
subcutaneous osseous muscle fascia. This fascia is sharply incised
flap with intact and carefully dissected off the interosseous muscle in a
B skin island
radial direction, until the ulnar border of the first meta-
carpal bone is reached. The FDMA lies just superficial
Reversed flap covering to the first dorsal interosseous fascia, thus requiring
recipient defect and inclusion of the latter during flap elevation to prevent
reconstructing avulsed
eponychial defect
damage to the pedicle. For this same reason, some
authors even advocate raising a cuff of first dorsal inter-
osseous muscle in case the FDMA lies deeper. Pedicle
dissection continues in a proximal direction and all
small perforating branches penetrating the interosseous
fascia are coagulated to yield a maximal pedicle length,
Thin
which can vary from 6 to 8 cm. The pedicle is raised
full-thickness
skin graft with a generous cuff of subcutaneous fibrofatty tissue
Originally elevated without skeletonization. If required, tunneling is created
thin full-thickness
skin flap covering by undermining subcutaneous skin, and the flap is
donor defect transferred into the defect without tension, compres-
sion, or kinking. Nevertheless, when harvesting an
C FDMA flap, an overlying skin bridge over the pedicle
Figure 35-2 Step-by-step description of a reverse cross-
should also be harvested so as to avoid tunneling and
finger flap elevation. Either a thin split-thickness or full- possible pedicle compression. We perform this for all
thickness skin graft can be used to cover the wound. intrinsic pedicle flaps. The arc of rotation of the FDMA
flap allows it to reach the thumb tip, volar second MCP
joint, distal antebrachial region, and fifth MCP joint.
The donor site is covered with a full-thickness skin graft
(see Figure 35-3).
D
Figure 35-3 A, Dorsal tissue defect of left thumb with exposed phalanges and loss of extensor pollicis longus tendon.
B, Harvest of a 3.0 × 5.5-cm flap based on the dorsal metacarpal artery with a skin island kept over the pedicle to avoid
tunneling the flap and compression to the flap and vascular compromise. C, The FDMA flap was harvested over the first and
second interosseous muscle with incorporation of the fascia to not injure the pedicle. A wide base of subcutaneus tissue of
the flap was harvested to maximize arterial inflow and venous outflow. The skin paddle can be extended passing the PIP joint
for a longer flap, and this flap can also be made sensate by including a dorsal branch of the ulnar or radial digital nerve, or the
digital nerves of the thumb. D, Final inset of the FDMA flap with well-vascularized coverage over the thumb. Note that the
FDMA flap is not tunneled. The donor site is covered with a full-thickness skin graft.
The first dorsal interosseous muscle fascia must be entire second web space for reconstruction of thumb
included in flap elevation to avoid inadvertent injury degloving injuries.
to the FDMA. The pedicle should not be skeletonized The SDMA generally runs along a line joining the
and should be raised with a generous cuff of fibrofatty anatomical snuffbox and second web space. In 23 of
tissue. 29 (79%) cadaveric hands studied by Early and Milner,
the SDMA originated from the dorsal carpal arch. In the
Second Dorsal Metacarpal Artery Flap remaining six specimens, the SDMA originated from the
The second dorsal metacarpal artery (SDMA) flap is a deep palmar arch, the FDMA, the anterior interosseous
reliable sensate flap with a wide arc of rotation.2-4 Like artery, or the radial artery. The SDMA passes deep to the
the FDMA flap, it serves as a useful and reliable tool for extensor digitorum and extensor indicis muscles of the
coverage of hand and thumb defects. This flap can be index finger, and superficial to the second dorsal inter-
combined with the FDMA island flap to harvest the osseous muscle fascia. As the SDMA reaches the second
web space, one or more large perforators can be found are elevated in a subdermal plane with appropriate
between the second and third metacarpal heads in the superficial veins and branches of the radial nerve. Dis-
second intermetacarpal space. These perforators origi- section is deepened along the ulnar aspect of the
nate from the deep palmar arch and pass dorsally to index extensor tendons. After radial retraction of these
communicate with the SDMA to supply the dorsal skin. tendons, the SDMA can be seen coursing over the second
The perforators arise at the level of the metacarpal necks dorsal interosseous muscle and fascia. The SDMA
and give off distal branches, which anastomose with the pedicle is dissected from the second dorsal interosseous
dorsal cutaneous branches of the PPD arteries. These muscle much like the FDMA (i.e., with a generous cuff
perforator vessels form the basis of the extended SDMA of fascia and muscle), until the flap safely reaches its
flap and the reverse flow SDMA flap. intended destination. The donor site is closed primarily
The SDMA runs in an oblique line between the ana- or with a full-thickness skin graft.
tomical snuffbox and the center of the second web As in the dissection of the first dorsal metacarpal
space, between the heads of the second and third meta- artery flap, the second dorsal interosseous fascia should
carpal bones. Depending on defect size and location, be included during the elevation of an SDMA flap to
the flap can be designed over the second intermetacar- avoid inadvertent injury to the SDMA. In addition, the
pal space, over the proximal phalanx of the middle pedicle should not be skeletonized and should be
finger, or over the superficial web space. The proximal raised with a generous cuff of fibrofatty tissue to mini-
intersection of the extensor tendons to the index and mize risks of venous congestion, vasospasm, and vascu-
middle fingers can be considered the pivot point of lar injury.
the flap.
The flap is incised circumferentially and dissected off Perforator-Based DMA Flap
the extensor tendon paratenon of the proximal phalanx. As described by Quaba and Davidson,5 the reverse flow
Dissection is performed in a distal-to-proximal fashion. dorsal metacarpal flap can be harvested without incor-
When the second web space is reached, the communi- porating the DMA. Dissection of the flap proceeds from
cating perforator from the palmar metacarpal artery proximal to distal, and is carried above the dorsal inter-
must be identified and ligated. An S-shaped incision is osseous fascia without including the DMA. The flap may
then made from the base of the flap and carried proxi- be raised on the second, third, or fourth intermetacarpal
mally over the SDMA toward the anatomical snuffbox space and is designed as an ellipse, which can extend
until the required pedicle length is obtained. Skin flaps from the MCP joint to the wrist crease (Figure 35-4).
A B
Figure 35-4 A, Soft tissue defect in the right long finger with exposed extensor tendon following repair. This defect is an
excellent indication for a perforator-based metacarpal artery flap. In this cased, an SDMA perforator-based flap “Quaba flap”
was used. The same flap can be raised from the third and fourth DMA perforators. B, The axis of the flap was designed parallel
to the third metacarpal and extends from the intermetacarpal head space, to the distal wrist crease, and not beyond this
point. A pinch test is used to estimate the maximal width of the flap. A larger flap can be harvested but the donor site will
require a skin graft.
The flap width and length can vary from 1 to 3.5 cm Thumb Dorsal Radial Artery Flap
and 2 to 9 cm, respectively. This flap is an excellent A thumb dorsal radial artery flap can be used for smaller
option for dorsal digital coverage. It will easily cover defects in the dorsum of the thumb. This is based on
defects involving exposed MCP joint, proximal phalanx, recurrent branches from the radial digital artery. Vascu-
and even the PIP joint (see Figure 35-4). This flap is larity is ensured by the communication between both
elevated suprafascially from proximal to distal with the the ulnar and radial digital arteries of the thumb via
overlying skin and subcutaneous tissue from the dorsum dorsal branches of the digital artery and communicating
of the hand. The axis of the flap is parallel to the meta- branches along the dorsum of the thumb. The flap is
carpals, and dissection is stopped just distal to the junc- elevated on the dorsal radial aspect of the thumb overly-
turae tendinum, where a major cutaneous perforator ing the MCP joint and is dissected from proximal to
can be found originating from the dorsal metacarpal distal, leaving a wide base of fibrofatty tissue along the
artery. The recurrent cutaneous perforator branch of the pedicle (Figure 35-5). Inset is performed under minimal
DMA, which communicates with the deep carpal arch tension, and the donor site is either closed primarily or
or metacarpal artery at the level of the metacarpal neck, closed with a skin graft. Any exposed pedicle that cannot
is found just distal to the intertendinous connections be covered with primary closure should be skin grafted
and represents the pivot point of the flap. The arc of to minimize any compression. This skin graft can be
rotation varies from 0° to 180° and can cover the excised at a later date, but often the swelling and soft
dorsum of the metacarpal bone, web space, and dorsal tissue contracture will minimize any need for revisions
proximal and middle phalanges, up to the distal inter- in the future.
phalangeal (DIP) joint. This modification converts the
standard axial type reverse flap into a reverse perforator Local Flaps
flap via this recurrent branch. The advantages of this Dorsal hand defects can be either covered with local,
modification include ease of elevation and thinner cov- regional, or distant flaps. Many dorsal hand defects with
erage for dorsal digital defects. exposed extensor tendons can be covered with either
Karacalar and Özcan6 have described a modified
version of the reverse flow dorsal metacarpal flap. Their
flap had an extended arc of rotation and covered the
distal phalanx in five patients. It is based on the
second and third intermetacarpal spaces as well as
connections between the dorsal branches of the digital
artery and the terminal branches of the DMA at the level
of the proximal phalanx. The largest flap size measured
7 × 3 cm. Flap survival rate was 100%. Dissection is
similar to dissection of the Quaba reverse flow dorsal
metacarpal flap but is carried more distally. The perfo-
rating recurrent branch of the dorsal metacarpal artery
is ligated and a pedicle is developed based on connec-
tions between the dorsal branches of the digital artery
and the terminal cutaneous branches of the DMA over
the proximal phalanx. Pedicle skeletonization should A
be avoided and a generous cuff of fibrofatty tissue
should be harvested with the flap. Angiographic studies
by Yang and Morris confirm the anatomical basis of this
flap modification.7 This modification allows coverage of
more distal defects at the level of the distal phalanx,
which could not be treated with a standard reverse flap
design.
Care must be taken to harvest the flap while respect-
ing integrity of the paratenon if a skin graft is antici-
pated. The flap inset is performed under minimal
tension. The flap should preferably not be tunneled to
minimize any risk of congestion and ischemia, and B
sutures are taken out 2 weeks later, and light active range Figure 35-5 A, Soft tissue defect in the right thumb with
of motion is begun after 1 to 2 weeks. This flap is an landmarks drawn for a dorsal radial thumb flap. B, Harvest
excellent option for all exposed extensor tendons within of the flap with a large cuff of subcutaneous tissue kept
the digit from the MCP joint to the DIP joint. surrounding the pedicle.
a pedicle radial forearm flap, posterior interosseous for exposed defects on the ulnar and dorsal aspect of
artery flap, or dorsal ulnar artery flap. These are three the hand.
very good options when the forearm has not been The flap is raised as an island flap subfascially, and
compromised. dissection is started from the ulnar side of the wrist and
forearm from proximal to distal. The pedicle is exposed
Radial Forearm Flap by retracting the flexor carpi ulnaris tendon radially and
The flap provides excellent thin and pliable skin the major perforator pedicle can be seen emerging from
coverage for reconstruction of soft tissue defects of the ulnar artery 2 to 5 cm proximal to the pisiform. The
dorsal hand. It may be harvested with a vascularized dorsal ulnar artery is dissected down to the origin of the
segment of radius for reconstruction of metacarpal ulnar artery to allow rotation of the flap 180° and to
bone defects and with palmaris longus tendon for prevent inadvertent pedicle kinking and twisting. For
extensor tendon defects. Additional composite recon- smaller flaps, the donor site can be closed primarily; if
struction is also possible by incorporating antebrachial not, then a split-thickness skin graft is used for closure.
cutaneous nerve.
The flap is supplied by the multiple septocutaneous Free Flaps
perforating branches of the radial artery in the forearm, Free flap reconstruction is now well established for pro-
and flap territory extends from lower third of the volar viding a safe and reliable means of obtaining wound
aspect of the arm proximally to the flexion crease dis- closure and composite structural repair. With current
tally. Distal width is from the extensor pollicis longus success rates of over 95%, and the availability of mul-
tendon radially to the extensor carpi ulnaris tendon tiple donor sites, free flaps offer virtually unlimited
ulnarly and proximally from lateral to medial epicon- freedom in complex reconstruction of the dorsum of the
dyles. The diameter of the artery is approximately hand. Key requirements for soft tissue reconstruction
2.5 mm, and that of the concomitant veins 1.3 to include provision of a stable bony framework, adequate
2.5 mm. The typical radial forearm flap creates rather recipient vessels outside the zone of injury, adequate
marked scar in exposed forearm and need sacrifice of blood supply of tissue adjacent to the recipient site, a
a main artery truck,8 which became less used than stable patient, and a surgeon experienced in microsur-
before, because a myriad of other options are currently gery. Free tissue transfer for extensor tendon coverage is
available. indicated when local pedicle flaps cannot be harvested
Alternatively, for small to medium-sized defects, a outside the zone of injury or when soft tissue defects are
perforator-based radial forearm flap can also be used extensive.
without sacrifice of the radial artery. At least one major Several key features favor the use of free flaps over
radial artery perforator can be found within 2 cm from pedicled or local flaps, including avoiding additional
the radial styloid. donor site burden or surgical trauma to an already com-
promised region, including avoiding sacrifice of a major
Posterior Interosseous Artery Flap blood vessel, and providing ample well-vascularized
The posterior interosseous flap is also a very credible tissue to promote wound healing, minimize infection,
option for dorsal coverage. The pedicle can be found and enable coverage of larger wounds. A composite
from the lateral epicondyle to run in between the ECU reconstruction using vascularized bone, tendon, and
and the EDQ. Dissection proceeds from proximal to nerve is also generally easier to design. The structural
distal, and identification of the posterior interosseous complexity and aesthetic demands of a recipient site
artery is found with perforators emanating from the may also dictate that a graded approach using the recon-
septum between both the previously mentioned structive ladder is not always appropriate. In these cir-
muscles. Pivot point is just proximal to the distal radio- cumstances, free flap soft tissue reconstruction should
ulnar joint, and care must be taken to protect the pos- always be considered early in the treatment algorithm if
terior interosseous nerve during dissection. This flap a better end result can be anticipated. Despite increased
will cover small to moderate-sized defects of the dorsum technical requirements and length of operation, free
of the hand and is a viable option when the radial flap reconstruction often results in fewer postoperative
forearm flap is not available. complications due to better vascularization, which is
important when early postoperative mobilization or
Becker Flap (Ulnar Artery Dorsal Perforator Flap) adjuvant therapy is required.
The dorsal ulnar artery fasciocutaneous flap was first Free flap reconstruction is contraindicated in pati-
described by Becker and Gilbert in 1988, which is vas- ents with significant comorbidities. Diabetes, cigarette
cularized by the ascending branch of the dorsal ulnar smoking, corticosteroids, and immunosuppressants
artery without sacrifice of the ulna artery.9 The Becker may lead to wound healing complications. Presurgical
flap is in essence a pedicle perforator flap based of angiography may be required following high-energy
the ulnar artery and can provide excellent coverage injuries to the upper extremity where vascular injury is
suspected or in patients with extensive atherosclerotic Brachialis m.

disease. Ant. radial
Brachioradialis m.
The availability of free flap donor sites is extensive collateral a.
and selection should involve not just coverage but
should be tailored and individualized to meet the recip-
ient site requirements. Consideration should also be
given to the function and aesthetics of both the recipient
and donor sites. There are now a myriad of free flap
options for dorsal hand coverage, and ultimately the
choice of flap is determined by both patient donor site
characteristics and surgeon preference. The following
should be evaluated in the recipient site: dimensions,
the color and texture of the tissues surrounding the
defect, structures needing reconstruction, available Radial Radial n. Triceps m. Lower lateral Posterior radial
recipient vessels, level of contamination, and the need collateral a. cutaneous n. collatral a.
of the arm
to restore sensation. Following radical débridement the
Figure 35-6 Schematic demonstrating the major
wound is often much larger and deeper than antici-
landmarks and pedicle for the lateral arm flap.
pated, and the microvascular anastomosis must be
placed well out of the zone of injury. It is therefore
desirable to choose a flap with a large and reliable cuta-
neous territory and a long pedicle of large caliber, nerves of the arm and forearm. During dissection the
enabling anastomosis out of fields of trauma, thus posterior cutaneous nerve of the forearm is usually
reducing the risk of vessel spasm and thrombosis at the sacrificed.
anastomosis. Available flaps include lateral arm flap,
scapula/parascapular flap, anterolateral thigh flap, tho- Scapula/Parascapular Flap
racodorsal artery perforator flap, etc.10,17 The scapula and parascapular flaps afford consistent
Fasciocutaneous flaps provide excellent coverage for vascular anatomy, an easily accessible vascular pedicle,
dorsal hand defects and provide an excellent gliding good vessel diameter and length, and flap safety and
surface for tendons and joints in the hand. The ability reliability. The flap is also useful for dorsal hand cover-
to easily and quickly reelevate fasciocutaneous flaps is age hand reconstruction and can also be combined with
a definitive advantage when staged reconstruction of the latissimus dorsi or serratus muscle on the same
bone, nerve, or tendon is anticipated under the flap. subscapular system for additional coverage.
Lateral Arm Flap Anterolateral Thigh (ALT) Flap

The lateral arm flap is excellent for providing thin cover- The ALT flap includes a large and reliable adipocutane-
age for small to medium defects of the hand. It can be ous territory, minimal donor site morbidity, capability
harvested as a composite flap, incorporating a segment for sensory neurorrhaphy, long vascular pedicle, and the
of up to 10 cm in length of the humerus or a segment potential for flap thinning in the primary or secondary
of vascularized triceps tendon for extensor tendon setting to improve flap contour.10 Multiple components
reconstruction (Figure 35-6). can be raised on different perforators from the lateral
The flap is located on the lateral aspect of the upper femoral circumflex artery, including separate skin
arm, centered on a line drawn from the insertion of the paddles, the vastus lateralis muscle, and iliac crest,
deltoid to the lateral epicondyle, and spans the distal enabling accurate reconstruction of complex three-
half of the lateral arm and the proximal third of the dimensional multicomponent defects.
dorsolateral forearm. The pedicle is the posterior radial The flap is based on the descending branch of the
collateral artery and venae comitantes, which is 0.75 to lateral femoral circumflex artery, located between the
2.0 mm in diameter and varies from 6 to 8 cm in length rectus femoris and vastus lateralis muscles, with a per-
(see Figure 35-6). forator almost always found at the midpoint of a line
The flap can be designed with a 6- to 8-cm width, between the anterior superior iliac spine and the supero-
which allows primary closure of the wound. If the width lateral aspect of the patella. The perforator is musculo-
is larger, the donor site requires skin grafting. It can also cutaneous in approximately 80% of cases. The pedicle
be harvested as a pure fascial flap with split-thickness can be up to 15 cm in length with an average arterial
skin grafting, which provides excellent coverage of external diameter of 2 to 3 mm (Figure 35-8).
exposed extensor tendons when ultra-thin flap coverage Flaps in excess of 40 cm in length have been safely
is required (Figure 35-7). This flap also can be designed harvested based on only one perforator. Primary closure
as a sensate flap based on the antebrachial cutaneous can be achieved if the flap width does not exceed 8 to
A B
C D
Figure 35-7 A, Contracture of the dorsum of the left hand in a 50-year-old male patient due to extensive burn. B, Defect
size following resection of burn scar, tenolysis, and MCP joint capsulotomies. C, Lateral arm flap skin paddle design based on
size and geometry of defect template. D, Flap inset following microanastomosis of posterior radial collateral artery end-to-side
to radial artery and vena comitans end-to-end to dorsal vein.
10 cm. The flap may be harvested in the suprafascial ease of dissection, large flap size potential, and minimal
or subfascial plane. There is a reduced incidence of donor site morbidity.
muscle herniation with suprafascial dissection, although
SECONDARY PROCEDURES
a 5-cm radius cuff of deep fascia should be preserved
around the perforator. A sensate flap can be achieved by Secondary procedures may be required following the
incorporating the lateral femoral cutaneous nerve (see initial flap coverage, and these may involve, for example,
Figure 35-8 and Figure 35-9). flap debulking, tenolysis, capsulotomy, tendon grafting
Other options for dorsal hand coverage also include following Hunter rod removal, etc. One major advan-
muscle flaps. Keep in mind that we prefer to use skin tage of using a fasciocutaneous flap for extensor tendon
flaps for dorsal hand coverage in the event that second- coverage is the ability to easily reelevate the flap at a
ary reconstruction or revisions are required in the form later stage for tenolysis or other procedures. This can
of tenolysis. If tenolysis is anticipated in the future, or even be performed under local anesthesia using a “wide-
capsulotomy, it is much easier to reelevate a fasciocuta- awake” approach to better judge the effects of surgery.
neous flap rather than a muscle flap, although muscle If the flap requires debulking we prefer to wait at least
flaps will atrophy very nicely and provide excellent 3 months postoperatively before performing liposuc-
cosmesis and coverage. This is preferentially reserved tion. Peripheral incisions and excess skin removal are
for patients that do not have any extensor tendon loss performed an additional 3 months later to ensure ade-
or defects and have simply only exposed extensor quate vascularity.
tendons.
SUMMARY
Adipofascial flaps, such as the temporoparietal fascial
flap, are also a viable option for extensor tendon recon- Soft tissue coverage of extensor tendons in the hand
struction. We prefer to use an ALT adipofascial flap or and digits that have either been primarily repaired or
an ALT flap as opposed to a temporoparietal flap due to grafted is of paramount importance to promote proper
E
Figure 35-8 A, Extensive degloving injury, following a motor vehicle accident, of the dorsal right hand, with bone, extensor
tendon, and soft tissue defects. Note complete loss of EDC tendons on the dorsum of the distal forearm and hand. B, A
fasciocutaneous ATL flap was selected for coverage instead of a muscle flap in anticipation for future secondary surgeries and
need to reelevate the flap. C, ALT flap harvest with extension of fascia lata showing well vascularized tissue. D, Long extensor
tendon grafts harvested from the leg for primary extensor tendon reconstruction. E, Flap coverage after tendon grafting to
reconstruct the EDC tendons.
B
Figure 35-9 A, Hand motion and cosmetics 6 months postoperatively following coverage of a dorsal hand with an ATL flap,
which is in the case shown in Figure 35-8. B, Flap appearance after liposuction performed 3 months postoperatively.
gliding, minimize adhesion, and maximize function. débridement and well-vascularized coverage will allow
The reconstructive surgeon needs to have a wide arma- patients to start early active range of motion and reha-
mentarium of flap options for exposed extensor tendon bilitation to maximize function. Significant defects
coverage. Any extensor tendon devoid of adequate soft often require more intricate reconstructions to maxi-
tissue will be at high risk for delayed wound healing, mize function. Therefore surgeons should not hesitate
tendon desiccation, contracture, stiffness, and potential to use a more direct “reconstructive elevator” approach
loss of hand function. The combination of adequate to provide the best outcome.
References
1. Foucher G, Braun JB: A new island flap transfer from the 10. Wei FC, Jain V, Celik N, et al: Have we found an ideal soft-
dorsum of the index to the thumb, Plast Reconstr Surg 63:344– tissue flap? An experience with 672 anterolateral thigh flaps,
349, 1979. Plast Reconstr Surg 109:2219–2226, 2002.
2. Earley MJ, Milner RH: Dorsal metacarpal flaps, Br J Plast Surg 11. Angrigiani C, Grilli D, Siebert J: Latissimus dorsi musculocu-
40:333–341, 1987. taneous flap without muscle, Plast Reconstr Surg 96:1608–
3. Dautel G, Merle M: Dorsal metacarpal reverse flaps. Anatomi- 1614, 1995.
cal basis and clinical application, J Hand Surg (Br) 16:400– 12. Kim JT: Latissimus dorsi perforator flap, Clin Plast Surg
405, 1991. 30:403–431, 2003.
4. Dautel G, Merle M: Direct and reverse dorsal metacarpal flaps, 13. Kim JT: Two options for perforator flaps in the flank donor
Br J Plast Surg 45:123–130, 1992. site: latissimus dorsi and thoracodorsal perforator flaps, Plast
5. Quaba AA, Davison PM: The distally-based dorsal hand flap, Reconstr Surg 115:755–763, 2005.
Br J Plast Surg 43:28–39, 1990. 14. Scheker LR, Langley SJ, Martin DL, et al: Primary extensor
6. Karacalar A, Akin S, Ozcan M: The second dorsal metacarpal tendon reconstruction in dorsal hand defects requiring free
artery flap with double pivot points, Br J Plast Surg 49:97–102, flaps, J Hand Surg (Br) 18:568–575, 1993.
1996. 15. Sundine M, Shecker LR: A comparison of immediate and
7. Yang D, Morris SF: Vascular basis of dorsal digital and meta- staged reconstruction of the dorsum of the hand, J Hand Surg
carpal skin flaps, J Hand Surg (Am) 26:142–146, 2001. (Br) 21:216–221, 1996.
8. Lutz BS, Wei FC, Chang SC, et al: Donor site morbidity after 16. Harpf C, Papp C, Ninković M, et al: The lateral arm flap:
suprafascial elevation of the radial forearm flap: A prospective review of 72 cases and technical refinements, J Reconstr Micro-
study in 95 consecutive cases, Plast Reconstr Surg 103:132– surg 14:39–48, 1998.
137, 1999. 17. Gosain AK, Matloub HS, Yousif NJ, et al: The composite
9. Becker C, Gilbert A: The cubital flap, Ann Chir Main 7:136– lateral arm free flap: vascular relationship to triceps tendon
142, 1988. and muscle, Ann Plast Surg 29:496–507, 1992.
CHAPTER
36
TREATMENT OF BOUTONNIÈRE
AND SWAN-NECK
DEFORMITIES
Fraser J. Leversedge, MD, and Felicity G.L. Fishman, MD
OUTLINE The boutonnière and swan-neck deformities of the

digits are differentiated as being the sequelae of trauma,
The treatment of boutonnière and swan-neck deformi- or as a part of the spectrum of rheumatoid disease.
ties of the digits is guided by the etiology and staging
of the condition, primarily differentiated as being the POST-TRAUMATIC DEFORMITY
sequelae of trauma or as a part of the spectrum of
rheumatoid disease. A thorough evaluation should Post-Traumatic Boutonnière Deformity
include consideration for the current or potential Post-traumatic boutonnière (or “buttonhole”) deformi-
pathology of adjacent joints, the active and passive ties, characterized by hyperextension of the meta
motion of involved joints, subjective concerns for pain carpophalangeal (MCP) joint, flexion of the proximal
or instability, and radiographic assessment. Careful interphalangeal (PIP) joint, and hyperextension of the
assessment of the deformity is critical to the decision distal interphalangeal (DIP) joint, are caused by disrup-
on an appropriate and individualized treatment strat- tion of the central slip. Attenuation of the triangular
egy. The primary goals of treatment of boutonnière ligament allows the lateral bands to migrate volar to the
and swan-neck deformities are to alleviate pain and PIP joint axis of rotation, transforming the lateral bands
to improve function. Treatment ranges from splinting into a flexion force at the PIP joint and extension force
and therapy to operative intervention. The surgical at the DIP joint (Figure 36-1).
procedures include ligament repair or reconstruction Traumatic injuries to the central slip can be divided
and tenodesis or arthrodesis. Long-standing and severe into two groups: (1) Closed injuries: Typically, avulsion
deformities are difficult to correct and consequently of the central slip from its insertion occurs due to a
full function of the digits may not be achieved. Patient hyperflexion injury or volar dislocation of the PIP joint.
selection is critical to achieving successful surgical An associated avulsion fracture from the dorsal base of
outcomes. the middle phalanx may be present. (2) Open injuries:
Lacerations to the dorsal digit can disrupt the central
The intricate and coordinated functions of the hand and slip directly.
digits rely extensively on the complex but balanced Often, patients present with complaints of “jamming”
interactions between the extrinsic and intrinsic muscu- or spraining the affected digit and the clinician should
lature of the hand. Alterations in the relationships be suspicious of a central slip injury particularly in the
between these extrinsic and intrinsic systems due to presence of localized swelling, ecchymosis, and/or ten-
trauma or secondary to the effects of systemic disease derness to the dorsal PIP joint and a loss of full active
may cause the development of functional deformities PIP joint extension; a lack of motion should not be
such as a boutonnière or swan-neck deformity. Such disregarded as a consequence of swelling or pain. Early
changes may be acute or chronic in nature. Treatment diagnosis may be complicated by the delayed develop-
for these conditions should be guided by a comprehen- ment of the deformity, often 2 to 3 weeks following
sive evaluation of the patient, a consideration for associ- initial injury.
ated injuries or structural deficiencies, the timing of Physical examination findings supportive of an acute
injury, and the severity of the deformity. Importantly, a central slip injury include: (1) A 15° to 20° extension
functional assessment and recognition of the patient’s lag at the PIP joint with the wrist and MCP joint held
activity requirements and expectations are critical for in full flexion.1 (2) Absence or weakness of resisted
creating a plan of care. active extension of the PIP joint with the PIP joint
383
Post-Traumatic Swan-Neck Deformity

Post-traumatic swan-neck deformity is characterized by
the inability of the terminal slip to extend the DIP joint
combined with laxity of the PIP volar plate resulting in
CS
hyperextension of the PIP joint and flexion of the DIP
joint. Attenuation of the transverse retinacular ligament
clb coupled with hyperextension of the PIP joint leads to
dorsal migration of the lateral bands in relation to the
PIP joint axis of rotation, thereby exerting an extension
force on the PIP joint and a flexion force on the DIP
joint.
Laxity or incompetence of the volar plate can be
caused by dorsal dislocation of the PIP joint. Recurrent
injury may lead to chronic dorsal instability of the PIP
joint. Conversely, terminal tendon avulsion from its
Figure 36-1 Lateral view of the digit demonstrating the insertion at the base of the distal phalanx may cause an
volar subluxation of the lateral bands (clb) in a simulated imbalance in the extensor mechanism, resulting in
boutonniere deformity (central slip [CS]). (Reprinted with hyperextension of the PIP joint.
permission: © 2004 Leversedge FJ, Goldfarb CA, Boyer MI.) Patients may present with a history of acute injury
or recurrent dorsal PIP hyperextension injuries cul
minating in progressive subluxation or dislocations,
often unrecognized. Patients presenting with a chronic
starting in 90° of flexion.2,3 (3) Elson test: The patient “mallet” deformity should arouse suspicion for PIP
attempts to extend actively the PIP joint of the involved hypermobility. On physical examination, the affected
finger against resistance from a 90° starting position digit will exhibit PIP joint hyperextension and DIP joint
over the edge of a table. The absence of extension force flexion posturing, often with MCP joint flexion. For
at the PIP joint accompanied by fixed extension of the patients with flexible PIP and DIP joint deformities,
DIP joint confirm disruption of the central slip as exten- active and passive motion of the PIP joint should be
sion forces are being transferred to the DIP joint by the assessed and a Bunnell’s intrinsic tightness test should
lateral bands.4,5 (4) Boyes test: A positive test may be be performed.
found in progressive stages of boutonnière deformity Bunnell’s intrinsic tightness test: Increased resistance to
but is not reliable for the diagnosis of acute central slip passive PIP joint flexion with the MCP joint in extension
injuries.5 Loss of active flexion of the DIP joint with the compared with flexion indicates a relative shortening of
PIP joint held in passive extension due to tension across the intrinsic muscle–tendon units.
the lateral bands following disruption of the central The post-traumatic swan-neck deformity may prog-
slip. Active flexion of the DIP is possible with the PIP ress through four characteristic stages7:
joint flexed.
1. Full passive PIP joint range of motion
After a traumatic injury to the central slip, the bou-
2. Intrinsic tightness secondary to prolonged hyper-
tonnière deformity generally progresses through five
extension of the PIP joint
stages6:
3. Fixed hyperextension of the PIP joint regardless of
MCP position due to attenuation and contraction
1. Disruption of the central slip results in resting
of the transverse retinacular ligament and dorsal
flexion of the PIP joint and weak extension of the
subluxation of the lateral bands
middle phalanx via the lateral bands
4. Articular degeneration and fixed hyperextension
2. Absent active PIP joint extension combined with
deformity of the PIP joint
attenuation of the triangular ligament and con-
tracture of the transverse retinacular ligaments RHEUMATOID DEFORMITY
results in the volar migration of the lateral bands
3. Extension forces are transmitted through the Rheumatoid Boutonnière Deformity
lateral bands, causing hyperextension at the DIP of the Fingers
joint Rheumatoid boutonnière deformities occur due to pro-
4. Progressive contracture of the PIP joint volar plate gressive erosion of the central slip, transverse retinacular
and the oblique retinacular ligament causes fixed ligaments, and the triangular ligament by the destructive
flexion contracture at the PIP joint synovitis characteristic of rheumatoid arthritis. As the
5. Progressive articular degeneration occurs after pro- restraints provided by triangular ligament are lost, the
longed and untreated pathology lateral bands migrate in a volar direction, transforming
Chapter 36: Treatment of Boutonnière and Swan-Neck Deformities 385
them into a flexion force at the PIP joint. The continued  Type III—Decreased PIP joint motion in all posi-
flexion deformity of the PIP joint results in contractures tions of MCP joint flexion and extension
of the oblique retinacular ligament, the volar plate, and  Type IV—Fixed extension contracture of the PIP
the collateral ligaments; progression from a flexible to joint with degeneration of PIP joint articular
a fixed deformity of the PIP joint occurs with time. The cartilage
classic boutonnière deformity involves flexion of the
PIP joint and hyperextension of the DIP and MCP joints Rheumatoid Thumb Deformity
and evolves through three stages.8 Stage I is considered Thumb deformity associated with rheumatoid disease
a mild, involving PIP joint synovitis and a passively cor- may be classified based on changes specific to the car-
rectable flexion deformity of the PIP joint. Stage II, or a pometacarpal (CMC), MCP, and interphalangeal (IP)
moderate deformity, involves a flexion contracture of joints, as outlined by a modified classification system of
the PIP joint and concomitant MCP joint hyperexten- six types initially proposed by Nalebuff.9,10
sion. Stage III involves a fixed contracture of the PIP The most common rheumatoid thumb deformity is
joint and destruction of the articular surfaces. the type I (boutonnière) deformity. This is characterized
by IP joint hyperextension and MCP joint flexion
Rheumatoid Swan-Neck Deformity without primary involvement of the CMC joint. Typi-
of the Fingers cally, the type I deformity begins with proliferative syno-
Swan-neck deformities associated with rheumatoid vitis within the MCP joint, which leads to attenuation
disease are characterized by hyperextension of the PIP of the extensor pollicis brevis (EPB) tendon insertion
joint and concurrent MCP and DIP flexion deformities. and expansion of the extensor hood. Concurrently, the
A swan-neck deformity may be caused by primary collateral ligaments become attenuated and the exten-
pathology affecting the MCP, the PIP, or the DIP joint.7 sor pollicis longus (EPL) is displaced ulnar and volar to
the MCP joint axis of rotation. Subsequently, the proxi-
 MCP joint pathology: The characteristic rheumatoid
mal phalanx becomes subluxed palmarly relative to the
digital deformity of flexion and ulnar drift leads
metacarpal head and the altered pull of the intrinsics
to imbalance of the extensor mechanism. The PIP
and the EPL leads to IP joint hyperextension and MCP
is hyperextended by the extension force exerted
joint flexion. Radial abduction of the thumb metacarpal
across the PIP by the dorsal shift of the lateral
can occur in compensation for MCP joint flexion. Type
bands. The MCP joint component of a swan neck
I deformities are further divided into stages: (1) stage I,
deformity is flexion, which can be secondary to
or mild: PIP joint synovitis and mild fully correctable
chronic synovitis with degeneration of the sagittal
extensor lag; (2) stage II, or moderate: marked flexion
bands, intrinsic tightness, and/or articular destruc-
deformity of PIP joint, flexible or fixed; and (3) stage
tion resulting in volar subluxation of the MCP
III, or severe: PIP articular destruction.
joint.
The second most common rheumatoid thumb defor-
 PIP joint pathology: The volar plate of the PIP joint,
mity is the type III (swan-neck) deformity (Figure
the collateral ligaments, and the insertion of the
36-2).9,11 CMC joint synovitis leads to erosion of the
flexor digitorum superficialis (FDS) tendon can
articular surface and capsular attenuation, which con-
become attenuated in rheumatoid disease, result-
tributes to the dorsal and radial subluxation of the CMC
ing in PIP hyperextension. Also, progressive atten-
joint. An adduction contracture of the metacarpal devel-
uation of the transverse retinacular ligaments
ops due to the alteration in forces across the CMC joint
results in a loss of the normal restraints to the
with daily activities such as pinch and grasp. Compensa-
dorsal migration of the lateral bands, leading to
tory MCP joint hyperextension and IP joint flexion,
PIP joint hyperextension.
 DIP joint pathology: Synovitis of the DIP joint may
characteristic of a type III swan-neck deformity, is poten-
tiated as functional compensation for the progressive
cause attenuation and eventual rupture of the ter-
adduction contracture.12
minal extensor tendon. Subsequently, the extensor
forces are concentrated at the PIP joint, resulting
in a hyperextension deformity of the PIP joint. METHODS OF TREATMENT
Nalebuff classified rheumatoid swan-neck deformities Post-Traumatic Boutonnière Deformity

into four distinct types7: Nonoperative Management
Generally, non-surgical management is indicated for
 Type I—Fully mobile and flexible PIP joint, regard- closed injuries within 8 to 12 weeks from the time of
less of MCP joint position injury. This treatment is appropriate when the anatomi-
 Type II—Active and passive PIP joint motion is cal length relationship between the central slip and the
limited with MCP joint held in extension due to lateral bands is restored after correction of the defor-
intrinsic tightness mity. Nonoperative treatment can also be attempted in
A B
Figure 36-2 A, Palmar and lateral clinical photograph of a swan-neck deformity of the thumb; B, lateral radiograph of
the thumb demonstrating a swan-neck deformity involving CMC joint subluxation, metacarpal adduction contracture,
hyperextension of the MCP joint, and thumb IP joint flexion. (Reprinted with permission: © 2004 Leversedge FJ, Goldfarb CA,
Boyer MI.)
the cases with a volar dislocation or central slip avulsion

fracture if the PIP joint is stable and acceptable joint and
fracture reductions are achieved.
PIP joint extension splinting is applied when full
passive extension and congruent reduction of the PIP
joint is maintained. Supplemental transarticular Kirsch-
ner wire fixation can be considered. If a flexion contrac-
ture of the PIP joint is present, progressive static splinting
or serial casting, or dynamic extension splinting is uti-
lized in the attempt to restore a supple joint.
The splinting is maintained at all times for 6 to 8
weeks to completely immobilize the PIP joint. After this
period, following reevaluation to confirm stable reduc-
tion, the patient is transitioned to buddy straps during
the day and night-time extension splinting for an addi-
tional 4 to 6 weeks. Throughout the duration of the PIP Figure 36-3 A figure-of-eight ring splint (Silver Ring Splint;
joint splinting, the patient is instructed for active and Charlottesville, VA) used to prevent PIP joint hyperextension
passive DIP joint range of motion exercises. in a mild, flexible swan-neck deformity. (Reprinted with
permission: © 2004 Leversedge FJ, Goldfarb CA, Boyer MI.)
Operative Management
Surgical intervention should be considered for patients
who have failed 3 months of conservative treatment, considered. As PIP joint flexion and grip strength are
such as extension splinting, and for open injuries or compromised rarely with a boutonnière deformity, the
patients with fixed deformity and associated degenera- surgeon should avoid trading active digital flexion for
tive joint changes. Full passive extension of the PIP joint improved extension.
should be sought prior to surgical reconstruction.
Burton and Melchior emphasized that boutonnière Post-Traumatic Swan-Neck Deformity
reconstructions are generally more successful in patients Nonoperative Management
with flexible joints and that a first-stage joint contrac- Although nonoperative treatment is rarely effective in
ture release, followed by an exercise and splinting treating post-traumatic swan-neck deformities, a small
program, can sometimes obviate the need for further subset of patients with flexible deformities who are
procedures.13 If arthritic changes are present, a soft tissue capable of actively initiating PIP joint flexion may
reconstruction may not yield a satisfactory outcome benefit from a trial of figure-of-eight ring splinting to
and, therefore, PIP joint reconstruction with arthrodesis maintain the lateral bands in their anatomical position
or arthroplasty with extensor reconstruction should be and to prevent PIP joint hyperextension (Figure 36-3).
Surgical reconstruction is indicated for those patients
with a flexible deformity who have failed nonoperative
management, for patients with flexible deformities
who cannot actively initiate PIP joint flexion, and for
patients with a fixed deformity. Mobilization and volar
transfer and tenodesis of the lateral bands to prevent
PIP joint hyperextension can be performed for patients
with flexible deformities. For those with fixed deformi-
ties, treatment is determined by the status of the PIP
joint articular surfaces. If the articular surfaces are
preserved, release of the PIP joint with concomitant
procedures to restore flexion may prove beneficial.
However, if the articular surfaces are degenerated, PIP
joint arthrodesis is considered.
Rheumatoid Deformity—General Figure 36-4 Lateral radiograph of the finger following PIP
joint arthrodesis using a tension-band technique. Typically,
Surgical correction of both rheumatoid boutonnière due to hardware prominance, the pins and wire are removed
and swan-neck deformities is guided by the stage of at a time commensurate with osseous union and bony
deformity present. Goals include relief of pain and maturation. (Reprinted with permission: © 2004 Leversedge
improvement of overall function of the digit.14 Fortu- FJ, Goldfarb CA, Boyer MI.)
nately, the advances in medical pharmaceutical treat-
ments for rheumatoid arthritis have reduced the rate of
disease progression. It remains important, however, to
perform a thorough global examination, including the slip and terminal extensor tendon release may be indi-
entire upper limbs and the cervical spine, as a localized cated.12,15 For severe deformities in stage III, destruction
area of pathology might influence reconstructive options of the PIP joint will limit reconstructive options.
elsewhere. Pending treatments of the spine and lower Arthrodesis of the PIP joint is a reliable option for
extremities may influence the timing of upper extremity relieving pain and for improving function by creating a
intervention due to consideration of ambulatory aids of stable digit. Arthrodesis of the PIP joint may be consid-
devices. In the upper extremity, the pathology of the ered, also, for patients with a fixed flexion contracture
elbow and/or wrist should be considered in the preop- of the PIP joint without articular destruction (Figure
erative planning for hand and digital reconstruction. 36-4). Implant arthroplasty of the PIP joint with con-
comitant terminal extensor release is a less reliable
Rheumatoid Boutonnière Deformity option based on a history of soft tissue instability.16-18
Nonoperative Management
Nonoperative treatment includes pharmacologic therapy Rheumatoid Swan-Neck Deformity
as well as low-profile PIP joint extension splinting and/ Nonoperative Management
or buddy strap use. Intra-articular corticosteroid injec- Digital splinting, such as a figure-of-eight ring splint,
tions and oral anti-inflammatory medications are uti- can be applied to type I deformities with minimal PIP
lized to decrease joint synovitis. joint synovitis, in attempting to prevent PIP joint hyper-
extension and to improve initiation of PIP joint flexion.
For the stage I rheumatoid finger, surgical intervention Operative Management
should be considered for patients who have failed to Surgical treatment is guided by the type of deformity
improve with conservative treatment or have a substan- present. For type I deformities, it is important to deter-
tial functional deficit. PIP joint synovectomy can be mine the primary etiology of the flexible swan-neck
beneficial for persistent joint synovitis despite pharma- deformity. The deformity may be the result of DIP joint
cologic intervention. Additionally, if attenuation of the synovitis as extension forces are transferred to the PIP
soft tissue over the dorsal PIP joint is present, central joint, or more commonly, the result of PIP synovitis and
slip reconstruction and dorsal repositioning of the weakness of the volar PIP joint restraining structures.
lateral bands may be indicated. Sectioning of the termi- The MCP joint must be evaluated carefully, as flexion
nal extensor tendon over the dorsal middle phalanx may contracture at the MCP joint or subluxation of the
ease limitations caused by DIP joint hyperextension. extensor tendon at this level should be addressed prior
In patients with stage II disease, if the cartilage of to, or at the same time of, surgical correction of the
the PIP joint is preserved, reconstruction of the central swan-neck deformity. If passive range of motion of the
PIP joint is near normal, DIP joint arthrodesis may be reconstruction has a high incidence of deformity recur-
considered. Postoperatively, the DIP joint is protected rence, it may be indicated as substantial functional
in a mallet-finger splint and the PIP joint is left free to improvements can be achieved.10 EPL tendon rerouting
promote mobilization. In patients with type I swan- coupled with synovectomy of the MCP joint will lead
neck deformities who are unable to initiate PIP joint to an increased extensor moment at the MCP joint via
flexion from a resting hyperextended position, soft the dorsal MCP joint capsular attachment of the EPL.9
tissue reconstructive procedures that prevent PIP joint In moderate type I deformities, a fixed MCP joint
hyperextension may be considered. These procedures deformity is present. Appropriate planning includes
include volar skin dermodesis, oblique retinacular liga- assessment of the CMC and IP joints. The relative condi-
ment reconstruction, lateral band tenodesis,19 and PIP tion of these adjacent joints may guide a decision to
joint flexor tenodesis.2,20 proceed with arthroplasty or arthrodesis of the MCP
In type II swan-neck deformities, intrinsic tightness joint. If the CMC or IP joint pathology necessitates or
results in the MCP joint being held in extension and PIP has resulted in fusion, it may be desirable to preserve
joint motion is limited both actively and passively. As motion at the MCP joint with an implant arthroplasty,
with type I deformities, the presence of MCP joint avoiding arthrodesis at consecutive joints. Extensor
pathology and intrinsic tightness should be considered reconstruction, including EPL rerouting, can be per-
prior to surgical intervention for correction of the swan- formed concomitantly with arthroplasty of the thumb
neck deformity. If MCP joint arthroplasty or intrinsic MCP joint to augment extensor and abductor forces.23
release is performed, flexor tenodesis of the PIP joint Following extensor reconstruction and MCP joint
may be necessary. Intrinsic release may be performed as arthroplasty, the thumb MCP joint is splinted in exten-
described by Nalebuff, in which the lateral band and sion for 4 to 6 weeks, allowing for CMC and IP joint
extensor hood are exposed via a dorsal approach, and a exercises. If arthrodesis of the MCP joint is performed,
1-cm segment of the lateral band and sagittal band the joint is positioned for fusion in approximately 15°
fibers is excised.7,14 of flexion and in slight pronation. Several surgical
Type III deformities generally require more extensive options are available for arthrodesis of the thumb MCP
soft tissue reconstructive procedures, as PIP joint con- joint, including tension band wire fixation, crossing
tractures and lateral band adhesions have developed. Kirschner wires, headless compression screws, or plate
There is decreased active and passive motion of the PIP and screw fixation.24 Postoperatively, interphalangeal
joint with fixed positioning of the lateral bands, dorsal joint motion is encouraged; however, the fusion site
to the PIP joint axis of rotation. Reconstruction involves is protected until radiographs demonstrate evidence
lateral band release and volar translocation, dorsal of union.
PIP joint capsulectomy, collateral ligament release, and Severe type I deformities are characterized by fixed
extensor tenolysis.16,19,21,22 deformities of both the MCP and interphalangeal joints.
Type IV deformities are characterized by degenerative Often, the condition of the interphalangeal joint will
changes of the PIP joint articular surfaces in combina- warrant arthrodesis. Options for MCP joint arthrodesis
tion with a fixed hyperextension deformity of the PIP and arthroplasty are the same as for moderate type I
joint. Typically, soft tissue procedures alone will not rheumatoid thumb deformities. The CMC joint should
achieve improved function or provide substantial pain be considered carefully in severe deformities as it is
relief. Options for type IV deformities include implant affected commonly in this stage of the disease process.
arthroplasty and arthrodesis.16,22 Motion sparing procedures are preferred, and include
resection or hemiresection arthroplasty with ligament
Rheumatoid Thumb Deformity reconstruction and soft tissue interposition arthro-
Nonoperative Management plasty.24 The use of a trapezial implant arthroplasty
The treatment includes pharmacologic therapy, includ- should be considered carefully in the rheumatoid popu-
ing intra-articular corticosteroid injections and oral lation due to the higher risk for dislocation or implant
anti-inflammatory medications to decrease joint syno- failure.24
vitis. Functional splinting using custom-molded ther- Type III rheumatoid swan-neck deformities are
moplast materials or neoprene may be beneficial for divided into subtypes: mild, moderate, and severe. Mild
stabilization of the thumb for pinch and grasp activities type III deformities consist of isolated CMC joint patho
and for positioning of the thumb tip for dexterity- logy. Therefore, surgical correction is directed toward
related tasks. alleviation of CMC joint discomfort and dysfunction. If
conservative treatment fails to provide symptomatic
Operative Management relief, CMC hemitrapeziectomy or trapeziectomy and
Surgical correction of type I, or boutonnière, thumb ligament reconstruction with soft tissue interposition
deformities is based on the subtype: mild, moderate, or arthroplasty are considered. Moderate type III deformi-
severe. In mild type I deformities, although soft tissue ties are characterized by mild MCP joint involvement
(flexible deformity) in addition to CMC joint patho Central Slip Reconstruction Using Local Tissue
logy. Progressive MCP joint hyperextension should be Several methods have been described for central slip
addressed concurrently with surgical intervention for reconstruction using local tissues when insufficient
CMC joint involvement. MCP joint volar plate capsu- central slip is available for direct repair and a flexible
lodesis, sesamoidesis, or volar tenodesis can be coupled deformity is present:
with CMC hemitrapeziectomy or trapeziectomy and
ligament reconstruction with soft tissue interposition 1. Snow’s Technique.28 The proximal stump of the
arthroplasty. Transarticular pin stabilization of the MCP central slip is isolated from surrounding tissues. A
joint in 20° to 30° of flexion for 3 to 4 weeks postop- distally based flap of extensor tendon, sufficient to
eratively protects the joint while permitting early motion span the central slip deficit is elevated sharply and
of the interphalangeal joint. is turned back on itself. The flap is repaired to the
The severe type III deformity consists of CMC joint lateral bands using nonabsorbable suture. Follow-
dislocation, adduction contracture of the metacarpal, ing repair, passive PIP joint flexion of greater than
and fixed MCP joint hyperextension. Each of these com- 60° without excessive tension on the repair site
ponents should be addressed in the surgical interven- should be possible.
tion performed for severe type III rheumatoid thumb 2. Aiche’s Technique.29 The radial and lateral bands/
deformities. Generally, arthrodesis of the MCP joint is conjoined lateral bands are isolated by longitudi-
warranted to correct the rigid MCP joint hyperexten- nal division from the trifurcation of the extrinsic
sion. Treatments options for the CMC joint are the same extensor tendon to the triangular ligament. The
as those for mild and moderate deformities, including dorsal half of each lateral band / conjoined lateral
CMC resection arthroplasty and ligament reconstruc- band are mobilized dorsally and are sutured
tion or tendon interposition arthroplasty. Often, adduc- together using nonabsorbable suture. Relocation
tion contracture of the thumb metacarpal is corrected of the remaining lateral band is recommended if
with metacarpal base resection during resection arthro- it remains volar to the PIP joint axis of rotation.
plasty of the CMC joint; however, if the correction is 3. Littler and Eaton’s Technique.30 The radial and ulnar
inadequate, fasciotomy of the first dorsal interosseous lateral bands/conjoined lateral bands are isolated
and adductor muscles and, rarely, first web to space and incised over the middle phalanx. The ORL
reconstruction with z-plasties, may be performed.24 must be preserved; otherwise, DIP joint extension
will be compromised. The divided lateral bands
SURGICAL PROCEDURES are mobilized dorsally and sutured into the inser-
tion of the central slip. This method is not indi-
Boutonnière Reconstruction cated in the presence of severe attenuation of the
Primary Central Slip Repair central slip.
A dorsal approach is used, preserving the extensor 4. Matev’s Technique.31 The lateral bands/conjoined
paratenon. The central slip is isolated and redundant lateral bands are isolated longitudinally. The ulnar
fibrous tissue is excised after assessing central slip length lateral band is divided at the level of the DIP joint
with the PIP joint held in extension. In certain cases, a and the radial lateral band is incised at the mid-
V-Y advancement is required if tissue is insufficient. If point of the middle phalanx. The proximal stump
an avulsion fracture is present, the fragment is carefully of the ulnar lateral band and the distal stump of
elevated, preserving the central slip attachment. If the the radial lateral band are sutured over the dorsal
fragment is smaller and fixation with Kirschner wires digit, thereby lengthening the lateral band. The
or screws is inappropriate, then the fragment is excised proximal stump of the radial lateral band is sutured
and the central slip is repaired directly to the dorsal into the remaining central slip and the base of the
base of the middle phalanx using a suture anchor or middle phalanx in order to assist with PIP joint
pullout suture method. If a larger fragment, amenable extension. The PIP joint is held in extension for
to fixation, is present, then it is anatomically reduced 6 weeks postoperatively, with or without transar-
and stabilized with two small Kirschner wires or screws. ticular Kirschner wire fixation (Figure 36-5).
The lateral bands are restored to their anatomical
location. Incising the transverse retinacular ligaments Central Slip Reconstruction Using Tendon Graft
may be required to permit mobilization dorsal to the A dorsal exposure of the digit is used, elevating full-
axis of rotation of the PIP joint. The lateral bands are thickness skin flaps and preserving the extensor
stabilized in their anatomical position using non paratenon. The central slip remnant is isolated and ele-
absorbable suture. Following repair, the PIP joint is vated from the surrounding tissues. An autologous
maintained in full extension for 6 weeks. Often, a trans tendon graft, often the ipsilateral palmaris longus (PL)
articular Kirschner wire is used to temporarily stabilize tendon, is harvested and is passed through an osseous
the joint.15,17,18,21,25-27 tunnel created through the dorsal base of the middle
LS
clb
O TRL
TT
ORL
Figure 36-6 Location of extensor tenotomy (solid vertical

line “I”) distal to the triangular ligament and proximal to the
ORL insertion at the terminal tendon. Lateral view of the
digit demonstrating the coalescing fibers of the lateral slip
(LS) and oblique fibers of the extensor apparatus (O) which
combine to form the conjoined lateral band (clb). The two
conjoined lateral bands combine to form the terminal
tendon (TT), which inserts into the dorsal base of the distal
phalanx. The transverse retinacular ligament (TRL) prevents
dorsal subluxation of the lateral bands. The oblique
retinacular ligament (ORL) passively links the PIP and DIP
joints as it travels from volar to dorsal from the fibro-
osseous gutter (middle third of the proximal phalanx and A2
Matev technique pulley) to the proximal aspect of the distal phalanx through
the extensor tendon. (Reprinted with permission: © 2004
Figure 36-5 Illustration of Matev’s technique for extensor Leversedge FJ, Goldfarb CA, Boyer MI.)
reconstruction.
phalanx. The two limbs of the tendon graft are weaved of the flexor sheath, from the distal margin of the A2
into the lateral bands with the digit held in neutral. A pulley to the proximal margin of the A4 pulley is ele-
temporary, transarticular Kirschner wire may be placed vated, exposing the flexor tendons. One slip of the FDS
to stabilize the joint and to protect the reconstruction. tendon is identified and divided at the level of the
decussation, preserving its insertion into the middle
Extensor Tenotomy phalanx. The free, proximal end of the divided FDS
It is indicated in the presence of a flexible deformity and slip is passed from deep to superficial (dorsal to volar)
in patients for whom prior PIP joint surgery has been through a transverse incision in the A2 pulley, approxi-
unsuccessful.26 This procedure can be considered in con- mately 3mm from the distal margin of the pulley. The
junction with PIP joint arthrodesis. The terminal tendon tendon slip is sutured back onto itself using nonabsorb-
is isolated and is elevated proximally over a distance of able suture, tensioning the repair to hold the PIP joint
1.5 cm from the underlying DIP joint and middle in approximately 20° of flexion (Figure 36-7).
phalanx. After surgery, the repair is protected in a dorsal block-
The terminal tendon is incised transversely, distal to ing splint with the PIP joint at approximately 30°
the triangular ligament. The ORL must be preserved so flexion for 6 to 8 weeks; protected flexion exercises are
as to not compromise DIP joint extension. The incised started at 2 to 3 weeks.
tendon ends are separated by passively extending the PIP
joint and passively flexing the DIP joint (Figure 36-6). Lateral Band Tenodesis
The extensor apparatus is exposed via a dorsal curvilin-
Swan-Neck Reconstruction ear incision. Cleland’s ligaments are divided and the
PIP Joint Flexor Tenodesis flexor sheath is accessed. The dorsally subluxated lateral
A check-rein to PIP hyperextension can be created using band is dissected free from the central slip and the tri-
a slip of the FDS tendon.17,18,21,32-34 The flexor sheath is angular ligament; the lateral band is left intact proxi-
exposed from the base of the digit to the A4 pulley via mally and distally. The lateral band is translocated volar
a Bruner or mid-axial incision. The membranous portion to the PIP joint axis of rotation and is stabilized by a
A
A4 Lateral
band
A4
B
Flexor Figure 36-8 Illustration of the lateral digit demonstrating:
digitorum A, Incision of the lateral band at its insertion into the
superficialis terminal tendon; B, the lateral band is elevated, brought
(FDS)
tendon proximally to be re-routed through a 1-cm portion of the A2
pulley before being repaired back to the terminal tendon
A2 insertion over the dorsal DIP joint.
A B graft is passed volarly, deep to the radial neurovascular

bundle, and is sutured to the distal margin of the A2
pulley after appropriate tensioning. The A2 pulley may
Figure 36-7 Illustration of the volar digit demonstrating be stabilized by passing the tendon graft from deep to
(A) the incised FDS slip proximally at the FDS decussation in superficial through a small incision 2 to 3 mm proximal
relation to the A2 and A4 pulleys and (B) the passage of the
to the distal and lateral margin of the pulley, before
FDS slip through a transverse incision in the A2 pulley and
repair back onto itself, holding the PIP joint in 20° to 30°
folding it back upon itself and securing it with nonab-
flexion. sorbable suture. Prior to suture repair, the DIP joint is
held in full extension and the PIP joint in 25° of flexion
using temporary, transarticular Kirschner wires that are
dorsally based flap of the flexor sheath at the level of left in place for approximately 6 weeks.
the PIP joint.
Alternatively, the lateral band may be incised at its Type III Swan-Neck Reconstruction
distal insertion into the terminal tendon and rerouted Via a dorsal curvilinear incision, the extensor apparatus
from proximal to distal through a 0.5- to 1.0-m segment is exposed. The following procedures are considered, as
of the flexor sheath. The tendon slip is repaired subse- indicated: (1) lateral band release from the central
quently to its insertion at the terminal extensor tendon tendon and from the triangular ligament; (2) dorsal PIP
(Figure 36-8). joint capsulectomy; (3) release of the radial and ulnar
The repair is protected postoperatively with a dorsal collateral ligaments symmetrically from dorsal to volar
blocking splint, which maintains the PIP joint in greater as needed to permit passive flexion of the PIP joint to
than 30° flexion for 6 to 8 weeks. Early protected digital 90°; (4) lateral band stabilization volar to the PIP joint
flexion exercises are encouraged. axis of rotation is not required, typically, as they trans-
late passively with PIP joint flexion; and (5) the PIP
Oblique Retinacular Ligament Reconstruction joint in 20° flexion is stabilized using a transarticular
ORL reconstruction may be indicated in the presence of Kirschner wire that is removed 2 to 3 weeks postopera-
a well-preserved DIP joint when a flexible swan-neck tively. The reconstruction is protected in a forearm-
deformity develops as the result of a chronic mallet based splint, which may be removed to permit MCP and
injury. The digit is exposed via an incision from the DIP joint motion.
MCP joint flexion crease along the radial midaxial line,
SUMMARY
curving dorsally to end over the DIP joint. The radial
neurovascular bundle is protected and the A2 pulley The treatment of boutonnière and swan-neck deformi-
and the terminal tendon slip are identified. A suitable ties of the digits is guided by the etiology and staging
graft (ideally the ipsilateral PL tendon, when present) is of the condition, primarily differentiated as being the
harvested. The graft is sutured to the terminal tendon sequelae of trauma or as a part of the spectrum of rheu-
slip using nonabsorbable suture and the free end of the matoid disease. Treatment may range from splinting
and therapy to operative intervention and, therefore, the with rheumatoid disease, the swan-neck deformity can
careful assessment of the patient and the deformity is be secondary to pathology at the MCP, PIP, or DIP
critical to the formulation of an appropriate and indi- joints. Determination as to the specific type of defor-
vidualized treatment strategy. A thorough and global mity is critical to successful treatment in this setting.
evaluation of the extremity should include consider- Nonoperative treatment rarely leads to a favorable
ation for the current or potential pathology of adjacent outcome in patients with an advanced swan-neck defor-
joints, the active and passive motion of involved joints, mity. However, the flexible swan neck deformity may be
subjective concerns for pain or instability, and pertinent treated successfully in a figure-of-eight splint. Surgical
radiographic assessment. In patients with rheumatoid options for rheumatoid and post-traumatic swan neck
disease, reconstruction for wrist and/or MCP joint deformities include volar positioning of the lateral band
pathology may influence decision-making for PIP and with tenodesis, oblique retinacular ligament reconstruc-
DIP joints, including surgical techniques and the tion, DIP arthrodesis, and PIP joint arthroplasty or
sequence of reconstruction. arthrodesis.
A boutonnière deformity, post-traumatic or rheuma- Boutonnière or swan-neck deformity of the thumb
toid, develops from an injury to the central slip at the PIP can develop in the presence of rheumatoid disease. It is
joint. The deformity may evolve in a progressive fashion imperative to assess both individually and collectively
secondary to trauma and, therefore, may not be imme- the status of the CMC, MCP, and IP joints in formulat-
diately appreciated clinically following injury. Outcomes ing a treatment plan. Operative intervention varies,
are improved with early diagnosis, particularly utilizing with options ranging from soft tissue reconstruction
the Elson test. However, if the diagnosis is within 2 to 3 procedures to arthroplasty and arthrodesis. In the CMC
months of the time of injury, extension splinting (with joint, implant interposition arthroplasty may have an
or without use of a temporary transarticular Kirschner increased failure rate due to poor soft tissue restraints
wire holding the PIP joint in extension) is an effective and an increased risk of dislocation.
treatment. Surgical intervention for boutonnière defor- Ultimately, the primary goals of treatment of swan
mities that have failed conservative treatment range from neck and boutonnière deformities are to alleviate pain
central slip reconstruction with lateral band reposition- and to improve function. Preoperative patient educa-
ing to PIP joint arthroplasty and arthrodesis. tion will help to avoid unrealistic expectations and or
Swan-neck deformities are characterized by laxity of the consequences of unanticipated outcomes. Patient
the PIP volar plate and an inability of the terminal slip selection and thorough preoperative evaluation are criti-
to extend the DIP joint, leading to hyperextension of cal to guiding appropriate intervention and to achieving
the PIP joint and flexion of the DIP joint. In patients successful outcomes.
References
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Clin 11:441–447, 1995.
CHAPTER
37
VASCULARIZED TENDON
GRAFT FOR EXTENSOR
TENDON RECONSTRUCTION
Roberto Adani, MD, Luigi Tarallo, MD,
Massimo Corain, MD, and Jean Claude Guimberteau, MD
OUTLINE can be included are the palmaris longus (PL) and a strip
of the brachioradialis tendons along with fascia and
This chapter describes different vascularized compo skin, and a slip of flexor carpi radialis (FCR) tendon.21,22
site tissue graft procedures incorporating tendons to The ulnar island flap of the forearm allows for the inclu
reconstruct the tendons and overlying soft tissue sion of the PL and a strip of the flexor carpi ulnaris
defects in the hand. The options are the dorsalis pedis (FCU) tendons.23,24
flap, the radial forearm flap, and the ulnar artery–
based island flap. The radial island fasciotendinous OPERATIVE TECHNIQUES
flap is an excellent evolution of the radial forearm flap
for coverage of soft tissue defects of the hand; we rec Dorsalis Pedis Cutaneotendinous Free Flap
ommend this composite fascial flap to reconstruct the The surgical procedure uses two operative teams: one to
dorsum of the hand that requires simultaneous grafts harvest the cutaneotendinous free flap and the other to
of two or three tendons. prepare the recipient site. A pattern outlining the soft
tissue defect on the dorsum of the hand is transferred
Composite tissue loss of the hand involving tendon to the dorsum of the foot centered on the second meta
defects represents a great clinical challenge. These injuries tarsal bone using Doppler examination. It is helpful to
require restoration of both skin coverage and tendon also outline the venous drainage. Flap elevation begins
function. These injuries are approached by different ways: distally between the first and the second toes, identify
multistage reconstructions of soft tissue then tendon, or ing the first dorsal metatarsal artery that is tied and
single-stage vascularized composite tissue grafting.1 sutured to the distal skin margin. The flap is elevated
Multistage reconstructions include skin coverage from distal to proximal and laterally to medially below
with distant flaps and tendon grafting in a later stage.2 the level of the first dorsal metatarsal artery. The flap is
Nonvascularized tendon grafts in conjunction with ped dissected to include in continuity, the long toe extensors
icled flaps or free tissue transfer are termed partially to the second through fifth toes tendons, keeping the
vascularized tissue transfer.1 Skin,3-8 fascial,9-11 and muscle areolar tissue around the tendons, vessels, and nerves
flaps12,13 can be used for this purpose. A completely with the flap. The extensor digitorum tendons are fol
vascularized single-stage reconstruction uses a compos lowed proximally and are divided, according to the
ite flap in which different tissue components (skin, number of destroyed tendons in the hand. Care should
tendon, and nerve) are included. be taken to preserve the paratenon on the extensor hal
In 1979, Taylor and Towsend14 described for the first lucis longus tendon, which is left on the foot. During
time a composite free flap, with attached vascularized elevation, the long saphenous vein or median dorsal
segments of the extensor hallucis brevis to the great toe vein is preserved, In addition, the superficial peroneal
and the extensor digitorum longus to the second toe. nerve must be included in the flap. Finally, the extensor
Subsequently, several authors15-19 have described good retinaculum is divided and the dorsalis pedis artery can
results for the treatment of compound injuries with the be traced until a sufficient pedicle length is obtained.
dorsalis pedis composite flap; this flap provides four
vascularized tendons (extensor digitorum communis Radial Artery Forearm Island Flap With
[EDC]) of adequate length. Vascularized Tendons
Reid and Moss20 modified the radial artery forearm This is a modification of the radial artery forearm flap.
flap to include flexor tendons from forearm. The tendons Preoperatively, an Allen test must be done to ensure the
394
Chapter 37: Vascularized Tendon Graft for Extensor Tendon Reconstruction 395
Figure 37-1 Skin incision for harvesting the ulnar artery- Figure 37-2 Ulnar artery island skin flap with the FCU
based skin flap incorporating half of the FCU tendon. tendon connecting to the flap by fascia.
presence of a complete vascular palmar arch. The pres Then, the ulnar pedicle is separated from the ulnar nerve
ence of a PL tendon is also confirmed. The pattern of on its dorsal aspect along its whole length from the
the dorsal defect is outlined around the radial vessels, lower third of the forearm to Guyon’s canal. This ulnar
and the flap is raised including skin and fascia. Two 7- to skin flap is raised together with the FCU tendon.
8-cm-long strips of FCR tendon and brachioradialis The FCU tendon is longitudinally split into two parts.
tendons might be included in the flap with the PL One is maintained in place with the muscle and the
tendon, if it is present. Care is taken to preserve the other one (i.e., the medial part) is transected at its distal
areolar tissue around the tendons, which receive their insertion on the triquetrum. The proximal portion is
blood supply from the deep fascia. The radial artery and transected at the musculotendinous junction. All the
its venae comitantes are ligated proximally, and the flap other branches of the ulnar artery are ligated, except
is mobilized distally. Due to cosmetic reasons, this flap branches to the skin flap on the anterior side and to the
is less favored by many surgeons in recent years. periosteum in the event of a bone transfer. The ulnar
pedicle is dissected distally and the combined tendon–
Ulnar Artery–Based Island Flap With skin transfer is performed (Figure 37-2).
Vascularized Tendons (Used by J.C.G.) The FCU and ulnar skin transfer is generally used as
At the distal third of the wrist, just proximal to the flexor a retrograde flap by preserving the inflow from the distal
retinaculum, the ulnar artery on its lateral side gives off portion of the ulnar artery. One method is by transpos
one or two branches of around 1 mm in diameter to the ing to the anterior and radial side for thumb and index
distal part of the FCU tendon. Two types of arterial reconstruction. The other method is transposing to the
branching can be observed, either directly from the ulnar and posterior direction. Because the transfer is
ulnar artery or from the dorsal branch of the ulnar oriented on the lateral side of the hand, caution has to
artery. These vascular branches are constant and easily be taken concerning the sensory branches of the radial
identified on the lateral side of the pedicle. It is possible nerve. Sutures for extensor tendon reconstruction are
to carry out not only tendinous vascular transfers but various, from simple sutures to Pulvertaft weaves.
also a cutaneotendinous transfer, and even the triple
POSTOPERATIVE CARE
transfer of skin, tendon, and bone.
Preoperative evaluation includes the Allen test and We perform split-thickness skin grafting on the defect
Doppler testing to ascertain that the radial artery pro immediately following flap harvesting. When the dor
vides adequate blood supply to the hand. Angiography salis pedis flap is used, the ankle, foot, and toes are
of the arm is also advisable. A bayonet-shaped incision splinted to prevent movement under the graft. When the
is first traced and then made on the medial side of the radial forearm flap is used, the wrist and the fingers are
forearm, the axis of the incision overlying the lateral immobilized for 10 days with the wrist in 20° to 30° of
border of the flexor carpi ulnaris (Figure 37-1). The extension with the metacarpophalangeal (MCP) joints
ulnar pedicle is dissected and all its branches are care in 50° of flexion and the interphalangeal (IP) joints in
fully separated and divided. extension.4
First, the cutaneous branches between the ulnar Initially, the hand is splinted with the wrist at 30° of
artery and the skin, emerging from the volar aspect of extension and MCP and IP joints in 0°. In our case
the pedicle and which are the principal components series, these injuries have been managed with variable
of the ulnar forearm flap, are then carefully isolated. periods of immobilization after repair; nevertheless,
rehabilitation of the extensor tendon has recently been

settled in favor of early mobilization.25
Mobilization is started after 1 week, allowing 0° to
30° movements at MCP joints with IP joints free to
move during exercise. The flexion movement of MP
joints is gradually increased, and after 5 weeks MCP and
IP joints are left free to move during the day with night
splinting. The splint is continued for 6 weeks. Patient
motivation is very important: without the patient’s
active participation, functional recovery could be very
limited.
OUTCOMES A
Between 1988 and 2008, the lead author (R.A.) and his
colleagues treated 21 patients with composite loss of
tendon and skin on the dorsum of the hand. The skin
defects ranged from 8 × 5 cm to 11 × 13 cm. The interval
from injury to flap transfer ranged from 2 to 40 days,
with an average of 14 days. The time between injury and
reconstruction was long because initial trauma in most
cases were treated elsewhere and referred to us later. The
number of transferred tendons in each patient was three
on average. We used cutaneotendinous dorsalis pedis
flap in 8 cases, and the radial tendinous island flap in
13 cases (a cutaneous flap in 10 cases and a fascioten
B
dinous flap in 3 cases).
The aim of extensor tendon reconstruction is to
achieve free gliding of the tendons and normal finger
movement. The transferred tendons function well in
our patients. In one case the flexion of the fingers
and the extension of MCP joints were full, but there were
IP joint extension deficits of the middle, ring, and little
finger due to the original interosseous muscle avulsion.
Tendon adhesions markedly limiting hand motion
were seen only in one case; tenolysis was necessary. In
the donor site, toe extension was weak. However, toe
motion was not impaired because the short extensors of
the toes were intact. Partial skin graft loss at the donor
C
site occurred in the majority of the cases treated with
dorsalis pedis flap but did not require additional surgery
except that skin grafting was redone in one patient with
radial artery flap. Hypertrophic scarring occurred in all
patients at the donor site; however, this improved with
time, particularly in the foot.
Ulnar artery–based composite flap tendon transfer
was performed in 14 patients by J.C.G. and his col
leagues. There were no cases of complete necrosis, but
there was one case of partial skin loss because the flap
was passed in a subcutaneous tunnel. The sacrifice of the
ulnar artery is the main disadvantage. In the long term,
the flap may remain somewhat swollen for 3 or 4 months.
D
It may be necessary to reshape the skin flap in the months
that follow. The tissue quality is excellent, being fine, fat Figure 37-3 A case of skin defect and EPL tendon defect
free, and virtually hairless (Figure 37-3). There are over the proximal part of the thumb. A and B, An island
minimal concerns at the donor site. The scar on the ulnar artery flap with the FCU tendon was transferred to
forearm is usually very limited and not hypertrophic. cover skin defect and reconstruct the EPL tendon. C and
D, Postoperatively, the cosmetic appearance is excellent
and thumb extension was restored.
DISCUSSION
The dorsum of the hand is covered by a thin skin with
little subcutaneous tissue, underneath which lie the
extensor tendons; traumatic loss of skin is often associ
ated with extensor tendon defects. These injuries are
conventionally treated with primary distant flap transfer
(axial and random pattern flaps, groin flap, etc.) and
secondary tendon grafts or transfers.2 The treatment
does not yield satisfactory results either aesthetically or
functionally because of the need for immobilization of
the hand in a nonfunctional position and bulky flap
coverage.14,15 Moreover, the risk of tendon adhesions
may require the staged tendon reconstruction preceded A
by silicone rubber tendon implants in the first stage.26
Multiple operations also require a prolonged period of
physiotherapy and functional recovery.
The partially vascularized tissue transfer allows the
hand to be placed in a functional position and ensure
early mobilization. Flaps of various forms can be
used: island or free skin flaps, island or free fascial
flaps, island or free muscle flaps. Fascial and muscle
flaps do not always allow immediate tendon repair.9-12
Tendon reconstruction is more difficult under muscle
or fascial than with cutaneous flaps.27 Muscle flaps are
too bulky, requiring subsequent thinning, and they
adhere to tendon grafts extensively.6,7 This have been
B
partially solved by using partial superior latissimus or
partial medial rectus flaps; in this way, the debulking
rate has decreased, which may allow one-stage tendon
reconstruction.13
Distally based radial3,4 and ulnar5 flaps sacrifice a
major vascular supply to a hand, and this may jeopar
dize blood flow to an already compromised area.6
Scheker and colleagues6 used primary tendon grafts
covered by a free flap from either the lateral arm or groin.
Free tendon grafts were placed through a subcutaneous
tunnel under the flap. This technique may damage the
flap vessels, which has resulted in hematomas, causing
C
tendon adhesion.8 To minimize this problem, the groin
flap can be harvested along with a sheet of external
oblique aponeurosis preserving the vascular connec
tions between it and the under surface of the groin flap.
This aponeurosis is used to create a gliding surface for
tendon grafts, reducing tendon adhesion.8
The vascularized flap incorporating extensor tendons
allows one-stage reconstruction of all lost structures.
The vascularized tendon grafts may heal faster with less
adhesion.14 Hand motion can be initiated earlier because
union of the tendon junction is achieved sooner than D
with conventional tendon grafts.21 The dorsalis pedis
Figure 37-4 A case of severe friction injury to the dorsum
cutaneotendinous flap has been used most commonly. of the hand caused by road accident. A, Loss of skin and
It can provide four vascularized tendons of adequate EDC tendons of index, middle and ring fingers and extensor
length completely surrounded by paratenon and loosely indicis proprius tendon. B, Transfer of dorsalis pedis artery
attached to skin as thin as that on the dorsum of the flap with extensor tendons. C and D, Aesthetic and
hand (Figure 37-4). functional results.
A B C
D E F
Figure 37-5 A patient with severe friction injury on the dorsum of the hand. A, Loss of skin and extensor tendons to the
middle and ring fingers. B, Dorsalis pedis artery flap of 7 × 11 cm with two extensor digitorum longus tendons of the toe was
harvested and transferred to the hand. The extensor digitorum longus tendons were sutured to the extensor communis
tendons in the dorsum of the hand. C, Immediate postoperative view. D–F, Aesthetic and functional results.
In our cases, tenolysis was not necessary and a defat The size of the flap should be limited and surgeons
ting procedure was never used with the dorsalis pedis should avoid raising the flap too distally: the morbidity
flap. Recently, the dorsalis pedis flap has been less of the donor site is related to both the site and the loca
used as a free skin flap transfer because of variations tion of the flap harvested. In the literature, increased
in donor site anatomy, delayed wound healing, tedious morbidity seems to accompany harvested flaps that
dissection, and scar formation on the dorsum of the extend to within 2 cm of the metatarsophalangeal
foot.21,27-29 However, the cosmetic appearance of the (MTP) joint crease.28 In contrast, when the flap was
donor site of the foot is rather acceptable in our patients raised 2 cm or more proximal to the MTP joint crease,
after dorsalis pedis flap transfer (Figure 37-5). These there were no problems with the distal portion of the
patients believe the overall benefits of the procedure donor site.
outweighed the donor-site morbidity. There was only Some authors20, 21 preferred a radial forearm cutaneo
minimal functional deficits. Delayed donor site healing tendinous flap. The flap transfer is quick and simple, but
was common in this series of patients and late wound only a limited number of tendons are available. The PL
breakdown was also common. However, this rarely tendon can be taken completely with strips of the FCR
produced a significant long-term functional deficit.27 tendon and the brachioradialis tendon as vascularized
None of our patients had ulcerations, and all were able grafts (Figure 37-7). The sacrifice of the radial artery
to walk normally. Only two patients had contractures does not generally cause significant problems. In cases
of the skin at the grafted area overlying the extensor of severe hand trauma, use of the reverse radial forearm
hallucis longus tendon and the extensor digiti minimi flap can be contraindicated.6 In our cases, there were few
tendon with minimal deficits of toe plantar flexion donor site complications. To minimize donor site mor
(Figure 37-6). bidity, the radial border of the flap should not be
We believe that some technical pearls can help reduce extended beyond the radial border of the forearm and
donor site problems associated with dorsalis pedis flap. the FDS muscle must be imbricates over the FCR tendon
A B C
D E F
Figure 37-6 A patient with hot press injury. A, Loss of
dorsal skin and all extensor tendons to the four fingers.
B, Defects of all extensor tendons in the dorsum of the
hand. C, Harvest of a free cutaneous tendinous dorsalis
pedis flap including four extensor digitorum longus
tendons: intraoperative view showing tendon
reconstruction. D, Immediate postoperative result.
E–G, Aesthetic and functional results of the hand.
to prevent exposure of this tendon.4 The cosmetic tendons has not been popular. Reid and Moss20 used a
appearance of the flap donor site could be improved radial artery–based flap of fascia and tendon alone,
covering it with artificial dermis (Integra, Integra Life leaving the forearm skin unattached. The fascia flap
sciences, Plainsboro, NJ, USA).30 However, in recent includes nerve and tendon units to facilitate true com
years, more surgeons prefer not to use this site as a posite tissue reconstructive efforts,10 which provide thin,
donor because of obvious cosmetic reasons in the pliable tissue with no or minimal donor site morbidity.
forearm. We have used radial forearm cutaneotendinous flap in
An evolution of the radial forearm cutaneotendinous three cases thus far (Figure 37-8). We obtained excellent
flap is the radial island fasciotendinous flap.31 This radial functional and aesthetic results in the hand with
fascial flap in combination with vascularized extensor minimal donor site morbidity. None of the patients had
A B C
D E F
Figure 37-7 A, A case of hot press injury on the
dorsum of the hand with section of EDC tendon of
the middle finger and loss of EDC tendons of the
ring and little fingers and extensor digit minimi
proprius. B, Intraoperative débridement of the
dorsal wound. C, Reconstruction with radial
artery cutaneotendinous island flap; detail of
reconstruction of the extensor apparatus of the
little finger with PL tendon. D–F, Aesthetic and
functional results after surgery. G, Donor site
result in the forearm.
symptoms of cold intolerance due to the sacrifice of the flap can also be applied in cases of one or two extensor
radial artery, or functional deficits due to the harvesting tendon reconstruction, as much as it is a simpler tech
of the tendons. The outcomes of the use of this flap are nique, with no microsurgical risks, and followed by
encouraging. minor complications. The dorsalis pedis flap and radial
forearm flap are less often used now because of the donor
SUMMARY
site morbidity.
The dorsalis pedis flap, radial forearm cutaneotendi Based on our preliminary results in a series of three
nous flap, and island ulnar artery flap may provide good patients, we believe that radial island fasciotendinous
options for one-stage simultaneous reconstruction of flap represent an excellent evolution for coverage of
skin and tendon defects on the dorsum of the hand. In soft tissue defects of the hand and we recommend the
our patients, we achieved good cosmetics and function use of this composite fascial flap in the reconstruction
after these composite flap procedures. of cutaneotendinous injuries of the dorsum of the
When grafting of three or four tendons is required, the hand that require the use of two or three tendon grafts.
dorsalis pedis flap can be used with careful management Harvesting a small dorsalis pedis flap or ulnar side
of the donor site. The radial forearm cutaneotendinous island flap for reconstruction of extensor tendon in the
A B C
D F G
Figure 37-8 A patient with injury to the dorsum of the hand. A, Soft tissue defect located on the dorsum of the hand with
absence of extensor tendons from the index and middle finger. B, The forearm fascia flap was raised on a distal pedicle with a
strip of the brachioradialis and flexor carpi radialis tendons. C and D, The flap was transferred to the dorsum of the hand and
is covered with a full-thickness skin graft. E and F, Aesthetic and functional results. G, Appearance of the donor site in the
forearm.
dorsum of the digits remains a practical and attractive composite tissue grafting in one stage is expected to
option. confer the best opportunity to patients for functional
The replacement of combined loss of skin and recovery, allowing patients a relatively rapid return to a
tendons on the dorsum of the hand with vascularized normal life.
References
1. Dessai SS, Chuang DC, Levin SL: Microsurgical reconstruc 6. Schecker LR, Langley SJ, Martin DL, et al: Primary extensor
tion of the extensor system, Hand Clin 11:471–482, 1995. tendon reconstruction in dorsal hand defects requiring free
2. Winspur I: Distant flaps, Hand Clin 1:729–739, 1985. flaps, J Hand Surg (Br) 18:568–575, 1993.
3. Soutar DS, Tanner NS: The radial forearm flap in the manage 7. Sundine M, Scheker LR: A comparison of immediate staged
ment of soft tissue injuries of the hand, Br J Plast Surg 37:18– reconstruction of the dorsum of the hand, J Hand Surg (Br)
26, 1984. 21:216–221, 1996.
4. Jones NF, Jarrahy R, Kaufman MR: Pedicled and free radial 8. Jeng SF, Wei FC, Noordhoff MS: The composite groin fascial
forearm flaps for reconstruction of the elbow, wrist, and free flap, Ann Plast Surg 35:595–600, 1995.
hand, Plast Reconstr Surg 121:887–898, 2008. 9. Weinzweig N, Chen L, Chen ZW: The distally based radial
5. Grobbelaar AO, Harrison DH: The distally based ulnar artery forearm fasciosubcutaneous flap with preservation of the
island flap in hand reconstruction, J Hand Surg (Br) 22:204– radial artery: An anatomic and clinical approach, Plast
211, 1997. Reconstr Surg 94:675–684, 1994.
10. Carty MJ, Taghinia A, Upton J: Fascial flap reconstruction of 21. Yajima H, Inada Y, Shono M, et al: Radial forearm flap with
the hand: A single surgeon’s 30-year experience, Plast Reconstr vascularized tendons for hand reconstruction, Plast Reconstr
Surg 125:953–962, 2010. Surg 98:328–333, 1996.
11. Buehler MJ, Pacelli L,Wilson KM: Serratus fascia “sandwich” 22. Adani R, Marcoccio I, Tarallo L: Flexor coverage of dorsum of
free-tissue transfer for complex dorsal hand and wrist avul hand associated with extensor tendons injuries: A completely
sion injuries, J Reconstr Microsurg 15:315–320, 1999. vascularized single-stage reconstruction, Microsurg 23:32–39,
12. Brody GA, Buncke HJ, Alpert BS, et al: Serratus anterior 2003.
muscle transplantation for treatment of soft tissue defects in 23. Glasson DW, Lovie MJ: The ulnar island flap in hand and
the hand, J Hand Surg (Am) 15:322–327, 1990. forearm reconstruction, Br J Plast Surg 41:349–353, 1988.
13. Parrett BM, Bou-Merhi JS, Buntic RF, et al: Refining outcomes 24. Guimberteau JC, Panconi B, Boileau R: Mesovascularized
in dorsal hand coverage: Consideration of aesthetic and donor island flexor tendon: new concepts and techniques for flexor
site morbidity, Plast Reconstr Surg 126:1630–1638, 2010. tendon salvage surgery, Plast Reconstr Surg 92:888–903, 1993.
14. Taylor GI, Townsend P: Composite free flap and tendon trans 25. Koul AR, Patil RK, Philip V: Complex extensor tendon inju
fer: An anatomical study and a clinical technique, Br J Plast ries: early active motion following single-stage reconstruc
Surg 32:170–183, 1979. tion, J Hand Surg (Eur) 33:753–759, 2008.
15. Hentz VR, Pearl RM: Hand reconstruction following avulsion 26. Cautilli D, Schneider LH: Extensor tendon grafting on the
of all dorsal soft tissues: A cutaneo-tendinous free tissue dorsum of the hand in massive tendon loss, Hand Clin
transfer, Ann Chir Main 6:31–37, 1987. 11:423–429, 1995.
16. Vila-Rovira R, Ferreira BJ, Guinot A: Transfer of vascularized 27. Tomaino MM: Treatment of composite tissue loss following
extensor tendons from the foot to the hand with a dorsalis hand and forearm trauma, Hand Clin 15:319–333, 1999.
pedis flap, Plast Reconstr Surg 76:421–427, 1985. 28. Samson MC, Morris SF, Tweed AE: Dorsalis pedis flap donor
17. Caroli A, Adani R, Castagnetti C, et al: Dorsalis pedis flap with site: Acceptable or not? Plast Reconstr Surg 102:1549–1554,
vascularized extensor tendons for dorsal hand reconstruction, 1998.
Plast Reconstr Surg 92:1326–1330, 1993. 29. Chen HC, Buchman MT, Wei FC: Free flaps for soft tissue
18. Lee KS, Park SW, Kim HY: Tendocutaneous free flap transfer coverage in the hand and fingers, Hand Clin 15:541–554,
from the dorsum of the foot, Microsurg 15:882–885, 1994. 1999.
19. Cho BC, Lee JH, Weinzweig N, et al: Use of free innervated 30. Murray RC, Gordin EA, Saigal K, et al: Reconstruction of the
dorsalis pedis tendocutaneous flap in composite hand recon radial forearm free flap donor site using integra artificial
struction, Ann Plast Surg 40:268–276, 1998. dermis, Microsurg 31:104–108, 2011.
20. Reid CD, Moss LH: One-stage flap repair with vascularized 31. Adani R, Tarallo L, Marcoccio I: Island radial artery fascioten
tendon grafts in a dorsal hand injury using the “Chinese” dinous flap for dorsal hand reconstruction, Ann Plast Surg
forearm flap, Br J Plast Surg 36:473–479, 1983. 47:83–85, 2001.
CHAPTER
38
STATE OF THE ART FLEXOR
TENDON REHABILITATION
Karen M. Pettengill, MS, OTR/L, CHT, and
Gwendolyn Van Strien, LPT, MSc
OUTLINE success of the repair. In discussing the various rehabilita-

tion programs available, we will focus almost entirely
There are three approaches to management of the on the first few weeks, with discussion of basic concepts
repaired flexor tendon during the first few weeks: and techniques, and rationale for advancing the program
immobilization, passive mobilization (passive flexion according to individual patient and surgical factors. We
and active or passive extension), and active flexion will also examine emerging trends and issues in flexor
initiated within the first several days. The “classic” tendon rehabilitation, raising questions we hope to see
early passive mobilization programs have been modi- answered in the years to come.
fied, improving results. While the literature now sup- In 1917, Harmer1 published his results of uncon-
ports the efficacy of early active mobilization over trolled early active flexion and extension following
early passive and early passive mobilization over flexor tendon repair. Over the course of the past 100
immobilization, there is little evidence behind indi- years, we have come full circle in our approach: For a
vidual techniques. Rehabilitation programs must be long period, injured flexor tendons in the hand were
individually designed, based on such factors as char- immobilized or resected, with later grafting. In the
acteristics of injury and repair, concomitant injuries, 1960s, passive mobilization programs were in vogue,
patient access to therapy, and patient ability to perform and today we have returned with greater sophistication
a given program. This requires close surgeon–therapist to active mobilization as the preferred approach. None-
collaboration. There are a number of ways to safely theless, there is limited high-quality evidence support-
progress active flexion programs and to provide splint ing one form of early mobilization over another.2,3
protection. Splints (or orthoses) are dorsal and provide
IMMOBILIZATION
some protection from excessive extension through
metacarpophalangeal joint and wrist position; the The more conservative approaches of immobilization
traditional wrist and finger positions have been modi- and/or resection and grafting were a response to the
fied over the years. One published active flexion complexity of the flexor tendons in zone 2, known as
plan involves a splint with a wrist hinge. Growing “no man’s land.” Surgeons were understandably hesi-
evidence suggests greater incorporation of neuro tant to perform a repair at that level because of the
muscular theory and purposeful activity into therapy, unacceptably high risk of rupture or development of
preventing loss of cortical representation of involved restrictive adhesions. In 1941, Mason and Allen4 found
digits and facilitating recovery of fluid functional that in immobilized repairs there was an initial drop in
motion. We need more specific measures of functional repair strength, followed by a gradual increase. At 3
outcomes for both surgery and therapy, to better rep- weeks, repair strength was equivalent to that on the first
resent the success of each individual’s rehabilitation. postoperative day. Because of the observed dip in
strength, it was considered necessary to protect the
Methods of rehabilitation after flexor tendon repairs are repair with complete immobilization for 3 weeks. Since
evolving. Earlier chapters examined the anatomy, then research has supported the value of controlled
healing, surgical repair and other aspects in great detail, early mobilization of repairs. Even though immobiliza-
offering a biological, mechanical, and surgical basis for tion is no longer the preferred approach, there are many
establishment of current rehabilitation principles and cases in which this is the treatment of choice (e.g., in
methods. It is well recognized that the first few weeks young children).
following repair are crucial in flexor tendon rehabilita- When a repair must be immobilized, the cast or
tion: Management during this phase will determine the splint is designed to keep the repaired flexor tendon on
405
406 Section 5: Rehabilitation of Tendon Surgery
slack by positioning the wrist at neutral to 20° to 30°

of flexion, the metacarpophalangeal (MCP) joints in
40° to 70° of flexion, and the interphalangeal (IP)
joints at 0°. Following 3 weeks of immobilization, there
are two predictable problems. Since immobilized repairs
grow weaker before they return to their immediate post-
operative strength, we can expect a higher risk of rupture
with active motion in these patients. At the same time,
frustratingly, restrictive tendon adhesions will have
developed. Therapy in these cases focuses on increasing
tendon excursion while protecting the repair from
excessive stress. A 1991 article by Cifaldi Collins and
Schwarze5 describes a systematic approach to regaining
tendon function following initial immobilization of
repairs in zones 2 and 3. They provide timing guidelines
for initiating tendon gliding exercises, blocking and
other specifically targeted interventions to restore gliding Figure 38-1 In this modification of the Kleinert program,
without overstressing the immobilized repair. the patient manually releases rubber band traction during
extension to facilitate full PIP extension in an effort to avoid
CONTROLLED EARLY MOBILIZATION development of a PIP flexion contracture.
In earlier chapters, authors have covered the beneficial
effects of early motion on tendon healing and biome-
chanics, and the supporting research showing that early (Figure 38-1).10 Some immobilize the interphalangeal
mobilization of the repair provides at least a partial joints in extension at night, and others use the splint
solution to the problems of immobilization: better design proposed by May and colleagues,11 with the
adhesion control and increased repair strength. dorsal finger component ending at the PIP joint for
optimal PIP joint extension. At night a separate volar
EARLY PASSIVE MOBILIZATION
piece is strapped on to the splint to keep the IP joints
Before any significant research had been performed in in extension.11 In the same study, May and colleagues
early mobilization of tendon repairs, forward-thinking examined the issue of using dynamic flexion for all four
surgeons such as Kleinert6 and Duran7 had designed fingers versus only the involved finger.11 They concluded
postoperative management programs incorporating that incorporation of all four fingers contributed to
controlled passive motion of the repair in the first 3 to improved results by making passive flexion easier to
4 weeks. These programs involved protecting the tendon attain. Other authors10 have recommended incorporat-
repair by placing it on slack in a dorsal protective splint ing only the involved finger in traction. Some practitio-
in some degree of wrist and MCP joint flexion as ners apply traction to only the involved finger(s) for
described above. For both programs, elastic traction flexor digitorum profundus (FDP) repairs, in order to
held the fingers in flexion. Therapy consisted of passive facilitate inadvertent “cheating” with active motion of
flexion and either active or passive extension, to provide the uninvolved providing limited active motion of the
passive tendon gliding of the flexor tendon with minimal involved finger(s).
stress to the repair. To provide greater passive excursion of the FDP
Kleinert’s technique, designed for zone 2 and which through flexion of the distal interphalangeal (DIP)
he also advocated for zone 1, involved hourly active joint, a palmar pulley can be added to redirect the
extension against dynamic traction, followed by relax- line of traction to the distal palmar crease (Figure
ation of the finger and passive flexion by means of the 38-2).10,12,13 To mobilize the flexor pollicis longus (FPL),
elastic traction, premised on the theory that the flexors the thumb MCP joint is immobilized and the IP joint
would relax with resisted extension. However, later must be passively flexed, with active or passive exten-
research8,9 has shown that the desired relaxation of the sion (Figure 38-3).14
flexors does not occur consistently. Duran’s approach7 involved less frequent mobiliza-
Over the years various authors have proposed modi- tion entirely through passive flexion and extension. His
fications of the Kleinert approach. To prevent or mini- exercises were designed to provide passive excursion of
mize the risk of proximal interphalangeal (PIP) joint the repair relative to surrounding tissues and differen-
flexion contractures, elastic resistance to extension tial glide between the FDP and flexor digitorum super
can be decreased by manually releasing rubber band ficialis (FDS) in zones 2 and 3. In 1980 Strickland and
traction during active extension or by using a lighter Glogovac15 published a study showing improved results
rubber band for exercises as in the Washington regimen in zone 2 repairs mobilized passively compared with
Chapter 38: State of the Art Flexor Tendon Rehabilitation 407
authors have looked at the stresses placed on the tendon

and the amount of excursion attained with SWM.9,17,18
Amadio and Tanaka19,20 have proposed a further modi-
fication on a passive SWM exercise. The wrist is in flexion
initially, with the fingers in extension, followed by
passive finger flexion, wrist extension and MCP joint
extension (holding the IP joints in flexion). The combi-
nation of wrist extension and MCP joint hyperextension
with the DIP and PIP joints fully flexed produces an
increase in flexor tendon tension. They hypothesize that
in vivo this small increase in tendon tension may
increase FDP excursion. An added benefit would be
control of any intrinsic muscle tightness developing in
response to blocking the MCP joints in flexion in the
splint.
Figure 38-2 A palmar pulley at the distal palmar crease EARLY ACTIVE MOBILIZATION
redirects the line of traction to attain DIP flexion and thus
attain greater excursion of FDP tendon. Although early passive mobilization produced improved
results,15 surgeons and therapists questioned whether
they could attain even better functional results with
techniques producing greater excursion of the repair
site. The model of passive excursion is logical and clearly
safe in theory, but in practice the repaired tendon and
adjacent tissues may be edematous, with added bulk
from sutures and related injuries. In those cases passive
flexion may simply fold the tendon or cause it to bunch
up due to the gliding resistance it encounters.
Once again, clinical development preceded support-
ing research: Surgeons and therapists began using con-
trolled active flexion to attempt to provide gentle
proximal tendon glide more effectively than was possi-
ble with passive flexion. As new suture techniques were
developed to provide improved strength and gliding
characteristics, therapists became more and more com-
fortable using active flexion for repair mobilization.
Figure 38-3 For FPL repairs, the MCP joint should be Hitchcock and colleagues21 showed that controlled
immobilized in extension for IP joint passive flexion (whether active mobilization actually increased the strength of
applied by elastic traction or manually). the repair in the first few postoperative days, in contrast
to the accepted dip in strength demonstrated in immo-
immobilized repairs. For that study they used a modi- bilized repairs.
fied version of the Duran approach, now known as Savage22 studied the effect of wrist position on active
modified Duran. They eliminated the rubber band trac- tension on the flexor tendon, or the force required to
tion, splinting fingers in IP joint extension between flex the interphalangeal joints against the passive resis-
exercises, modified the wrist flexion angle in the splint, tance of the extensors. He found that the smallest
and added composite passive flexion and active exten- amount of force was required with the wrist in 45° of
sion to the original exercises. Over the years the Strick- extension, and the greatest amount of force was required
land and Glogovac approach has been further modified when the wrist was in 45° of flexion. Since then, other
to include more frequent mobilization and other authors23-28 have explored this problem in greater depth,
variations. taking into account the total force exerted by the repaired
A study by Cooney and colleagues16 found that incor- tendon, due to edema, joint stiffness, and the gliding
porating synergistic wrist motion (SWM) would increase resistance at the tendon–pulley interface. In practice,
passive flexor tendon excursion in zones 2, 3, and 5: therapists must deal with the total work of flexion with
extending the wrist assists passive digit flexion via teno- all of its components.
desis, while wrist flexion during digit extension uses Savage’s work22 supported the concept of either posi-
tenodesis to decrease stress on the repaired flexor(s) and tioning the wrist in extension during flexor mobiliza-
allows greater digit extension. Since then a number of tion or incorporating synergistic wrist motion with
Figure 38-4 The patient extends the wrist actively with

simultaneous passive digit flexion. (Modified from Cannon N: Figure 38-5 The patient maintains digit flexion with a
Post flexor tendon repair motion protocol, Indiana Hand gentle active muscle contraction. (Modified from Cannon N:
Center Newsletter 1:13-18, 1993.) Post flexor tendon repair motion protocol, Indiana Hand
Center Newsletter 1:13-18, 1993.)
finger flexion and extension. As a result, early mobiliza-
tion programs were adapted to bring the wrist into less
flexion, and in some cases, into extension. More recently
a study by Kursa and his colleagues9 provided additional
evidence, at least for FDS, for which greater forces were
recorded with finger flexion and extension when the
wrist was at 30° of flexion.
Active mobilization programs can be divided into
three basic approaches: active,29-32 assisted active,33 and
place-hold (active-hold).34-36 The first two programs are
self-explanatory. In place-hold programs the involved
fingers are placed in flexion and the patient holds the
position with a gentle muscle contraction. Assisted
active and place-hold flexion exercises are designed to
decrease the work of flexion by overcoming passive Figure 38-6 The wrist is allowed to relax into flexion
resistance manually. All of these approaches assume with simultaneous digit extension (limited to 60° at the
metacarpophalangeal joints). (Modified from Cannon N: Post
that the tendon will be protected through splint posi-
flexor tendon repair motion protocol, Indiana Hand Center
tion, and that work of flexion will be reduced through
Newsletter 1:13-18, 1993.)
edema control and passive exercises performed prior
to active flexion. Most published programs include a
dorsal protective splint with the MCP joints in some weeks. Some of the interventions used by experienced
degree of flexion, IP joints allowed to extend to 0° and clinicians (functional activities, blocking exercises,
the wrist in slight flexion, neutral or slight extension to splinting to address joint and tendon tightness) were
decrease the work of flexion.29,32,33,35,36 One published introduced later than either of these authors would have
program, the Indianapolis program,34 adds an exercise expected. An experienced clinician progresses the
splint with a hinged wrist, allowing wrist extension to program according to evaluation of tendon function:
30°, to incorporate SWM and thus both increase excur- e.g., slowing down the progression if tendon excursion
sion and decrease work of flexion (Figures 38-4 to is returning rapidly and treating more aggressively in
38-6). Although the authors do not state that the the presence of severe adhesions. Although it may be
program is for zone 2 repairs, the program is based on that the therapists overseeing the passive mobilization
the issues of excursion and work of flexion crucial to program took some liberties with the stated timetable,
rehabilitation of zone 2 injuries. the article does not say so, leaving the impression that
A recent study3 showed clearly superior results in all of the passively mobilized tendons were moved with
zone 2 flexor tendon repairs treated with active versus similar caution. If that is the case, then these patients
passive mobilization. The authors used a hinged-wrist might have achieved better results if treated according
splint program for active mobilization and a modified to current best practice in passive mobilization. This
Kleinert program for passive mobilization. The passive diminishes the implications of the study, but not the
mobilization program was conservative, starting active importance of its publication.
flexion using place-hold with the wrist at neutral (within In choosing an appropriate early active mobilization
the splint), and delaying true active flexion until 6 technique, there are several factors to consider: patient
selection, ways to control force of contraction (primarily

through wrist and digital position), timing of initiating
motion,24,25,28,37 and methods of reducing work of flexion
prior to exercise.
PATIENT SELECTION
Patient characteristics are difficult or impossible to
control, and should dictate the choice of program.
Therefore it is crucial to choose an approach that fits the
patient, rather than imposing unrealistic expectations
on a patient incapable of performing a complex
program. Recent research has found that a high percent-
age of patients are noncompliant with their home reha-
bilitation programs.38,39 In fact, in one study 67% of
patients with flexor tendon repairs removed the splint
against therapist instruction.39 The most common
Figure 38-7 If the patient flexes to touch the second
reason given was hand washing: an all-too-familiar finger with the first finger out of the way, the patient will
story to an experienced hand therapist! automatically tend to flex the PIP and MCP joints instead of
CONTROLLING FLEXION FORCE the DIP and PIP joints.
There are a number of different ways to ensure that the

patient exerts the minimal flexion force needed to flexion (place-hold) with “minimal active muscle
achieve sufficient tendon excursion. Studies have shown tension” (MAMT) through partial digital flexion and
that placing the wrist in flexion increases the force slight wrist extension.
required to flex the fingers.9,22 Placing the wrist in neutral Another convenient way to gradually increase the
or extension reduces the force required to flex the fingers. amount of flexion over the first 4 weeks was proposed
Incorporating synergistic wrist extension with finger by Sheila Harris (personal communication, 2010). The
flexion favors proximal gliding of the flexor tendons and patient is asked to place the four fingers of the uninjured
decreases the force required to flex the fingers. Forces hand in the palm of the injured hand with the little
transmitted through the flexor tendons increase with finger resting at the distal palmar crease and the fingers
increasing active flexion of the fingers and wrist.9 To perpendicular to the plane of the palm. In the first week
determine the optimum splint position (or to choose the patient flexes to touch the index finger. In the second
whether or not to use an SWM program), the therapist week the patient is asked to move away the index and
must consider zone and type of injury. For example, try to touch the middle finger (Figure 38-7). In the third
placing the wrist in slight extension benefits gliding of and fourth week the patient is asked to flex to touch the
the tendon repaired in zone 2 in the digits and reduces ring and small finger respectively in the same way. A
the forces applied to the tendon during active finger useful modification was added by van Strien in order to
flexion. Nevertheless, some wrist flexion or a more add more DIP joint flexion. By leaving the four fingers
limited range of wrist synergistic motion should be of the uninjured hand in place and sliding the fingertip
chosen to protect multiple nerve and tendon repairs in across the dorsum of the fingers to reach the next finger
zone 5, avoiding nerve compression by limiting degree more DIP joint flexion is achieved (Figure 38-8). Not
of wrist flexion, and limiting passive traction on nerve only does this method gradually increase the force
and tendon repairs by limiting degree of synergistic exerted through the tendon, but with the modification
wrist extension. A lesser degree of MCP joint flexion in it also encourages the patient to flex both the PIP and
the splint is appropriate in zone 2 and 3 injuries to the DIP joints, thus theoretically achieving greater FDP
avoid development of intrinsic muscle tightness in con- excursion and differential FDP/FDS glide.
junction with adhesion formation. Place-hold (active-hold) flexion may decrease the
Some authors recommend gradually increasing the force of muscle contraction, but only if the fingers are
IP joint flexion demands over time. The Belfast proto- partially flexed (as noted earlier), or if the wrist is syner-
col29,32 for zone 2 repairs sets increasing range of flexion gistally extended to assist passive proximal excursion. If
goals from week to week. Evans and Thompson35 used the fingertips are flexed to the DPC passively before con-
a biomechanical model to calculate the force placed on tracting the flexors to hold the position, there is a risk of
flexor tendon repairs at various points in the range of increasing the stress to the tendon if the passive flexion
flexion and concluded that a partial fist places consider- produced only buckling or folding of the tendon (which
ably less stress on the repair than does a full fist. On this must now be unfolded, requiring a theoretically greater
basis they proposed a program designed to elicit active amount of force than would be required for unassisted
edema cannot be adequately controlled, there is a higher

risk of rupture.
FUNDAMENTAL CONCEPTS AND TECHNIQUES
OF EVALUATION AND TREATMENT
Choosing the most appropriate rehabilitation approach
requires an understanding of all the factors affecting
tendon healing and recovery of function. The mecha-
nism of injury will affect both surgical and therapy deci-
sions. A crush injury, for example, has a higher risk of
formation of restrictive adhesions, whereas a clean lac-
eration may be more easily repaired and may recover
function more easily. The effect of the level of injury is
discussed in Chapter 39.
The therapist must know what kind of repair was
performed. Despite all the recent evidence cited in pre-
Figure 38-8 With the first finger kept in place, the patient
is encouraged to slide the fingertip down to the second vious chapters supporting the use of four-strand core
finger, thereby using DIP and PIP joint flexion rather than sutures and strong peripheral sutures for early active
just PIP and MCP joint flexion. flexion programs, many surgeons use a two-strand
Kessler and a simple running peripheral suture. In a
2006 survey of members of the Irish Hand Surgery
active flexion). We propose that assisted active flexion is Society, Healy and colleagues40 found that a clear major-
a safer way to decrease force of contraction. ity preferred the latter to the former. In addition to the
Before active flexion exercises, work of flexion must type of repair, the therapist should be informed of any
be minimized by decreasing the resistance to passive intraoperative findings that may influence clinical deci-
flexion, not only through positioning to minimize resis- sions, such as concomitant injuries, repairs performed
tance from the extensors but also through reducing under tension, pulley resection, venting or repair, or
resistance caused by edema and passively ranging the other repair characteristics that may affect gliding or
finger joints to reduce stiffness. Cao and Tang24 found strength of the repair. Gliding resistance from surround-
that six cycles of digit motion in a chicken model sig- ing tissues is not the only reason why active or passive
nificantly decreased work of flexion. flexion may be difficult to attain. Postoperative edema
and joint stiffness in particular pose resistance to
INITIATING ACTIVE MOBILIZATION
motion, increasing the risk of rupture or repair deforma-
Determining the best time to initiate active mobilization as well as decreasing repair mobility.
tion is difficult, due to both conflicting evidence in the Amadio19 has proposed the concept of a safe zone,
literature24,25,27,28 and variability of patient healing char- which allows the therapist and surgeon to make deci-
acteristics. It is widely accepted that active mobilization sions about mobilizing tendons based on the various
is both safe and effective only if started within the first factors increasing work of flexion (Figures 38-9 and
postoperative week. In a recent study in a chicken 38-10). For example, if the repair is strong but bulky, it
model, Tang and colleagues24 divided the early postop- will withstand the stress of active motion but will glide
erative phase into three stages: days 0 to 3, increasing poorly, and may even “catch” on surrounding tissues,
resistance due to postoperative inflammatory edema; thereby exceeding its resistance to rupture. This would
days 4 to 7, further increase in resistance from edema; lower the upper limit of the safe zone and could pre-
and after days 7 to 9, hardening of the subcutaneous clude active motion. Likewise, if edema and joint stiff-
tissue with development of adhesions. On the basis of ness are not well controlled, the passive resistance to
this and other studies,25,27,28,37 it is reasonable to assume flexion increases, and again may preclude safe active
that in an otherwise appropriate patient, active flexion mobilization. Recent work of Cao and colleagues and
may begin at 3 to 4 days, if edema and wound healing Tang and colleagues has demonstrated increased tendon
appear well under control. repair strength and decreased gliding resistance with
All of these studies further underline the importance partial excision of the A2 pulley,41,42 which suggests that
of controlling edema in order to decrease work of flexion venting pulleys may further widen the “safe zone” as
in the crucial early days. A patient with an unusually described by Amadio.19
edematous finger or other complications of healing Such factors make it imperative that the therapist
presents a dilemma: If motion is delayed for too long, gather all pertinent information through clear commu-
adhesions will have formed and subcutaneous tissue nication with the referring surgeon. Ideally, all hand
will have hardened, but if motion begins early and therapists should receive a copy of the operative report
Table 38-1 Assessment of Adhesions Based on

Strong grip
Clinical Findings (Modified Based on Groth)
Max strength in vitro
40 Adhesions* Clinical Findings†
Light grip Absent Tendons glide well; <5° discrepancy
Max strength in vivo between total active and passive
30
digital flexion.
Force (N)
Responsive ≥10% decrease in active motion lag

2 mm gap
20 is observed between one session and
Light active the next‡
Initial gap Unresponsive <10% decrease in active motion lag
10
Synergistic is observed between one session and
Safe zone
5
In vivo friction the next‡
Repair friction
Normal friction Passive motion *When adhesions are considered absent or responsive, the therapy
0.2 program does not need upgrading. When adhesions are
unresponsive, the therapist should consider upgrading the
Figure 38-9 Small safe zone for a four-strand repair with program.
40 N breaking strength. (Modified from Amadio PC: Friction †
Clinical findings were reworded from the Groth’s description for
of the gliding surface. Implications for tendon surgery and clarity based on the clinical judgment of the present authors.
rehabilitation, J Hand Ther 18:112-129, 2005.) ‡
Because frequency of therapy appointments varies according to
many factors, therapists should apply the definition of “responsive”
or “unresponsive” with due consideration to the number of days
between sessions.
Max strength
in vitro
40
Max strength response to intervention as absent, responsive, and unre-

at 1 week in vivo sponsive and suggested clinical observations that may
30
help assess adhesion severity. This classification is
Force (N)
further clarified and presented in Table 38-1. Groth’s

2 mm gap system helps the therapist decide how to advance up the
20 Improve strength:
Faster healing
proposed pyramid of force progression (graded passive
Stronger repairs and active mobilization) safely and effectively (Figure
Initial gap 38-11).43 As published the pyramid does not address the
10
Reduce friction:
progression of synergistic wrist motion programs; at the
In vivo repair Annual Meeting of the American Society of Hand Thera-
5 Lubricants
In vitro repair Smoother repairs pists in Boston in 2008, von der Heyde proposed a
Normal friction
0.2 modification of the pyramid that incorporates wrist
motion during the early weeks of therapy and proposes
Figure 38-10 Larger safe zone with increased suture repair progression to straight fist (DIP joints in extension as
strength and faster healing, and reduced friction through the MCP joints and PIP joints flex) and hook fist (MCP
use of lubricants and repairs with smooth gliding surfaces.
joints in extension, IP joints flexed) before full fist to
(Modified from Amadio PC: Friction of the gliding surface.
decrease work of flexion in the early postoperative
Implications for tendon surgery and rehabilitation, J Hand
Ther 18:112-129, 2005.) period.
Coert and colleagues44 used positron emission tomog-
raphy (PET) imaging to determine cortical activity fol-
as well as discussing with the surgeon any unusual lowing 6 weeks of passive mobilization of a repaired
aspects of history, injury, and repair. flexor tendon. In these patients changes in cortical func-
Observation and palpation are key skills for identify- tion were evident, showing inefficient motor control
ing edema, joint stiffness, and wound complications apparently due to deprivation of sensorimotor input.
that could influence treatment planning. Edema and Once active flexion was initiated, cortical function grad-
range of motion should be measured objectively as dic- ually returned to normal, reflecting more efficient motor
tated by the characteristics of the injury and repair, and control. The authors suggest that this inefficiency might
the therapist must repeat measurement periodically to be avoided with active mobilization or use of other
assess the effectiveness of treatment and to determine techniques such as mirror therapy (with active flexion
how best to advance or modify the program. Groth43 of the contralateral hand) combined with passive mobi-
proposed a classification of adhesion severity and lization during the first 6 postoperative weeks.
Resistive
isolated W
ris
joint motion tu
np
ro
Resistive hook and te
cte
straight fist d
Resistive composite fist

W
ris
Discontinuation of protective splint tp
ro
te
cte
d
Isolated joint motion
Hook and straight fist
Active composite fist
Place and hold
Passive protected extension
Pyramid of progressive force application
Figure 38-11 Progressive application of force to the repaired intrasynovial flexor tendon. (Modified from Groth G: Pyramid of
progressive force exercises to the injured flexor tendon, J Hand Ther 17:31-42, 2004.)
Many patients have a tendency to co-contract intrin- and basic science regarding the thermal and nonthermal
sic or extrinsic extensor muscles in their first attempts at effects of ultrasound.
active flexion. This can be very frustrating for the patient For that matter, there is insufficient evidence support-
and increases the difficulty of attaining flexor tendon ing use of any one tendon rehabilitation protocol over
excursion. One way to overcome the problem is to others.2 With the exception of the Evans protocol for
incorporate purposeful, goal-oriented activities, which zone 1 repairs, the published protocols either are
elicit more fluid and less effortful motion than do exer- intended for zone 2 repairs or do not specify the zone.
cises.45,46 For example, when asked to bend the tip of the The therapist must choose and adapt as needed the
thumb following FPL repair, a patient may tend to program most appropriate to the patient. This may be
co-contract or use excessive force. When asked to encir- dependent on many variables, not the least of which is
cle a dowel with thumb and index finger, the same cultural variation and differences in health care system
patient, focusing on the task rather than the motion, from one country to another. For example, some pub-
may easily and fluidly incorporate all involved muscles lished active mobilization protocols require closer mon-
in a functional tip pinch position including thumb IP itoring than others (some including postoperative
joint flexion. Once this position has been attained, the hospitalization), and may be feasible only within a
patient can be asked to gently scratch the tip of the index health care system that pays for frequent therapy or
with the thumb fingernail, thus eliciting greater IP joint postoperative hospitalization. Those protocols should
flexion. Some patients benefit from performing the be adapted if used with a different patient population
same task first with the uninvolved hand or perhaps or within a different health care system.
simultaneously with both hands. In comparing publications on surgical techniques
and rehabilitation programs, the reader must be alert to
QUESTIONS AND ISSUES
the different systems that can be used to assess clinical
There are many exercises, activities, splints, and adjunc- outcomes of flexor tendon repair. The most commonly
tive modalities commonly used and anecdotally suc- accepted and most logical is the modified Strickland
cessful. However, there is a dearth of evidence supporting formula, in which the total active motion (TAM) of the
most of these techniques. For example, many therapists involved digit (excluding MCP joint motion, which may
routinely use ultrasound to aid recovery of tendon glide, be within normal limits even with severely adherent
but this is supported only by extrapolation of theory repairs) is expressed as a percentage of normal. To
specifically evaluate FDP tendon function, DIP joint falling into disfavor, both because the rationale for its
flexion must be given greater weight, as suggested by use is in question and because it increases the risk of
Moieman.47 None of the existing clinical outcomes PIP joint flexion contractures. Early active flexion is
methods takes into account the position of the wrist proving to be the most effective approach, with mobi-
during measurement of finger flexion. Outcomes assess- lization starting within the first postoperative week. The
ments based on range of motion alone do not take into safety of active flexion is contingent on controlling
account all of the factors (such as coordination, quad- edema and other elements that pose resistance to tendon
riga effect, individual digit differences, and patient per- glide and thus dramatically increase the work of flexion.
ception of function) that determine success. Existing Safety is also dependent on very gradually increasing the
functional outcomes instruments such as the Disability motion demanded of the finger as tissue healing and
of the Arm, Shoulder, and Hand (DASH) questionnaire gliding resistance dictate. We can augment excursion
are not specific enough to be of much value in evalua- further by incorporating synergistic wrist motion and
tion of flexor tendon repairs. other specific maneuvers such as passive MCP joint
extension. The successful flexor tendon repair depends
not only on surgical and therapeutic expertise, but also
SUMMARY
on patient selection, ample communication between
Several distinct trends are apparent in current postop- surgeon and therapist, and careful and continual reas-
erative management of the repaired flexor tendon. sessment of tendon function to determine when and
Dynamic traction into flexion (Kleinert technique) is how to progress the rehabilitation program.
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CHAPTER
39
CUSTOMIZING FLEXOR
REHABILITATION BASED ON
ZONE OR TYPE OF INJURY
Fiona H. Peck, MCSP
OUTLINE these injuries require not only specialized knowledge in

the field but also the ability to use advanced clinical
This chapter details the information that must be reasoning skills to select appropriate postoperative exer-
assimilated before selecting an appropriate rehabilita- cise programmes.3 Early active motion in different forms,
tion regimen for flexor tendon repairs at all areas. The used in conjunction with multistrand repair techniques,
postoperative management of these injuries depends has gained increasing popularity but application must
primarily on the extent of the injury, concomitant depend on consideration of a number of variables.1-3
damage to surrounding tissues, surgical methods, and The aim of this chapter is to examine the implications
other factors. The type of tendon injury, timing and of these variables on regimen selection and assist the
strength of the repair, and the age and characteristics therapist with the provision of evidence-based practice
of the patient all affect the details of the regimen. following primary flexor tendon repair at all levels.
Within each zone of injury, a number of anatomical
and biomechanical factors need to be considered in
CUSTOMIZING A REGIMEN
the decision making process. In the absence of a defin-
itive evidence-based method of rehabilitation after Specialized hand therapy clinics with easy access to
flexor tendon repairs, the surgeon and the therapist expert medical and nursing staff provide the best envi-
together must customize the rehabilitation regimen ronment for the treatment of these injuries. Therapists
according to varying patient and surgical factors in with the responsibility for the selection of rehabilitation
order to achieve favorable outcomes. The chapter also programs must be well informed with regard to a variety
describes the different types of regimen available, of different factors. There should be a good working
detailing timing of motion, splintage, and the treat- relationship and excellent communication between the
ment of associated complications. surgeon and the therapist. Access to accurate medical
records is also vital to the process and clear recording
In recent years a significant amount of research in the of operative details will provide the therapist with the
field of flexor tendon treatment has contributed to relevant information.
advances in both surgical and rehabilitation tech-
niques.1,2 There is an overwhelming amount of evidence EXTENT OF INJURY
to show that carefully devised rehabilitation programs
are critical to achieving favorable outcomes following Mechanism of Injury
primary flexor tendon repair in the digits, but very little The mechanism of injury can impact on the outcome of
attention has been given to other zones of injury in the tendon repairs. Clean cut injuries with the finger in
hand and forearm. Whatever the level of injury, the extension require less extensive surgical exposure and
ultimate goal of both the surgeon and the therapist is the tendon can be easily retrieved and repaired with
to minimize or modify peritendinous adhesions and minimal interference with the surrounding tissues or
promote optimal tendon glide. At the same time the loss of tendon length. In uncomplicated tendon injuries
tendon repair must be protected from excessive stress to and in the presence of a strong multistrand repair, the
avoid gapping or rupture at the repair site. therapist can be more confident in selecting an active
Although early mobilization of primary flexor tendon protocol. Ragged saw or crushing injuries involving
repairs is now accepted practice, there is no one defini- bone, joint, and neurovascular structures can be very
tive rehabilitation regimen guaranteed to restore a full different and result in significant postrepair edema and
range of active digital motion. Therapists dealing with adhesion formation.
415
Number and Type of Structures Damaged

Although single-digit injuries are common, the therapist
is often presented with more complex injuries. In the
presence of multidigit injuries, each digit may require
an individual exercise scheme according to the nature
of the injury. Controlled active motion regimens will be
unsuitable for severely injured digits and will therefore
restrict the use of this form of rehabilitation in adjacent
digits that are damaged to a lesser degree. After replanta-
tion surgery, there is a requirement to balance the needs
of both the flexor and extensor tendons. It is necessary
to adopt a regimen which safeguards the most vulner-
able structures.
Injuries to the Skin

The nature of the skin wounds affects the decision
making during rehabilitation. Untidy wounds, includ-
ing a crushing element, will impact the final outcome
and the therapist must prioritize the prevention of joint
and scar contracture. The therapist should differentiate
between incisions made during the surgery and those
that are part of the original injury. Carefully designed
surgical incisions made to access the tendon for explora-
tion and repair of the tendon and other structures will
minimize postoperative contracture. Random longitudi-
Figure 39-1 Wound dressings must be kept to a minimum
nal wounds which cross the metacarpophalangeal and should not impede active motion following digital flexor
(MCP) and the interphalangeal (IP) joints may cause tendon repairs.
joint contracture.4 When the surgical incision is made
across these joints, active digital extension exercises and
prophylactic splinting should be incorporated into the
regimen to prevent loss of full joint extension.2-4 Injuries to Bone and Joint
In more severe soft tissue injuries, the presence of Concomitant injuries to bone impact postoperative
skin grafts or flaps necessary for wound closure delays management as the timing and type of exercises chosen
the start of postoperative mobilization until vascularity can be limited by the presence and characteristics of the
is ensured. In digital-level injuries, care must be taken bony injury and the stability of fracture fixation. Primary
not to impede joint motion or increase resistance to tendon repair is contraindicated in the presence of
tendon glide by the use of restrictive dressing. Dressings complex unstable or intra-articular fractures.2 In the case
should be shaped to reduce the resistance over the IP of stable, undisplaced fractures in the hand or digits, it
joints and should cover the wound area only, avoiding is possible to initiate an early motion regimen, provid-
the use of circumferential adhesive tape (Figure 39-1). ing supplementary splinting support for the fracture
Postoperative complications such as infection, heavily while at rest and additional manual support when per-
exuding wounds or skin loss may require more substan- forming exercises. Rigid fixation of fractures of the pha-
tive dressings, which will result in delays in initiating langes or metacarpals usually provides sufficient stability
active motion. In cases where there is infection involv- to permit the early passive and active motion following
ing the tendon sheath, all motion should be delayed discussion with the surgeon regarding safety. Injuries to
until the infection is treated. Where the status of the more than one digit presenting with different patterns
wound has the potential to impede active motion, for of injury in each require individual exercise plans for
example, in large open wounds with extensive edema, each digit. Care must be taken, however, initiating an
mobilization must be confined to gentle passive exer- active motion protocol in complex injuries to the
cises to preserve tendon glide and minimize stress on middle, ring, and little fingers due to the quadriga effect
the repair until the restrictive swelling has reduced. In of the conjoined flexor digitorum profundus (FDP)
the presence of heavily exuding wounds, dressings tendons. The most severely injured digit will dictate the
should be removed on attendance for hand therapy, and mobilization program and the therapist must devise
provided there is minimal edema, a controlled active an exercise regimen that most effectively preserves the
motion regimen may be initiated even in the presence tendon glide for each digit without placing excessive
of skin loss. stress on the repairs. This will be a combination of
Chapter 39: Customizing Flexor Rehabilitation Based on Zone or Type of Injury 417
passive only exercises for the more seriously injured

digits and careful active for those able to withstand
greater stress. In the presence of joint stiffness, restora-
tion of passive motion of the joint is imperative. Deep
lacerations to the digits may damage the palmar plate
or capsule of the IP joints, resulting in flexion contrac-
ture of the joints. Prophylactic extension splinting is
indicated to prevent the contracture from the early
stages of rehabilitation.
Injuries to Nerve
When nerves are repaired under tension, full range of
digital extension should be restricted in the early stages.
Major nerve injury at the wrist level is common, and
affects the details of the rehabilitation regimen. Con-
comitant median and ulnar nerve injuries at the wrist
or forearm levels, whether complete or partial, result in
some degree of intrinsic muscle paralysis and conse-
quent impairment of active digital motion. Under this
circumstance, special attention must be given to joint
positioning within the protective splint to optimize
tendon motion. Increased tendon excursion is facili-
tated if the MCP joints are positioned in 60° to 70° Figure 39-2 Following a strong multistrand repair of the
flexion with the wrist in neutral. Loss of sensation and flexor pollicis longus tendon active motion should be
cortical representation impacts the quality of motion isolated to the IP joint to preserve tendon glide.
during the early rehabilitation phase and delays func-
tional recovery.
Vascularity of Injured Structures Flexor Pollicis Longus (FPL) Injury

Injuries requiring revascularization (e.g., digital replan- The postoperative care of the repaired FPL tendon
tation) require careful management. Early mobilization requires special consideration. The FPL tendon appears
regimens should not be initiated until the viability of to have a greater tendency to rupture when active motion
the digit is established. Whether damage to the vincula regimens are applied following a two-strand core suture
affects adhesion formation remains uncertain.5 with simple peripheral stitches.8,9 Recent studies support
the use of active motion programs following a multi-
Triggering of the Repaired Tendon strand core, even without an epitendinous suture.10,11 If
Against the Pulley there is any doubt as to the ability of the repair to with-
Bulky tendon repairs may trigger and are prone to dis- stand active motion the therapist should use passive
ruption when gliding through annular pulleys.5,6 motion techniques. When using a controlled active
motion regimen, care must be taken to ensure that
TYPE OF TENDON INJURY movement is isolated to the IP joint (Figure 39-2). A
neutral position at the wrist benefits both flexion and
Complete or Partial Injuries extension at the IP joint. Positioning the wrist in exten-
Complete divisions of tendon require protected mobili- sion can impede active extension at the IP joint and
zation and a customized program of exercises with no place stress on the repair site.
functional activity of the hand for at least 6 weeks. Less
severe forms of the partial tendon injury (cut through OTHER FACTORS
less than 40% of the cross section) can be managed
conservatively without surgery. The patients should be Length of Time From Injury to Repair
permitted to move their injured fingers without restric- The therapist should have knowledge of the impact that
tions.7 Surgically repaired partial lacerations of the delayed repair may have on expectations and outcomes.
tendon (cut through greater than 40% of the cross Delaying the surgery for 7 to 10 days or more may result
section) are usually capable of withstanding the stresses in formation of adhesions and collapse of the sheath
of an active motion protocol and are less likely to rupture. and pulleys and the tendon becomes difficult to retrieve
The hand requires some form of dorsal splint protection because of muscle–tendon unit shortening. In these
but this may be removed as early as 3 to 4 weeks. cases, the repair may require increased postoperative
protection in a flexed position with serial extension as lead to poor outcomes are long travel distances to
appropriate. In the author’s own experience long delays therapy and long waiting times. Postoperative pain,
in repairing flexor tendons in zone 2 have been shown especially that which is neurogenic in origin, should be
to impact significantly on outcome leading to less favor- effectively controlled as this will significantly affect
able results than those that are repaired within the first compliance and behavior.20,21 Despite the best efforts,
48 hours. the therapist is often presented with patients who do
not or are unable to adhere strictly to the requirements
The Type and Quality of the Repair of the rehabilitation regimen for a variety of reasons. In
There has been a significant amount of research these situations a compromise must be reached to
devoted to improving the tensile strength of flexor prevent repair rupture while permitting the patient to
tendon repairs, permitting greater confidence in the continue with certain aspects of their daily life.
use of active mobilization regimens and resulting in
reduced rates of dehiscence.12-14 Although some have Age
demonstrated the successful application of active mobi- Both the very young and some elderly patients are not
lization regimen with two-strand repairs of varying tech- able to comply with treatment. A complex active motion
niques, others have reported unacceptably high rates of regimen is not suitable for elderly patients with dimin-
rupture.15-17 ished cognitive function or physical impairment. In
Before selecting an appropriate postoperative regimen these cases immobilization is the option of postopera-
the therapist should be acquainted with the caliber and tive care.
type of both core and circumferential suture in each The choice of immediate aftercare following tendon
particular case. Four- or six-strand core suture repairs repairs in children depends solely on the maturity of the
with 4-0 or 3-0 suture produce a repair strong enough child. The principles of postoperative management are
to accommodate early active motion of the repaired similar to those applied to adults but the ability to
digital flexor tendon. If the tensile strength of the repair comply with splinting and exercises must be carefully
is judged not to withstand the forces generated during considered. Older children and teenagers will be able to
active digital motion, alternative and safer methods of follow a specific regimen, but younger children may
maintaining tendon glide should be considered.18,19 inadvertently use the hand in functional activity and a
Venting the constrictive part of a major pulley (such as splint guard is thus required to deter use of the injured
the A2) will decrease the resistance to the tendon. hand (Figure 39-3). Although younger children may
Repairing the tendon just distal to the A2 pulley, without cooperate with a thermoplastic splint and a guard, they
venting the constrictive part of the pulley, may subject will require assistance with mobilizing exercises and the
the tendon to greater resistance during early active responsibility for this then falls to the carer. The selec-
tendon movement. Particular care should be taken tion of the type of exercises then depends on the capa-
when instructing the patient to move the tendons that bility of the carer and their ability to comply. Babies
are repaired just distal to the A2 pulley, as greater inci- and toddlers are at risk of dehiscence through falls and
dence of rupture of the primary repair is experienced in
this area.
Patient Characteristics and Compliance

The ability to comply with a rehabilitation regimen,
which involves commitment to a strict exercise program
within a protective splint for several weeks, vary among
individuals. Age, medical and mental health, and socio-
economic factors influence the choice of postoperative
management. Repairs are at risk of rupture if the patient
removes the splint for function and of poor gliding
action if they do not perform the required exercises.
Enhancing compliance requires a confident, knowledge-
able, and enthusiastic therapist who develops a good
working relationship with the patient. Good communi-
cation, the provision of high quality information, and
the enlistment of family support are also necessary. A
regimen that is versatile and tailored to suit the lifestyle, Figure 39-3 The addition of a guard to the protective
socioeconomic circumstances, and work commitments splint permits unimpeded active flexion and extension and
of the patient also promotes cooperation. Negative deters functional use of the hand in a child following
factors that are most likely to impact on compliance and reinsertion of the FDP tendon of the little finger.
Box 39-1 Zone 1 FDP Tendon Lacerations
Close to the Insertion (Zone 1A)*

 Requires reinsertion to the distal phalanx
 Risk of muscle-tendon unit shortening
 Risk of DIP joint flexion deformity
 Prioritize passive digital flexion
 Initiate careful active flexion from the DIP joint
 Kleinert regimen not appropriate
 In presence of delicate repair, Evans protocol affords
greater safety28
Distal to the A4 Pulley (Zone 1B)*

 Risk of snagging on the A4 pulley
 May include injury to the palmar plate
 Increased risk DIP joint fixed flexion deformity
 Emphasize active digital extension exercises
 Apply prophylactic digital extension splints
 Initiate careful active motion at the DIP joint to
ensure tendon glide through the pulley
Under the A4 Pulley (Zone 1C)*

 Difficult to repair
 Increased risk of tendon adherence
 Prioritize passive digital flexion
Figure 39-4 An occlusive boxing glove–type dressing will  Encourage careful active motion at the DIP joint to
protect tendon repairs in very young children and babies. ensure glide through the pulley
 Careful blocking of the PIP joint by the therapist will
facilitate this if necessary
 No blocking of the PIP joint by the patient to facili-
tate motion until after 6 weeks
functional activity and cannot follow mobilization regi-
*Subdivision of Moiemen and Elliot.
mens. For this reason the hand should be immobilized
in a substantial, occlusive dressing for a period of 4
weeks. An effective way to protect the tendon repairs is of zones 1 and 2, but there is very little to inform
the application of an above elbow plaster of Paris or evidence-based practice with regard of zones 3 to 5. The
resin cast. Nevertheless, both are prone to slippage and therapist has to rely on a combination of the available
may require removal under anesthesia in some children. evidence for digital injuries, clinical reasoning skills,
In our experience, a well-padded, occlusive, boxing and experience in dealing with zone 3 to 5 injuries.
glove–type dressing using generous amounts of adhe-
sive tape to prevent removal is equally effective (Figure Zone 1
39-4). This type of dressing can be easily reapplied in The postoperative regimen is dictated by the type and
an outpatient setting during the 4-week period of immo- anatomical location of the surgical repair. Within zone
bilization, permitting inspection of the wound and 1, the FDP tendon lacerations are subdivided into three
integrity of the repair along with passive exercises. The areas (Box 39-1)23:
paucity of literature on the subject leaves the therapist
with little guidance in this field. Much depends on the 1. Under A4 pulley—there is an increased likelihood
ability of the child to cooperate with a regimen likely of the formation of peritendinous adhesions if the
to provide the most optimal outcome. Immobilization repaired tendon does not move smoothly through
for 4 weeks in the very young child has no detrimental the A4 pulley. Each 10° of the distal interphalan-
effects on the result.22 geal (DIP) joint motion produces 1 to 2 mm of
tendon glide up to a total of 7 mm in the unin-
ZONE OF INJURY
jured finger.24 Following repair, edema and friction
Postoperative management should vary according to the to glide will reduce this excursion significantly and
zone of injury. Therapists must possess an intimate therefore exercises should focus on achieving
knowledge of the relevant anatomy and biomechanics active DIP joint motion where possible.25 Optimal
of each particular zone to customize the regimen accord- passive movement of the digit must be achieved
ingly. Particular attention has been given in the litera- before careful active flexion is initiated at the DIP
ture to both surgery and rehabilitation in tendon repairs joint (Figure 39-5).
Box 39-2 Closed FDP Avulsion Injuries

Active DIP joint flexion
Type 1—Tendon Retracted into Palm
 Muscle tendon unit may be shortened especially
after delay in treatment
 Loss of blood supply to the tendon
 Neutral position of wrist in protective splint
 Commence early action digital flexion initiated from
the DIP joint
 Prioritize active digital extension exercises
 Prioritize prevention of fixed flexion deformity at IP
joints
 Commence early passive finger extension stretching
Figure 39-5 Following repairs in zone 1 and zone 2 careful without tension on the repair
active digital motion should be initiated from the DIP joint  Remove protective splint and stretch IP joints into
to minimize stress on the repair site and promote differential extension with wrist and MCP joints in maximum
glide. flexion
 Use digital extension splinting at night and between
exercise periods
2. Distal to A4 pulley—Lacerations at the level of the
DIP joint may include concomitant damage to the Types II and III—Tendon Retracted to the PIP Joint
palmar plate resulting in increased potential for Level, With Small Bony Fragment (Type II) or
flexion contracture. Particular attention should be Remaining Distal to the A4 Pulley With Large Bony
given to active extension exercises and prophylac- Fragment (Type III)
tic extension splinting. At this level there is a risk  Less shortening of the muscle–tendon unit
that the tendon may snag on the distal edge of the  Delayed reinsertion has potential for favorable
A4 pulley, placing excessive stress on the repair site outcome

 Tendon retains good blood supply
and resulting in loss of DIP joint flexion. Close
 Wrist position in protective splint 10° to 30°
attention to the intraoperative details are required
extension
in defining rehabilitation parameters to minimize  Commence early action digital flexion initiated from
the risk of rupture while maximizing tendon the DIP joint
motion.  Prioritize active digital extension exercises
 Use prophylactic digital extension splinting at night
3. At the FDP tendon insertion—Tendon divisions at
close proximity to the FDP tendon insertion to prevent fixed flexion deformity
require reinsertion of the tendon to the distal
Rehabilitation Regimen for All 3 Types of Closed
phalanx. The consequences of surgery at this level FDP Tendon Avulsion Injuries
are some degree of tendon shortening and  Protective dorsal splint for 6 weeks
increased risk of DIP joint flexion deformity. Par-  Wrist position dependant on type of injuries
ticular attention should be paid to motion of the  MCP joints 30° flexion
DIP joint with emphasis on maintaining passive  Restore optimal passive digital flexion
flexion. Active flexion of the DIP joint is applied  Initiate early controlled active motion regimen
only following a strong repair which has no emphasizing DIP joint motion
reported impediment to gliding. The Kleinert-  Hourly exercises; 10 repetitions of digital flexion
 Encourage active digital extension exercises
type regimen, even with modification, is unsuit-
 Apply prophylactic digital extension splints
able because this regimen can not sufficiently
 Watch for complications arising from button reinser-
move the DIP joint.26 In the presence of a repair
tion technique—Infection, edema catching/breaking
which requires greater protection, the Evans proof exposed suture, and pain if this technique is used
tocol, using a dorsal block splint to restrict exten-  Excessive pain will impede compliance and motion
sion and limiting the arc of active motion to  Commence composite extension stretching at 6
between 45° and 75°, affords greater safety and weeks to treat muscle–tendon unit shortening
permits tendon glide of up to 3 mm in the early  Consider serial plaster of Paris casts at 6 weeks to
phase.27 treat residual IP joint flexion deformities (see Figure
39-6)
In closed avulsion injuries at the insertion of the FDP  Return to light function at 6 weeks and contact
tendon, selection of an appropriate rehabilitation sports at 12 weeks
regimen is decided by the type of the injury,30 as detailed
in Box 39-2. In all types of avulsion injury controlled
active motion is usually desirable.
the tendon suture through the nail and tying over a

button. Infection, edema, catching, and breaking of the
exposed suture and pain impeding motion are some
common problems. The source of pain should be inves-
tigated as persistent discomfort will deter compliance
with exercise regimen. The therapist should also be
careful to instruct the patient that the suture should
remain in situ for 6 weeks as early inadvertent removal
may result in separation of the reinserted tendon espe-
cially in the presence of an early motion regimen.
Zone 2
Rupture of the repairs, cross adherence, triggering, or
snagging of the repair on the A2 pulley and finger joint
contracture are common complications in this area. The
essential aim of rehabilitation is to restore sufficient
tendon gliding but avoid rupture of the repair during
tendon motion. Another objective is the preservation of
differential glide of the FDS and FDP tendons if both
tendons are repaired. The exercise program should be
designed to promote differential tendon movement
(Box 39-3). Once passive flexion is regained, active
Figure 39-6 Serial plaster of Paris casts may be applied to digital flexion exercises will promote optimal glide and
treat persistent fixed flexion deformities of the IP joints in prevent cross adherence (Figure 39-7).
the later stages of rehabilitation. If the surgical repair is judged strong enough, an
active motion program can be applied. The therapist
should have a clear knowledge of the resistance the
In type I injuries, a careful passive stretching element repaired tendon may encounter during early active
should be incorporated into the regimen taking care not finger motion. The presence of digital edema and posi-
to place any stress on the repair. To facilitate this, the tion of the MCP joint are important considerations. In
hand should be removed from the protective splint and an edematous finger, where there is resistance to active
all tension removed from the flexor tendon by position- motion and tendon glide, placing the MCP joints in
ing the wrist and MCP joints in maximum flexion while excessive flexion within the dorsal splint will bias active
carefully passively extending each IP joint individually. motion to the PIP joints and can impede the initiation
Provision of a palmar splint should be considered for of flexion from the DIP joint. Confining motion to the
use at night and between exercise periods and this may PIP joint only will encourage cross adherence, prevent-
be serially extended as rehabilitation progresses. At the ing differential glide. Therefore the patient should be
end of the protective phase residual flexion deformities encouraged to attempt active DIP joint flexion at the
or shortening may be addressed by progressive stretch- start of active finger flexion as in the early stages post
ing of the joints and composite stretching of the muscle repair they may be unable to perform this action in the
tendon unit with all joints in full extension. Despite inner range of motion30,31 Tang has demonstrated that
concerted effort flexion deformities may be a persistent the strength of the repair decreases as the angle of
problem and serial plaster casting should be considered tension increases and patients should therefore be dis-
as an early option (Figure 39-6).29 couraged from both performing composite flexion and
Type II and III injuries are less problematic as there using maximal effort to flex the DIP joints at the end of
is little or no retraction and shortening of the muscle– the range of flexion in the early postoperative stages.32
tendon unit. The surgical exposure required for reinser- If optimal DIP joint range of motion is to be encour-
tion necessitates a lesser incision and the tendon aged, active digital flexion should be initiated at this
maintains good condition via an intact blood supply. joint. This can be facilitated in most patients by posi-
Delayed reinsertion often produces favorable outcomes; tioning the wrist joint in 10° to 30°extension and the
however, there is still a tendency to develop flexion MCP joints in 30° of flexion.1,35
deformity especially at the DIP joint and the therapist Flexion contractures of the IP joints are a common
must work within the rehabilitation regimen to prevent complication and can occur even after simple clean
or correct this. The technique of insertion should not tendon injuries. Use of rubber band traction regimens
affect the choice of regimen but the therapist should be has been criticized for encouraging the development of
aware of potential complications in the case of stitching flexion contracture of the repaired fingers; thus, this
Box 39-3 Author’s Rehabilitation Regimens for Flexor Tendon Injuries Zones 2 to 5
Rehabilitation Regimens: Common to All Zones 2 to 5

 Protective dorsal splint for 6 weeks: joint positions may be changed within this period
 Prioritize restoration of passive digital flexion in all patients
 Initiate early controlled active motion regimen in cooperative patients if surgical repairs are robust and tendon gliding
resistance is judged not particularly high
 Promote differential glide if multiple tendons are repaired
 Encourage active digital extension exercises—vital to prevent extension deficits of joints
 Apply digital extension splints if there is early loss of active extension or significant joint injury
 Incorporate early active wrist motion as appropriate
 At 6 weeks commence stretching of residual flexion deformity in conjunction with serial splinting/casting
 Commence light functional activity at 6 weeks
 Return to normal activities at 10 to 12 weeks
Special Considerations
Zone 2
 Set wrist position at 10° to 30° extension and MCP joint at 30° flexion
 Commence early active motion regimen at 4 to 5 days if appropriate
 Restore optimal passive digital flexion prior to active motion. Passive digital flexion stretches repeated until free motion
achieved especially in an edematous finger
 Encourage hourly exercises—10 repetitions of active digital flexion. No forced active flexion. Slowly increase range of
flexion over the first 3 weeks
 Prevent cross adherence of FDP to FDS by encouraging exercises, which promote differential glide (see Figure 39-7)
 Do not initiate place and hold maneuver until full active tendon glide is ensured
 Permit early active wrist motion in trust worthy patients
 Ruptures of the repairs are most frequent when the repair sites are distal or under the A2 pulley (zones 2B and 2C).*
Majority of ruptures are in the first 1 or 2 weeks post surgery. Therapist and patient must take care to avoid repair
rupture during motion
Zone 3
 Wrist position 10° to 30° extension
 MCP joints position 30° flexion in absence of nerve injury and intrinsic damage
 MCP joints position 60° to 70° flexion with intrinsic muscle injury or denervation
 Beware risk of fixed flexion deformity at MCP joints due to palmar scar
Zones 4 and 5
 With major nerve injury: wrist position neutral for 2 weeks
 Position MCP joints at 60° to 70° flexion to prevent claw finger deformity and maximize tendon excursion
 Delay wrist motion for 2 weeks
 At 6 weeks begin composite extension by stretching and serial splinting
 Beware risk of and prevent development of intrinsic muscle tightness. Avoid prolonged splinting; use prophylactic
passive stretching techniques. Incorporate early sensory re-education to preserve cortical representation
*Subdivision by Tang.
method of rehabilitation has become less popular and Zone 3

some surgeons advocate that they should be abandoned There is little published information relating to zone 3
altogether.33 Effective means of maintaining digital rehabilitation and therapists have been obliged to adapt
extension should be incorporated from the early stages. those rehabilitation regimens designed for zone 2 inju-
There are various reported methods from thermoplastic ries. Anatomical differences and injury characteristics,
palmar splints to strapping the digits into extension at however, necessitate modification to splinting and exer-
night and between exercise periods.34-36 Flexion contrac- cise protocols. Lacerations in the mid-palm may include
ture at the IP joints prolongs the rehabilitation, and damage or denervation of the lumbrical and interosse-
more importantly, these contractures tend to be persis- ous muscles with resultant loss of function and scarring.
tent, and are a major cause of poor outcomes in zone 2 Tendons are likely to adhere to surrounding structures
tendon repair. They should be treated after 6 weeks by and the patient may experience difficulty in fully extend-
stretching and palmar based extension splinting at night ing the IP joints and may even develop flexion deformi-
(Figure 39-8). ties. Manual positioning of the MCP joints in greater
A B C D
Figure 39-7 To promote differential glide and prevent the development of fixed flexion deformity the components of an
active motion regimen should include four separate exercises. A, First, gentle active motion initiated at the DIP joint in a hook
type action. B, Second, active flexion at the PIP joints with the FDP tendons at rest. C, Third, once edema has subsided careful
composite flexion. D, In each exercise period, full active IP joint extension should be encouraged within the confines of the
splint.
Palmar extension splinting Palmar extension splinting joints should be positioned in 60° to 70° of flexion.
Care must be taken to ensure that an optimal range of
digital flexion can be achieved with the MCP joints in
this position to preserve tendon glide. Careful active
wrist motion with the digits in a relaxed semi flexed
position is permitted out of the splint in trustworthy
patients. Frequent monitoring of patients is required if
there has been intrinsic muscle damage or denervation.
This potent combination of flexor tendon and intrinsic
muscle injury can lead to claw deformity, which can
rapidly become fixed.
Flexion deformities of the MCP joints may also arise
as a result of palmar scar contracture but these are
usually easy to treat with serial extension splinting once
Zone 2 Zone 3 the dorsal protective splint has been removed (see
Tendon repair Tendon repair Figure 39-8).
Figure 39-8 Residual fixed flexion deformities and loss of Zone 4
composite extension should be treated with palmar based
serial extension splinting 6 weeks following repairs. Although tendon lacerations in this region are not
common, concomitant damage to the median nerve
and, less commonly, the ulnar nerve in Guyon’s canal
flexion may be necessary during exercise periods to will result in intrinsic muscle paralysis and loss of sen
facilitate IP joint extension and prevent the develop- sation. At this level, adhesions to the synovial sheath
ment of joint contractures. Edema of the digits is rarely and between the tendons in the restricted space under
a problem and free passive and active motion of both the retinaculum very quickly become established. The
the DIP and PIP joints should be encouraged. The wrist postoperative exercise regimen should promote the
should be positioned in 10° to 30° extension. If there maximum available tendon glide. An active motion
have been significant intrinsic muscle injuries, the MCP regimen is desirable, but the required amount of tendon
motion can be hard to achieve for a number of reasons. flexion should be emphasized to prevent the develop-
For example, wrist extension may increase tension on a ment of IP joint contracture, especially in the presence
median nerve repair. A neutral position or slight flexion of intrinsic muscle paralysis.
of the wrist is generally the best compromise. After 2 Active protocols are indicated as repairs are unlikely
weeks, the wrist can be gradually extended by altering to rupture. Exercises that focus on differential glide
the splint to promote greater tendon glide. should be incorporated to avoid adhesions between the
Loss of intrinsic muscle action and muscle–tendon tendons, although this may not affect the outcomes.37
unit shortening can result in a change in the resting Another commonly seen consequence is adhesions
position of the digits. To facilitate tendon motion, the between the skin and the tendons. These do not usually
MCP joints require positioning in a greater degree of restrict tendon glide but can be of cosmetic concern to
flexion than in digital injuries. Prior to application of the patient.
the protective splint active digital flexion should be The protective splint should be removed at 6 weeks
observed in varying positions of the MCP joints and the after surgery. At this stage common complications are
position from which the greatest tendon excursion can loss of composite extension and fixed flexion deformi-
be achieved selected. In patients with severe clawing of ties of the joints. Forearm based splints should be pro-
the digits, maintaining the MCP joint in 60° to 70° vided to achieve gradual restoration of extension. In the
flexion is recommended, to achieve active IP joint exten- presence of nerve injuries, anticlaw devices may be
sion and a greater range of IP joint flexion. Active digital required throughout the later stages of rehabilitation.
flexion and differential glide exercises should be encour- Sensory re-education techniques should also be
aged from the start of the rehabilitation. Active wrist incorporated into the rehabilitation regimen from the
extension exercises in conjunction with active digital start of treatment. These are designed to assist in the
flexion taking advantage of the tenodesis effect should preservation of cortical representation of the hand by
be initiated around 3 weeks, out of the splint in trust- modifying the functional reorganization, which will
worthy patients. inevitably occur within the somatosensory cortex.38
Zone 5 SELECTING A REGIMEN FOLLOWING

RE-REPAIR OF RUPTURES OF THE
Injuries at the level of the wrist and forearm may range
SURGICALLY REPAIRED FLEXOR TENDON
from an isolated tendon to a complex “spaghetti wrist”
involving neurovascular structures. In cases of injury to At any stage during rehabilitation the patient may
isolated wrist tendons, the dorsal protective splint report a loss of motion. This indicates rupture of the
should extend to the MCP joints only and the hand is surgically repaired tendon. The occurrence may vary
mobilized freely. The wrist should be positioned in from an obvious sudden event during exercise or
neutral or slight flexion depending on the tightness of unprotected use of the hand to a slower decrease in the
the repair and active wrist motion may commence at 3 amount of movement as a gapping repair slowly gives
weeks postoperatively. Patients can be permitted to way altogether. The exact cause or time of rupture can
perform light activity but should be deterred from be unclear and may even be masked in cases of infec-
strong gripping. When the injury involves multiple tion or significant edema. The rupture of the primarily
tendon and nerve injuries, the splint position should repaired flexor tendons in the hand can occur in a
be dictated by (1) protection of the repaired structures, period from several days to 6 weeks after surgery.15 The
(2) patient comfort, and (3) facilitation of active motion repaired tendon is at most risk of rupture during the
regimens. In the presence of nerve injuries the wrist first 2 weeks after repair with the second week being
should not be positioned in extension beyond neutral; the most dangerous. Diagnosis of a ruptured tendon is
minimal wrist flexion is more appropriate in the early made by examination of posture or manual tendon
postoperative period. The position of the wrist can be testing, but recent advances in the technique of diag-
gradually altered to achieve greater extension during the nostic ultrasound have made this process considerably
first few weeks of the protective phase usually to a more efficient. If a re-repair is to be undertaken, it is
maximum of 10° to 20°. Within the protective splint, vital that the surgeon, therapist, and patient are involved
the MCP joints should be positioned to facilitate digital in any decision making. These decisions must be based
flexion, inhibit the development of a claw deformity on the reason for the rupture, if known, and the likeli-
and allow maximal IP joint extension. As in zones 3 and hood of a favorable outcome of the re-repair. In 1982
4, 60° to 70° of MCP joint flexion is required depen- Leddy suggested that the best outcomes are likely if a
dent on the degree of clawing and the presence of a re-repair is undertaken soon after rupture and most
nerve injury. Digital edema is not usually present in the subsequent studies appear to support this although
early stages in injuries at this level and consequently careful consideration should be given to the little
there is no restriction to passive IP joint motion. Passive finger.39-41 Some patients choose not to opt for further
extension exercises with the MCP joints in maximal surgery because of inability to commit to an extended
period of rehabilitation. The therapist should be aware active motion or combined early passive-active motion
of the intraoperative findings of the re-repair before with resultant improvement in outcomes.1,2,8-11,17
embarking on rehabilitation, as the status of the
SUMMARY
re-repair should differ from that of the original. An
understanding of the mechanics of the rupture is neces- A skilled surgeon, experienced therapist, and compliant
sary whether due to technical failure or excessive force patient are desirable requirements but not a guarantee
placed on the repair. Tendon ends may have softened of an excellent result. Active motion regimens are best
necessitating careful handling and making re-repair dif- in all zones of injury as they provide the optimal require-
ficult to perform. The tendon may also be shortened ments for motion and tension following flexor tendon
due to excision of the previous repair site requiring repair. There are no standard protocols, however, and
careful postoperative positioning to ease the tension therapists managing these injuries must assimilate a
across the repair site. Following a re-repair the therapist considerable amount of information before selecting
should consider modifying the protocol and exercising the most appropriate treatment for each individual
caution in the use of active motion until safety is patient. The pursuit of optimal tendon glide must not
ensured. Generally, a lesser aggressive form of exercise take precedence over safety; however, there are a variety
is prescribed for the repair of the ruptured primary of alternative options available with the potential to
tendon repair. achieve favorable outcomes.
Over the past 20 years, the materials and methods
Acknowledgments
used in the postoperative management of flexor tendon
injuries have changed considerably. Although plaster of I would like to thank Professor Gus McGrouther and
Paris was originally used for the entire 6-week period of Mr. Stewart Watson, consultant hand surgeons at
protection, it is now used only in the immediate post- Wythenshawe Hospital, Burns and Plastic Surgery Unit,
operative period. It has been superseded by thermoplas- who read through my manuscript. The rehabilitation
tic material, which provides greater comfort and regimens described in this chapter are the result of expe-
longevity. In the late 1970s, when mobilization of flexor rience and close collaboration between the surgeons
tendon repairs became popular, the passive flexion regi- and the therapists in South Manchester. I would also
mens of Duran and Houser and Kleinert predomi- like to thank my specialist hand therapy colleagues
nated.18,19 Although these passive regimens still have Sarah Turner, Alison Roe, and Emma Kelly for their
their place, there has been a general transition to early contributions.
References
1. Elliot D: Primary flexor tendon repair-operative repair, pulley technique and controlled active mobilization, J Hand Surg
management and rehabilitation: invited personal review, (Eur) 34:758–761, 2009.
J Hand Surg (Br) 27:507–513, 2002. 11. Elliot D, Southgate CM: New concepts in managing the long
2. Tang JB: Indications, methods, postoperative motion and tendons of the thumb after primary repair, J Hand Ther
outcome evaluation of primary flexor tendon repairs in Zone 18:141–156, 2005.
2, J Hand Surg (Eur) 32:118–129, 2007. 12. Cao Y, Tang JB: Biomechanical evaluation of a four-strand
3. Pettengill KM: The evolution of early mobilization of the modification of the Tang method of tendon repair, J Hand
repaired flexor tendon, J Hand Ther 18:157–168, 2005. Surg (Br) 30:374–378, 2005.
4. Bruner JM: The zig-zag volar-digital incision for flexor-tendon 13. Dona E, Gianoutsos MP, Walsh WR: Optimizing biomechani-
surgery, Plast Reconstr Surg 40:571–574, 1967. cal performance of the 4-strand cruciate flexor tendon repair,
5. Lindsay WK, Thomson HG: Digital flexor tendons: an experi- J Hand Surg (Am) 29:571–580, 2004.
mental study. Part I: The significance of each component of 14. Birks M, Peck F, Lees V, et al: The influence of multistrand
the flexor mechanism in tendon healing, Br J Plast Surg repairs on the rupture rates of flexor tendon injuries in zone
12:289–316, 1960. II, BBSH Autumn Meeting 2008.
6. Tang JB, Wang YH, Gu YT, et al: Effect of pulley integrity on 15. Elliot D, Moiemen NS, Flemming AF, et al: The rupture
excursions and work of flexion in healing flexor tendons, rate of acute flexor tendon repairs mobilised by the con-
J Hand Surg (Am) 26:347–353, 2001. trolled active motion regimen, J Hand Surg (Br) 19:607–612,
7. Al-Qattan MM: Conservative management of zone II partial 1994.
flexor tendon lacerations greater than half the width of the 16. Peck FH, Bücher CA, Watson JS, et al: A comparative study of
tendon, J Hand Surg (Am) 25:1118–1121, 2000. two methods of controlled mobilization of flexor tendon
8. Sirotakova M, Elliot D: Early active mobilization of primary repairs in zone 2, J Hand Surg (Br) 23:41–45, 1998.
repairs of the flexor pollicis longus tendon, J Hand Surg (Br) 17. Silfverskiöld KL, May EJ: Flexor tendon repair in zone II with
9. Sirotakova M, Elliot D: Early active mobilization of primary combining passive and active flexion, J Hand Surg (Am)
repairs of the flexor pollicis longus tendon with two Kessler 19:53–60, 1994.
two strand core sutures and a strengthened circumferential 18. Duran RJ, Houser RG: Controlled passive motion following
suture, J Hand Surg (Br) 29:531–535, 2004. flexor tendon repair in zones 2 and 3. In AAOS Symposium
10. Giesen T, Sirotakova M, Copsey AJ, et al: Flexor pollicis on Tendon Surgery in the Hand, St Louis, 1975, Mosby,
longus primary repair: further experience with the Tang pp 105–114.
19. Lister GD, Kleinert HE, Kutz JE, et al: Primary flexor tendon 31. Cao Y, Tang JB: Resistance to motion of flexor tendons and
repair followed by immediate controlled mobilization, digital edema: An in vivo study in a chicken model, J Hand
J Hand Surg (Am) 2:441–451, 1977. Surg (Am) 31:1645–1651, 2006.
20. Dobbe JG, van Trommel NE, Ritt MJ: Patient compliance with 32. Tang JB, Xu Y, Wang B: Repair strength of tendons of varying
a rehabilitation program after flexor tendon repair in zone II gliding curvature: A study in a curvilinear model, J Hand Surg
of the hand, J Hand Ther 15:16–21, 2002. (Am) 28:243–249, 2003.
21. Sandford F, Barlow N, Lewis J: A study to examine patient 33. Tang JB: Clinical outcomes associated with flexor tendon
adherence to wearing 24-hour forearm thermoplastic splints repair, Hand Clin 21:199–210, 2005.
after tendon repairs, J Hand Ther 21:44–53, 2008. 34. Savage R: The influence of wrist position on the minimum
22. Elhassan B, Moran SL, Bravo C, et al: Factors that influence force required for active movement of the interphalangeal
the outcome of zone I and zone II flexor tendon repairs in joints, J Hand Surg (Br) 13:262–268 1988.
children, J Hand Surg (Am) 31:1661–1666, 2006. 35. May EJ, Silfverskiöld KL, Sollerman CJ: Controlled mobili
23. Moiemen NS, Elliot D: Primary flexor tendon repair in zone zation after flexor tendon repair in zone II: a prospective
1, J Hand Surg (Br) 25:78–84, 2000. comparison of three methods, J Hand Surg (Am) 17:942–952,
24. McGrouther DA, Ahmed MR: Flexor tendon excursions in “no 1992.
man’s land,” Hand 13:129–141, 1981. 36. Peck FH, Bucher CA, Watson SJ, et al: An audit of flexor
25. Silverskiöld KL, May EJ, Törnvall AH: Flexor digitorum pro- tendon injuries in zone II and its influence on management,
fundus tendon excursions during controlled motion after J Hand Ther 9:306–308, 1996.
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J Hand Surg (Am) 17:122–131, 1992. tendon repair in zone 5, J Hand Surg (Br) 23:642–648, 1998.
26. Slattery PG, McGrouther DA: A modified Kleinert controlled 38. Rosén B, Balkenius C, Lundborg G: Sensory re-education
mobilization splint following flexor tendon repair, J Hand today and tomorrow: A review of evolving concepts, Hand
Surg (Br) 9: 217–218, 1984. Ther 8:48–56, 2003.
27. Evans RB: Zone I flexor tendon rehabilitation with limited 39. Allen BN, Frykman GK, Unsell RS, et al: Ruptured flexor
extension and active flexion, J Hand Ther 18:128–140, 2005. tendon tenorraphies in zone II: Repair and rehabilitation,
28. Leddy JP, Packer JW: Avulsion of the profundus tendon inser- J Hand Surg (Am) 12:18–21, 1987.
tion in athletes, J Hand Surg (Am) 2:66–69, 1977. 40. Leddy JP: Flexor tendons–acute injuries. In Green DP,
29. Colditz JC: Plaster of Paris: the forgotten hand splinting editor: Operative Hand Surgery, New York, 1982, Churchill
material, J Hand Ther 15:144–157, 2002. Livingstone, pp 1347–1350.
30. Cao Y, Tang JB: Investigation of resistance of digital subcuta- 41. Dowd MB, Figus A, Harris SB, et al: The results of immediate
neous edema to gliding of the flexor tendon: An in vitro study, re-repair of zone 1 and 2 primary flexor tendon repairs which
J Hand Surg (Am) 30:1248–1254, 2005. rupture, J Hand Surg (Br) 31:507–513, 2006.
CHAPTER
40
STATE OF THE ART OF
EXTENSOR TENDON
REHABILITATION
Ton A.R. Schreuders, PT, PhD, and
Gwendolyn Van Strien, lPT, MSc
OUTLINE smaller excursion than the flexors and the forces gener-
ated by extensor muscles are weaker. The extensor mech-
The extensor tendons have complex anatomical struc- anism (e.g., the structures of the extensor tendons on
tures and mechanically they are dependent upon each the dorsum of the digits) consists of multiple tendon
other. A large variety of protocols are available to slips intertwined and intimately covering the dorsum of
accommodate therapy for the varied extent and regions the phalanges.1
of injuries. Generally, the protocols are classified into The extensor tendons do not have a synovial sheath
three types: immobilization, early passive controlled system, but at the wrist level (zone 7) (Figure 40-1),
motion by means of dynamic splinting, and early the extensors are restricted by the extensor retinaculum
active motion. After digital extensor tendon laceration that forms six fibro-osseous compartments within
and repair protective positioning of the finger is which 12 extensor tendons pass, which also help to
important to release tension across the repair and to prevent bowstringing. Adhesion formation after exten-
prevent contracture of the joints of the finger. Main- sor tendon injuries is not uncommon, but because the
taining the joint(s) in an extended position will ease requirement of tendon excursion is low and adhesions
tension on the tendon repair, and early motion can form under largely moveable skin, adhesions often do
prevent the joints from developing stiffness, a balance not pose an important problem for function of the
that should be carefully planned. In zones 5 and 6, extensor tendons. The extensor retinaculum at the wrist
most therapists and surgeons advocate early motion functions as a pulley, keeping the wrist and finger exten-
(including dynamic splinting and active motion pro- sor tendons close to the axis of the carpus during
tocols). Though these early motion protocols produce motion. At this location, dense adhesions may occur
earlier recovery of hand motion, the late outcomes are between extensor retinaculum and the tendons, that
similar to immobilization protocols. Adhesion forma- hinder tendon movement.
tion is less of a problem compared to the flexor tendon; The architecture of the extensor tendon is complex,
however, but in zone 7, where the extensor retinacu- especially at the proximal phalanx and middle phalanx
lum covers the extensor, occurrence of adhesions can level (zones 3, 4, and 5). Here the extensor tendon gives
drastically hamper tendon gliding. After injuries in off the central slip and lateral bands and connecting
this area, early movement of the tendon is critical to fibers, forming a broad expansion over the dorsum and
ensure recovery of function. After tendon repair in lateral aspects of the proximal phalanges with complex
zone 8, early movement of the tendon may not be a intertwined tendon fibers.2 The fibers of this extensor
necessity. Early motion is usually implemented from apparatus connect to the tendons of both the interosse-
3 to 5 days postsurgery and therapy may need to con- ous and lumbrical muscles. The central slip is the direct
tinue for 2 to 3 months. In the initial days, edema distal extension of the extensor digitorum communis
formation should be properly dealt with; information (EDC) tendon. Extensor tendons on the dorsal side of
about the severity of injuries, patient compliance, and the hand (zone 6) are separated tendons, but they have
strength of surgical repairs should be taken into serious connections through the juncturae tendinum.3 The
consideration to decide rigor of the early motion. juncturae tendinum coordinate the opening of the hand
via the extension of thumb, digits and wrist, as well as
The extensor tendons lie directly under the skin with assist in force redistribution through the extensors.4
very thin subcutaneous tissue above. In most parts, the Because of the interconnections and multiple inser-
tendons are thin and flat. The extensor tendons have tions, the extensor tendons are less likely to retract when
427
should be taken not to create gapping or rupturing of

the suture site if early motion is initiated. The extensor
tendon can be moved proximally through joint exten-
I sion or distally through joint flexion. Proximal move-
II ment of the tendon requires active contraction of the
extensor muscles (which are generally weaker compared
III to the flexors). Active or passive flexion of the joints
produces distal glide of the extensor tendons. Similar to
IV
the rehabilitation for the flexors, extensor tendon
therapy focuses on tendon gliding with a gradual
V T-I
increase of load to the repaired tendon.
T-II The development of protocols in flexor tendons was
VI T-III spurred on by new suture techniques. Suture techniques
for extensors have not seen similar advances. Neverthe-
T-IV
less, new extensor protocols have mostly followed the
same trends. Similarly, there are three types of protocols
VII T-V for the extensors: (1) immobilization, (2) passive mobi-
lization with a dynamic extension splint, and (3) early
active mobilization.
The Initiation of Therapy: Timing

No studies have discussed specifically the optimal timing
to initiate motion of the extensor tendons. Following
VIII
flexor tendon repair, investigators have proposed initiat-
ing active flexion at postsurgical day 3 to 5, based on
experimental evidence.7 Though it is unsure whether we
can extrapolate the conclusions from the flexor tendon
research to the extensors, we generally adopt these con-
clusions, because of a paucity of investigation on exten-
sors in this regard.
Ideally, postoperative mobilization should be initi-
ated when the therapist has a wide margin of safety
between the tendon gapping strength and the load
Figure 40-1 Zones of extensor tendon injuries. (Copyright required to initiate tendon gliding.5 Active tendon
of Judy Colditz.) gliding has to overcome resistance caused by (1) friction
between tendons and their surrounding structures;
injured than are the flexor tendons. Loss of length in the (2) resistance resulting from joint stiffness, edema, and
extensor tendon in the digits disturbs function of the adherence to surrounding tissues; and (3) resistance of
extensors, as structures in each segment are extremely antagonist muscles.5 In zone 7, the tendon encounters
different. Shortening of a phalanx greatly impairs the additional resistance from the restrictive extensor reti-
working capacity of the extensors. naculum, that covers the tendons tightly.
When the patient is immobilized for the first 3 or 5
GENERAL GUIDELINES FOR CARE AFTER
days after surgery, extra care must be taken to ensure
EXTENSOR REPAIRS
correct positioning of the hand, which should be
There have been fewer clinical investigations devoted to checked at the first or second day with assessment of
surgery and rehabilitation of the extensor tendons than pain, excessive swelling, or bleeding. An earlier dressing
the flexor tendons. Conceptually, many principles and change may be necessary.
methods used in the postoperative care were derived or
modified after those for flexor tendons. Essentially, ade- Patient Referral Information
quate edema control and protection of the tendon Detailed and specific information about the patient, the
repair from excessive stress by eliminating inadvertent injury, and operative procedures performed are helpful
hand use are important after surgery. Protective splint- in deciding protocols for individual patients. A copy
ing and instructions for home care should be given from of the operative report is invaluable in this regard.
the first postoperative days. The therapist needs to know the mechanism of injury,
As with care after flexor tendon repairs, therapy for level and severity of the tendon injuries, and structures
extensor tendons should start early after surgery, but care repaired. It is also important to know the type of tendon
Chapter 40: State of the Art of Extensor Tendon Rehabilitation 429
repair and the strength of the repair. The surgeon should returning to their daily activities directly after splint
inform the therapist if the tendon is frayed, if there is removal may risk a tendon re-rupture or develop a DIP
the possibility of a postoperative infection, or if tissues joint extension lag. The entire course of therapy can be
were seriously damaged. All these factors greatly influ- divided into the following phases:
ence the extent and amount of scar and the probability
of tendon adherence or repair rupture. Associated inju- First Phase (6 to 8 Weeks): Therapy During
ries of bones, nerves, blood vessels, and skin should also Splinting Phase
be taken into account in deciding protocols that best After a mallet finger injury, a splint is applied to hold
suit the patient. Information on the use of skin grafts the distal interphalangeal (DIP) joint in extension.13
and the location of repaired blood vessels is of great It is preferable to apply a custom made splint to posi-
importance since pressure over these areas should be tion the DIP joint in submaximal extension, that is,
avoided by careful design of a splint. Finally, therapists maximum extension that does not produce skin blanch-
should obtain information regarding pertinent medical ing. However, circulation is more often compromised
conditions that may influence wound healing or the by too much pressure of the splint rather than too much
normal progression of tendon healing.7 DIP joint hyperextension.
The splint should not include the proximal interpha-
Record Keeping langeal (PIP) joint and should allow full PIP joint
Active and passive range of motion of the hand should flexion. Nonelastic adhesive tape should securely fix the
be regularly measured and recorded. Improvement of splint to the volar skin of the middle part of the finger.
range of motion is an indication for the effectiveness of In the supple and hypermobile fingers, a mallet finger
therapy and helps to decide if a protocol needs modifi- injury encourages development of a swan neck defor-
cations. Function is assessed by measuring passive and mity. This can be prevented by adding a 30° extension
active range of motion of the joints. Extensor pollicis block for the PIP joint as part of the splint (Figure 40-2).
longus (EPL) function, after a transfer of the extensor When the patient is less compliant or needs more
indices to the EPL tendon, can be measured by the dis- secure protection, a plaster of Paris or Quickcast cylindri-
tance of thumb elevation from the surface of a table on cal cast is a good choice to immobilize the DIP joint.
which the hand is placed flat.8 In addition, the Kapandji Therapists often have difficulty keeping the DIP joint
thumb rule by giving a score (0-10 score; 0: to the meta- extended while fabricating a plaster cast. This difficulty
carpophalangeal joint level of the index finger, and 10: may be overcome if an adhesive nonelastic tape is first
to the distal palmar crease of the little finger) to how far applied starting on the volar aspect of the distal end of
the thumb can reach different parts of the fingers can the finger and ending on the dorsum, crossing the DIP
be used to score thumb opposition.9 joint crease and extending to the middle phalanx. This
The timing of initiating or modifying therapy and tape holds the DIP joint in extension and the plaster of
frequency of exercises, such as active joint extension, Paris is easily applied over it. The tape also prevents the
should be clearly recorded. The strength of finger and plaster from slipping off as the plaster adheres to the tape.
wrist extension, pain, and potential signs and symptoms With the splint/cast in place, the patient is instructed
of complex regional pain syndrome should also be to perform active PIP flexion exercises with the adjacent
recorded. fingers held in extension. With this exercise, the flexor
digitorum profundus (FDP) cannot be activated and the
REHABILITATION METHODS IN EACH ZONE: flexor digitorum superficialis (FDS) will flex the PIP
FINGER EXTENSORS joint only, eliminating flexion forces at the DIP joint.
Zones 1 and 2 (Mallet Finger)

Zones 1 and 2 extensor tendon injuries may involve
avulsion fracture from the base of the distal phalanx or
present as tendon disruption alone, leading to mallet
finger deformity. A full-time splint is usually applied
for 6 to 8 weeks with the DIP joint held in extension
for both types of mallet finger.10 After the initial 6 to 8
week splinting period, the splint should still be worn at
night and during strenuous activities for 2 to 6 weeks.
Several types of splint are available: foam-padded alu-
minum splints, molded plastic splints, and thermoplas-
tic splints. With splinting, most acute injuries achieve Figure 40-2 A mallet finger splint often used by these
a success rate of around 80%.11 Therapy after this authors to immobilize the DIP joint and prevent PIP joint
splinting period is not always continued.10,12 Patients hyperextension with a PIP joint extension block.
The patient is instructed not to carry heavy objects Third Phase (10 to 12 Weeks): Increase Loading
with the injured hand and to avoid playing contact The range of active DIP joint flexion during exercises can
sports, etc. We prefer not to have the patient remove the be increased and active extension of the DIP joint is
splint but have the therapist remove the splint carefully performed. Light daily activities can be started without
every week. If the skin has signs of pressure or macera- the splint and the time without splint can be gradually
tion, the splint needs to be adjusted or an alternative increased. Night-time splinting continues. If at any time
splint design considered. a marked DIP joint extension lag occurs, joint flexion
exercises should be stopped and the splint reapplied for
Second Phase (6/8 to 10 Weeks): Initial Exercises 4 extra weeks. The patient can return to all activities
Without Splint once the splint can be discontinued during the day.
Only when there is no extension lag at the DIP joint can Nighttime splinting may be continued for another
the patient be allowed to start actively flexing the DIP month or two for some patients.
joint and gently increasing the flexion force. The active When therapy starts late or joint stiffness or other
exercises are done 3 to 5 times a day out of the splint. complications develop during the course of therapy,
The amount of DIP joint flexion can be controlled by full DIP joint flexion may not be reached for 6 or 8
using a large diameter cylinder (Figure 40-3). With the months. If a DIP flexion contracture has developed,
hand on top of the cylinder rolling it forward allows therapy should focus on correcting the flexion contrac-
some DIP joint flexion and rolling it backward provides ture first.
a passive assistance for DIP joint extension. The patient
then lifts the hand and holds this position for 5 seconds, Zone 3: Central Slip Lesion
similar to place-hold active exercise. General instruc- (Boutonnière Deformity)
tions are to do the exercises slowly and stay within pain Closed injuries are often missed in the acute stage
limits. The splint is worn between exercises and at night. because the triangular ligament initially maintains
Only when patients understand the exercises should the dorsal positions of the lateral bands, helping to
they do them independently at home. maintain extension of the PIP joint. Only when the
Therapists should measure the active flexion and triangular ligament yields and allows the lateral bands
extension of the DIP joint, and if there is adequate active to slip volarly will the lack of PIP joint extension
DIP extension, both the frequency of exercises and the become apparent due to the developing boutonniere
range of joint motion allowed can be increased gradually. deformity.14-16 Chronic boutonnière deformity leads to
The range of flexion exercises can be increased by using flexion contracture of the PIP joint.
a smaller cylinder. Weaning off the splint gradually and For a boutonnière deformity after closed injuries, the
carefully increasing flexion range prevent a recurrence underlying pathology is attenuation or partial disrup-
of the mallet finger. Most patients require close monitor- tion of the central slip and nonsurgical treatment is
ing of splint wear and exercises during this phase. attempted first. The goal is to immobilize the PIP joint
in extension to allow the attenuated tendons to heal. A
thermoplastic splint can be used to maintain the PIP
joint in full extension for 6 weeks on a full-time basis.
Others prefer the PIP joint to be pinned in extension for
the first 3 weeks, or even 5 to 6 weeks. The DIP joint
should be free and is allowed to move actively. The
immobilization by splinting should be extended beyond
6 weeks if extension lag continues to exist after initia-
tion of PIP joint flexion. After the splint is discontinued,
gradual active flexion of the PIP joint is initiated.
After surgical treatment of the persistent deformity or
surgical repair of an open, complete disruption of the
central slip, the goal of therapy is to protect the central
slip, prevent adhesions, prevent DIP joint stiffness and
extension lag, and maintain the length of the oblique
retinacular ligament (ORL).
Treatment protocols include immobilization, passive
Figure 40-3 In the first phase of exercises after a mallet
finger injury, the amount of DIP joint flexion is controlled by early mobilization with a dynamic splint and immedi-
using a large diameter cylinder. When the cylinder with the ate controlled active mobilization of the PIP joint.17-19
hand on top is rolled forward it allows some DIP joint Maddy and Meyerdiercks advocate immobilizing
flexion; rolling back the DIP joint is pushed into extension the PIP at 0° of extension with a static finger-based
similar to a place-hold exercise. splint for 3 to 31 2 weeks followed by another 3 weeks
Figure 40-4 A Capener splint for correction of PIP joint

deformity.
Figure 40-5 Dynamic extension splinting after surgical
repair of zone 3 extensor tendons. Here active flexion and
of active flexion and assisted extension with a finger- passive extension is achieved by the dynamic traction of the
based dynamic extension splint.20 extension splint.
The dynamic extension splint in this study was a
custom-made spring coil finger-based splint, much like
a Capener splint (Figure 40-4). At 3 weeks, when the patient grasping a large cylinder. PIP joint flexion is
dynamic splint was fabricated, a structured program increased by 15° each week.
with three exercises was given to the patient: active DIP From week 3, place-and-hold exercises for finger
flexion with the PIP blocked manually in extension, extension can be incorporated by passively extending
active PIP flexion with the MP blocked in extension, and the PIP joint and actively maintaining the joint at this
composite active MP, PIP, and DIP flexion, with the position. The exercises are done one to two hours with
splint extending the PIP joint between repetitions of 10 repetitions each session.
each exercise. At week 4, active PIP joint extension is started. The
Some authors start the early controlled mobilization patient continues to use a small finger extension splint,
using a prefabricated spring coil dynamic PIP extension such as a neoprene splint, during the day to support
splint (Capener) as early as 10 to 14 days postopera- extension. At week 5, achieving 90° of active PIP joint
tively, following immobilization of the PIP joint in flexion is the goal. Starting at week 6, light activities of
extension with a static splint.21 Both groups initiated daily living are allowed. Resisted finger motion is started
active DIP flexion exercises with the PIP held in exten- at week 8. If the PIP joint has less than 60° of passive
sion within the first week. However, with extensive flexion, corrective flexion splinting can be applied by
dorsal tissue damage or severed lateral bands the DIP, bandaging the fingers in flexion for periods of 10 to 15
exercises were postponed until 4 weeks post-operation. minutes, several times a day. We emphasize that the
Because the intent is to passively extend not against above program is progressed only when the patient
the resistance of a flexion contracture but as an assist to maintains full active PIP joint extension. If the patient
healing extensors, the spring coil does not need to be does not have full extension, the period of splinting in
very strong, and a lower force type can be chosen or extension should be prolonged, and more emphasis
fabricated. The goal of the splint is to achieve maximum should be given to extension than to flexion. Walsh and
extension at rest with the lowest possible force and at colleagues22 compared the dynamic extension splint
the same time make active flexion easy to perform. The with static splinting and the results suggested an earlier
position of full PIP extension (possibly 10° of hyper return to work with less frequent therapy visits for the
extension) in both the static and the dynamic splints is dynamic extension splint group.
critical for a successful outcome.23 Early active digital extension is also used after surgical
The dynamic splinting can also be hand based,22,23 or repair of the extensor tendon in this zone. This method
extending across the wrist. The wrist is usually placed in advocated by Evans is known as Short Arc Motion.17 In
30° extension, metacarpophalangeal (MCP) joints in the active motion protocol, for the first 4 to 6 weeks, the
slight flexion, and interphalangeal (IP) joints fully digit is immobilized in a finger based static splint in full
extended24,25 (Figure 40-5). The DIP joint is allowed to extension with the MCP joint excluded. Every hour the
actively flex to release the tension on the central slip patient is allowed to perform intermittent limited active
and to ensure some gliding of the intact lateral bands. flexion and extension exercises using a template splint
During the first week of active PIP joint flexion, the PIP (Figure 40-6). The patient actively flexes to the limits of
joint is allowed to flex up to 30° either by putting a stop the template splint and actively extends to full extension.
on the outrigger line, by adding a volar splint or by the The template splint supports only the PIP and DIP joints
adherence. which restricts gliding of the extensor hood.

Therapists need to be aware of this extra risk and start
Full ext.
active gliding exercises as soon as possible. Protective
tendon gliding can be provided with a dynamic exten-
Template sion splint as in zone 3 injuries, or using gentle active
splint
exercises similar to the short arc motion method advo-
Limited cated by Evans.17
flexion
Zones 5 and 6: MCP Joint and Dorsum
of the Hand
In zone 5, the sagittal bands are responsible for main-
taining the extensor tendon central over the MCP joint.
Injuries may lead to subluxation of the extensor tendon.
The sagittal bands are tensed during MCP joint flexion.
Following sagittal band repair, MCP joint flexion should
be gentle. Flexing the IP joints while the MCP joint is
Figure 40-6 Limited active flexion and full extension kept in extension reduces tension on the sagittal bands
exercises of the PIP and DIP joints using a template splint. and ensures some gliding of the tendon.
The zone 5 extensor tendon repair can adhere to the
and allows for 30° active PIP and DIP joint flexion in MCP joint capsule. Immobilization of the joint in exten-
the first 2 weeks, increasing 10° flexion each week.26 sion would lead to contracture of the collateral liga-
Exercises are performed 4 to 6 times a day. At 6 weeks, ments. To prevent these complications, use of a protocol
both splints are discontinued, and exercises of full range with early MCP joint flexion is beneficial.
of active motion are started. In zone 6, the extensor tendon is more rounded than
Evans and Thompson17,26 calculated that the amount distal extensor tendons and allows stronger surgical
of force added on the repair was 3 N during early active repairs. Because of the juncturae tendinum connections
motion, which is well within the strength of most suture between the EDC tendons on the dorsum of the hand,
techniques (about 20 N in the first week)6 and the 30° movements of adjacent finger(s) affect tension on the
flexion limit keeps the force within a safe zone. repaired tendon. When the repair site is distal to the
Focusing on zones 2 and 3, the studies of Hung,27 interconnections, flexion of the adjacent digits may pull
Saldana,28 and Newport29 do not support the idea that through the interconnections on the proximal stump,
dynamic splinting has benefits over static splinting. moving it distally, toward the distal stump, bringing the
Therefore some regard static splinting to be as effective tendon ends together. Therefore, splinting the adjacent
and should be the standard care for simple extensor digits in slightly greater flexion or excluding the adjacent
tendon lacerations distal to the MCP joint, given its digits from immobilization and allowing them to flex,
simplicity and lower cost. may reduce tension across the repair site. In contrast,
For chronic boutonniere deformity of PIP joint with when the repair site is proximal to the interconnections,
a flexion contracture of over 30°, serial casting is a flexion of the adjacent fingers may increase tension on
useful way to correct the deformity. The cast is applied the repair site so the uninjured fingers should be held
to the PIP joint and is changed approximately every 2 in the same position in the splint. Zone 6 repairs benefit
weeks; PIP joint extension is progressively increased by from early motion protocols as postoperative edema on
5° to 10° after each change of the cast. the dorsum of the hand limits MCP joint flexion; early
A frequent complication in treating closed bouton- motion facilitates reducing edema.
niere deformity is incomplete correction of the defor- Lacerations of the extensor tendons in zones 5 and 6
mity. However, an extension lag of about 20°, in the are often treated with an early motion protocol using a
presence of full PIP and DIP active flexion leads to little dynamic splint.27 Within 2 to 5 days postoperatively, a
functional disturbance of a finger, and therapy does not dorsally based dynamic splint is applied holding the
necessarily need to continue if these degrees of digital wrist in 30° to 40° extension and dynamically extend-
motion have been achieved. ing the MCP joints to full extension via an outrigger
(loops around the proximal phalanx). At this time active
Zone 4: Proximal Phalanx flexion of the MCP joints is allowed to 20° to 30° for
In this zone, injuries to the tendon often cause no index and middle fingers, and 35° to 40° for the ring
functional loss because the wide extensor hood covers and little fingers while the IP joints are actively extended.
more than half of the proximal phalanx. However, when The second exercise is to flex the IP joints while main-
the tendon is repaired, due to the large contact area taining extension of the MCP joints (active hook fist).
to the underlying bone, it creates a substantial risk of Exercises are done 5 times every 2 hours in the first 2
Figure 40-7 Norwich exercise regimen. Combined active MCP and IP joint extension (lifting the extended digits off the
splint) and active MCP joint extension with IP flexion (making a hook fist within the splint).
weeks, and after that 10 times every hour. For patients

needing more support because they experience unrest
during sleep or exhibit a tendency toward development
of an extensor lag, a volar splint may be used to keep
the fingers in extension at night. At week 2, active flexion
of MCP joints is allowed to 45°, week 3 to about 60°
and week 4 to 90°. At week 4, place-and-hold exercises
for full finger extension are started and at week 6 the
splint is discontinued. Strengthening exercises are
started around week 7 and at 12 weeks the hand can be
used normally. Patients are progressed on this timetable
only if no extensor lag is observed. Figure 40-8 The Norwich splint can be modified with a
For isolated EDC injuries in zones 5 and 6, the imme- V-shaped insert holding the MCP and IP joints at 0° when
diate controlled active motion (ICAM) technique can extension lag persists.
be used, as described by Howell and colleagues.30 This
method allows immediate active controlled motion by
using a yoke splint which places the injured finger in (Figure 40-7). When extension lag persists, the splint
MCP joint extension slightly greater than the adjacent can be worn at night or part of the day, with a V-shaped
fingers, and a second splint is applied to hold the wrist insert holding the MCP and IP joints at 0° (Figure
in 20° to 25° extension. The ICAM protocol has the 40-8). During weeks 4 to 6, the splint can be removed.
following three phases: (1) Days 0 to 21—Two splints If an extension lag of the MCP joint is persistent and is
are worn full time and active composite finger flexion greater than 30°, splinting is resumed for 2 more weeks.
exercises are started. (2) Days 22 to 35—The patient If no lag is present, active finger flexion exercises are
continues to wear the yoke splint at all times but removes initiated at week 4 without wrist flexion.
the wrist splint only for wrist exercises. (3) Days 36 to A study by Bulstrode and colleagues32 compared the
49—The wrist splint is discontinued but the patient outcomes of the Norwich regimen to immobilization of
continues wearing the yoke splint while using the hand all the joints of the hand and static extension splinting
but removes it for active finger motion exercises. In of the wrist and MCP joints while leaving the IP joints
Howell’s report 81% patients achieved excellent results free. The total active range of digital motion in the
for both digital extension and flexion.30 Only five patients immobilization group was less at week 4. However, by
developed a lag and there were no tendon ruptures. 12 weeks, there was no statistically significant difference
The Norwich regimen31 designed for zone 5 and 6 between the three regimens, and all patients achieved
extensor tendon rehabilitation is an active protocol good or excellent results. The only significant finding
using a volar immobilization splint, which hold the was reduced grip strength compared to the uninjured
wrist in 45° extension, the MCP joints in 50° flexion, hand at 12 weeks for the immobilization group.32 Other
and the IP joints in full extension. Two exercises are investigators found better functional results for the
performed for 4 weeks, 4 times a day, with 4 repetitions dynamic splint method over early active mobilization
each time (“the rule of four”). After loosening the digital at 4 weeks but failed to identify significant differences
straps the following exercises are performed: combined in functional outcomes at 12 weeks.33 A study compar-
active MCP and IP joint extension (lifting the extended ing a dynamic outrigger splint with a static volar MCP
digits off the splint) and active MCP joint extension blocking splint also did not show statistically significant
with IP flexion (making a hook fist within the splint) differences in functional outcomes.34 There is no
evidence of superior results in the long term for any of finger extensors. A static splint or a dynamic extension
the different treatment methods in these publications. splint is used for 4 to 6 weeks, followed by progressive
Still, all the authors recommended early mobilization exercises of active thumb extension for a further 2 to 4
on the basis of lower cost and the simplicity of the early weeks. Between 70% and 90% of repairs of the EPL
active mobilization regimens with less time spent in tendons achieved excellent or good results, with these
therapy and especially with simpler splint fabrication protocols.46 Loss of thumb movement is often caused
and fewer adjustments. However, early mobilization has by tendon adhesions to the bone and skin, with thicken-
achieved earlier return of grip strength, which may be a ing of the dorsal joint capsules with scar formation.46
reason to choose early mobilization over static treat-
ment.32,45 One group, however, states that with similar Zone T1
outcomes the static regimen should be the treatment of Although not seen as frequently as mallet finger, a
choice with poorly compliant patients, as it is both a closed mallet thumb can be treated similarly to the
simple and an effective method.35 closed zone 1 digit injury with 6 to 8 weeks of immo-
Ip and Chow36 and Kerr and Burczak37 used a dynamic bilization of the thumb with splinting. Afterward,
splinting regimen after extensor tendon repairs in zones splinting is applied between exercises and at night for
4 to 8, with good outcomes and no rupture of the repairs. an additional 2 to 4 weeks, and thumb extension is
Newport and colleagues38 used static splinting for all allowed. However, a zone T1 laceration can also be
zones of injury and achieved similar good results. Static surgically repaired by virtue of the large size of the EPL
splinting has been described by Blair and colleagues,39 tendon as compared to the finger extensor.
Slater and colleagues,40 and much earlier by Stuart and After surgical repair, Elliot and Southgate46 place the
colleagues41 and Dargan.42 Soni and colelagues43 recom- hand in a palmar plaster of Paris splint with the wrist in
mended early active motion and consider it especially 30° of extension and both the MCP joint and the IP
beneficial in complex injuries distal to the MCP joint. joints in the neutral position. The tendon is mobilized
early after surgery in a dynamic extension splint, which
Zone 7: Extensor Retinaculum at the Wrist controls MCP joint flexion only, the loop being under
In zone 7, the extensor tendons run through tight com- the proximal phalanx. The IP joint moves freely into
partments formed by the extensor retinaculum and flexion and extension from the commencement of mobi-
distal radius. This restraining retinaculum increases the lization. For the first 5 days, the hand rests in the splint.
risk for adhesions and limits gliding of the healing From day 5, the MCP joint alone is actively flexed and
tendon. For these reasons, early mobilization of the extended, with the sling under the distal phalanx and
tendon in this zone is preferred. the base of the thumb supported with the other hand.
A practical treatment method is to splint the wrist in In the second week, the patient actively flexes and extends
30° to 40° of extension, and the MCP joints in 0° to both MCP and IP joint together, aiming for the base of
15° flexion for 3 to 4 weeks, allowing the PIP and DIP the ring finger, 10 repetitions hourly. Between days 12
joints full active range of motion. After 3 to 4 weeks the and 28, the patient performs active combined MCP and
MCP joints are left free but the wrist is still held in IP joint flexion and opposition, aiming for the base of
extension in a splint. Wrist flexion is started and weaning the little finger. After 28 days, the same exercise are con-
from the splint occurs while slowly increasing activities tinued without the splint, active combined MCP and IP
over the next 2 weeks.44 joint flexion and opposition are continued and thumb
active abduction, adduction, and opposition exercise are
Zone 8: Forearm added. These exercises continue from week 8 onward.
Injuries in the forearm involve tendons, the muscle–
tendon junction, or the muscle belly. Following surgery, Zone T2
the wrist is immobilized in mild extension with a pro- Injuries to the extensor at the proximal phalanx of the
tective splint, but thumb and fingers are left out of the thumb can be immobilized in a hand-based splint,
splint. Although active digital motion can be allowed, holding the MCP and IP joint at 0° and the thumb radi-
lifting of heavy objects should be avoided. Adhesions ally extended. Gentle active exercises can be initiated at
occurring in this zone are unlikely to restrict tendon 3 weeks, progressing flexion of the thumb slowly while
motion. splinting between exercise sessions.
Due to a high incidence of tendon-to-bone adher-
REHABILITATION METHODS IN EACH ZONE:
ence in this zone, early protective motion protocols
THUMB EXTENSORS
should be considered. Crosby and Wehbe18 use a
The three thumb extensors, extensor pollicis longus forearm-based splint, with the wrist in 20° to 30° of
(EPL), extensor pollicis brevis (EPB) and abductor pol- extension, MCP joint at slight flexion of 10° to 20°,
licis longus (APL), can be injured, mostly through open with a rubber band holding the IP joint extended. Active
wounds. Rehabilitation after repair is similar to that for flexion of the IP joint is allowed, with the IP joint
passively extended in the first 3 weeks. At weeks 4 to 5,

Rubber band
gentle active extension is initiated with the addition of
gentle active flexion of the IP joint. At week 8 and
beyond, graded resistive exercises are initiated. Elliot
and Southgate46 use the same regimen after zone T2 to
T4 EPL tendon repair as in zone T1.
Zones T3 to 5
Figure 40-9 Drawing showing the protective active thumb
The proximal zones of the thumb include the EPL,
motion with a forearm-based dynamic splint for the extensor
extensor pollicis brevis (EPB), and abductor pollicis tendons injured proximal to the MCP joint level of the
longus (APL). After repair of the APL tendon at zones thumb. The rubber band permits active MCP joint flexion
T3 and 4, the wrist is positioned at 30° extension, with and passive extension of the joint.
slight radial deviation and metacarpal extension. Exten-
sion is increased to 40° for zone T5 APL repair.
After EPL repair, immobilization by a static splint
worn full-time for 4 weeks, and starting active exercises
at 4 weeks is common practice. The splint can be dis-
carded at 6 weeks. However, if there is an extension lag
at 6 weeks, extension splinting is continued for another
2 weeks. If stiffness of the joints prevents full thumb
flexion and extension is normal or close to normal,
passive flexion exercises and flexion splinting should
start after 7 to 8 weeks.
Dynamic splinting protocols vary; for postoperative
management of a zone T4 to 5 laceration, Evans17 recom-
mended a dorsal forearm–based splint that positions
the wrist at 30 to 40° of extension, the carpometacarpal
joint at neutral, and the MCP joint at 0°. The IP joint is
held in neutral by a sling with dynamic traction. The
splint allows 60° of active IP joint flexion, which is pas-
sively brought back to extension via dynamic traction.
Evans now adds more motion when the patient is at
therapy. She does controlled passive motion to the MCP
joint of approximately 30° while the wrist is held in
maximum extension and the IP joint is held at 0°. To
ensure gliding, an “active hold” exercise is also done.
Crosby and Wehbe18 use a forearm-based splint and
rubber band traction to the proximal part of the thumb. Figure 40-10 A two-part forearm based thermoplastic
The MCP joint motion is not restricted. The rubber band splint with a removable plate allows flexion and extension of
traction produces MCP joint extension after active MCP the IP joint of the thumb following repair of the EPL tendon
in zones T 3 to 5. (Courtesy of Fiona Peck.)
joint flexion (Figure 40-9).
In the Manchester regimen (personal communica-
tion, with Fiona Peck, 2011), a 2 part forearm based of adhesions under retinaculum. At week 5 the splint is
thermoplastic splint is applied with wrist at 30° and removed. Active IP joint flexion and extension exercises
the MCP and IP joints at 0°. The thumb is positioned are continued and composite active MCP and IP joint
comfortably in abduction and extension. The remov- motion is encouraged to restore opposition. In the pres-
able plate allows active 0° to 60° IP joint flexion and ence of extensor lag, the splint continues to be worn at
extension exercises (Figures 40-10 and 40-11). In week night. Corrective passive flexion is initiated at 6 weeks
1, active IP joint flexion and extension exercises are if flexion is slow to progress. The patient returns to
initiated, progressing to 60° flexion during the first 3 normal activity by weeks 10 to 12.
weeks. No passive flexion is permitted and the splint is Hung and colleagues27 described a dynamic exten-
worn full time. At week 3, the splint is removed to sion splint for all EPL repairs that places the wrist at
perform careful wrist flexion and extension with thumb 40° extension and the thumb in mid-abduction/mid-
relaxed to encourage tenodesis action and promote extension. The IP joint is allowed to flex to 45° in the
tendon glide, especially in zone T5 where there is risk first week, and full flexion is allowed in the second
week. In the third week, the MCP joint is allowed to flex motion 3 to 5 days after repair and continued exercise
to 45°, increasing to full composite flexion by week 4. in the splint for 5 weeks. Chinchalkar48 suggested active
The dynamic splint is discontinued in week 5 and is wrist and thumb motion to start at 4 to 6 weeks for
replaced by a wrist cock-up for one additional week. For injuries at the first extensor compartment.
T4 and proximal zone injuries, full active flexion of the
CLINICAL EVIDENCE AND OUTCOMES
thumb is allowed within the dynamic splint, with the
wrist held in 20° of extension. Currently few randomized comparative clinical studies
Browne and Ribik47 also allowed full flexion across are available for extensor tendon injuries; rehabilita
the palm in a dynamic outrigger splint. They began tion methods for individual patients are largely
decided according to personal preference and judg-
ment. Talsma and colleagues49 reviewed findings from
five studies (Table 40-1), about one of the three regi-
mens: (1) immobilization, (2) early controlled passive
Active IP joint flexion Active IP joint extension
mobilization (dynamic splinting), or (3) early active
mobilization. There is strong evidence that early con-
trolled mobilization regimens used after surgical repairs
in zones 5 and 6 lead to better recovery of both range
of motion and grip strength of the hand compared
with immobilization in the short term. Nevertheless,
no conclusive evidence can be uncovered regarding the
long-term (6 months) effectiveness of these regimens.
The methods used to assess the outcomes include Buck-
Gramcko, White, Miller11 and Dargan.42
Surgical repairs of open extensor tendon injuries fol-
lowed by appropriate postoperative care have generally
favorable outcomes.27-29,36 Ip and Chow36 reported 101
primary end-to-end extensor tendon repairs due to
clean-cuts or crush open injuries in zones 4 to 8 of all
fingers or zones 1 to 6 of thumbs in 84 patients treated
with dynamic splinting and passive mobilization.
Figure 40-11 Active flexion and extension of the IP joint of Among 37 thumb extensor repairs, there were 67% (25
the thumb within this splint following repair of the EPL tendons) with excellent results, 30% (11 tendons) good,
tendon. (Courtesy of Fiona Peck.) and 3% (one tendon) fair by Buck-Gramcko criteria.
Table 40-1 Summary of Studies Comparing Outcomes of Extensor Rehabilitation Protocols49

Authors Interventions/Groups Zones Outcomes
45
Mowlawi et al Start 3 to 5 postoperative days 5, 6 ROM in group A was significantly
N = 34* A. Dynamic extension splint 4 weeks better than group B at 4 to 8 weeks
B. Immobilization for 3 weeks, active motion at and grip strength was greater at 8
4 weeks weeks, but not at 6 months
Bulstrode et al32 A. Immobilization in plaster, 4 weeks 5, 6 ROM in group B and C was better than
N = 42 B. Extension splint: wrist in 30° and MCP joints A at 4 and 6 weeks not at 8 and 12
extended; IP joints free, 4 weeks weeks with a compared with B
C. Extension splint: wrist in 45° and MCP in 50°
flexion, IP joints free, 4 weeks
Chester et al33 A. Early active motion. with a static splint, 4 to 8 ROM was better with a compared with
N = 54 4 weeks B at 4 weeks, but not at 12 weeks
B. Dynamic extension splint, 4 weeks No ruptures
Khandwala et al30 A. Dynamic extension splint 4 weeks 4 to 8 ROM had no differences in two groups;
N = 100 B. Early active with palmar blocking splint 4 weeks 1 rupture in group 1 and 2 in B
Russell et al35 A. Immobilization 2 to 3 weeks and dynamic 5 to 8 ROM had no differences between A
N = 65 splint 4 weeks. and B.
B. Immobilization, 4 weeks followed by static No ruptures
splint, 4 weeks
*N is the total number of patients.
With Dargan criteria, 83% (50 tendons) of the finger Nevertheless, we will need to make decisions about
extensor tendons had excellent results; 9% (6 tendons) which regimen to use in individual patients, considering
were good; 6% (4 tendons) were fair; and 2% (one other issues, such as patient compliance, ages of patients,
tendon) had poor results. No tendon rupture was and zones of injury, and the cost effectiveness of a pro-
recorded. Newport and colleagues38 reported that out of tocol. Dynamic extensor splints are arguably the most
91 fingers with surgical repair of open extensor tendon difficult to make and therefore time consuming. In addi-
injuries (zones 1 to 8, all treated with static splinting), tion, if such complicated splints result in less compliant
52% (47 tendons) achieved good or excellent results by patients, we may need to look into more simple regi-
Miller criteria. For the thumb, 60% (6 out of 10 thumbs) mens like immobilization or early active motion. In
had good or excellent results. No rupture was reported. comparing different regimens, it is necessary to integrate
Few studies have reported outcomes of surgical variables such as patient compliance, cost, access to
repairs of extensor tendons after loss of tendon length physical therapy, risk of rupturing the repair, and
due to extensive tissue damage or complex extensor expected time off work. Rate and quality of wound
tendon injuries in the fingers; persistent and marked healing, and the site of adhesion formation may be
loss of active and passive motion of the fingers after considered as well.
reconstructive procedures is a challenge for therapists. Therapists should aim for maximum functional
Dynamic splinting or early active motion appears to results by anticipating problems during the course of
be beneficial to extensor tendon repair in some areas. treatment, by paying close attention to details concern-
Comparing the dynamic extension splint regimens (early ing splint and edema control, and by monitoring ROM,
controlled mobilization) with early active mobilization, especially extension lag, and by modifying treatment
evidence indicated better total range of motion in the regimens accordingly as we go along. Early referral and
early period (6 to 8 weeks) for the active motion proto- good communication between therapist, surgeon and
col, but at three months postoperatively there were no patient throughout the entire treatment period is essen-
differences in motion between the two regimens.43 tial for achieving the best functional results.
Because of the lack of clinical comparative studies
which provide high quality evidence to support the Acknowledgments
use of any specific regimen, post operative treatment Therapy protocols were kindly contributed from following
regimens currently used in different units around the surgeons or therapists; protocols available in this book at
globe vary enormously. We found ourselves hard put to www.expertconsult.com are as follows:
recommend any one particular way of rehabilitation, 1. Therapy Protocols After Extensor Tendon Repairs: St Andrew’s
but the therapy guidelines and essential approaches Centre for Plastic Surgery, Broomfield Hospital, Chelmsford,
and considerations described in this chapter should be Essex, UK, from Dr. David Elliot
helpful in guiding therapists and surgeons in choosing 2. Therapy Protocols After Extensor Tendon Repairs of the Thumb:
St Andrew’s Centre for Plastic Surgery, Broomfield Hospital,
the post operative treatment best suited for their patient
Chelmsford, Essex, UK, from Dr. David Elliot
and their setting. Not only is it important to choose
3. Therapy Protocols After Extensor Tendon Repairs of Fingers, Mid
the most suitable regimen for each patient; it is also Essex Hospital Services, St Andrew’s Centre-Hand Therapy,
important to make appropriate modifications or adjust- Essex, UK, from Dr. David Elliot
ments to variable patient conditions to achieve the best 4. The Manchester Regimen for Postoperative Rehabiliation After
result possible. The ultimate goal of therapy is to achieve Finger Extensor Tendon Repairs, Manchester, UK, from Ms.
a smoothly gliding tendon without risking rupture of Fiona Peck
the repair, and to ensure early recovery of hand func- 5. Protocols of Exercise After Repair of Extensor Tendon Injuries,
tion. To provide further insight into the regimens cur- Queen Mary Hospital, The University of Hong Kong, Hong
rently used worldwide, we include regimens which were Kong, China, from Dr. Wing Yuk Ip
kindly sent to us from several hand centers around the 6. Extensor Tendon Rehabilitation Program, Queen Mary Hospital,
The University of Hong Kong, Hong Kong, China, from Dr.
globe. Their regimens for extensor tendon therapy are
Wing Yuk Ip
given in the online contents of this chapter.
7. Therapy Protocols After Extensor Tendon Repair, Springfield,
CONSIDERATIONS Mass, USA, from Ms. Karen Pettengill
8. Protocols of Sydney Hand Therapy & Rehabilitation Centre,
Passive mobilization through dynamic splinting and Sydney, Australia, from Ms. Rosemary Prosser
early active motion protocols allow for more rapid gain 9. Therapy Protocols from Royal Free Hamstead NHS Trust,
of range of motion compared with static splinting. London, UK, from Ms. Nikki Burr
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Appendix 1
Therapy Protocols After Extensor Tendon
Repairs: St Andrew’s Centre for Plastic
Surgery, Broomfield Hospital, Chelmsford,
Essex, UK
EXTENSOR TENDON REPAIRS 4. 14–28 Days (Weeks 3 and 4)

OF THE FINGERS Day 14—Remold splint so MCP +70°.
X10 hourly—extend to MCP 0°+PIP 0° +DIP 0°,
(i) Zones 5–8
(passively extend fingers to MCP 0°+PIP 0° +DIP 0°
(ii) Zone 9 with good strong repair of the intramuscular
if there is lag, and,
tendon.
if lag persisting, fabricate splint for night wear at MCP
1. Theatre 0°+PIP 0° +DIP 0°),
POP Palmar (volar) splint applied after tendon then actively flex MCPs back to +70°,
repair(s)— then actively fully flex the PIP and DIP joints to full
flexion of both over the end of the splint.
Wrist −30° Continue to elevate hand above elbow at all times.
MCPs +40° Continue shoulder and elbow exercises 5×5 per day
PIP 0° (5 exercises 5 times per day).
DIP 0° Continue X5 hourly—full thumb active flexion and
2. 0–5 days (Week 1) extension.
Rest in POP splint for 5 days. (Week 1) Continue X5 hourly—full forearm active supination
Elevate hand above elbow at all times. and pronation.
Shoulder and elbow exercises 5×5 per day (5 exer- Hygiene and splint check at 21 and 28 days.
cises 5 times per day). Ultrasound if necessary from week 3.
3. 6–13 Days (Weeks 1 and 2) 5. 28+ Days (4–8 weeks)
Day 6—Fabricate thermoplastic splint with same X10 hourly—full active flexion and extension of all
joint angle of the MCP (+40°) but with splint only joints of fingers without splint.
extending distally to just proximal to the PIP joints. X10 hourly—active wrist flexion and extension
X10 hourly—extend to MCP 0°+PIP 0° +DIP 0°, exercises with the fingers relaxed (fingers in the
passively extend fingers to MCP 0°+PIP 0° +DIP 0° position of the fingers in the wrist tenodesis maneu-
if there is extension lag, ver—wrist flexion with fingers loosely extended and
then actively flex MCPs back to +40°, wrist flexion with fingers loosely flexed).
then actively fully flex the PIP and DIP joints to full Also start active radial and ulnar wrist movements.
flexion of both over the end of the splint. Passive extension of wrist and fingers to neutral.
Continue to elevate hand above elbow at all times. Gradually increase active combined wrist and finger
Continue shoulder and elbow exercises 5×5 per day extension as comfortable.
(5 exercises 5 times per day). Add active combined wrist and digit flexion exercises
X5 hourly—full thumb active flexion and extension. at 6 weeks post-op if needed.
X5 hourly—full forearm active supination and MCPs +70° splint worn at night and in busy places
pronation. to 8 weeks.
Adjust pain control as necessary to allow this regime. Continue shoulder and elbow exercises 5×5 per day
Hygiene and splint check at 7 days and 14 days. (5 exercises 5 times per day).
438.e1
438.e2 Section 5: Rehabilitation of Tendon Surgery
Continue X5 hourly – full thumb active flexion and Dynamic flexion splinting if required.
extension + add active thumb abduction/adduc- From 8 weeks – return to light work and driving.
tion/opposition. From 12 weeks – return to heavy work and contact
Continue X5 hourly – full forearm active supination sports.
and pronation If there is extensor tendon tethering – forced passive
From 4 weeks – light hand use but not lifting any- flexion exercises + massage dorsal skin of digit and
thing more than 150 gm (6oz) = a full yogurt pot dorsum of hand with finger held in flexion +
6. 8 weeks onwards ultrasound.
Continue all exercises as above.
Passive finger flexion if required.
In Theatre Days 0–5 Week 1 Days 6–13 Weeks 1–2 Days 14 -28 Weeks 3–4 Day 28+ Weeks 4–8
POP Rest in POP splint Thermoplastic Thermoplastic Thermoplastic + 70°
Palmar Splint Splint to PIP level Splint to PIP level Splint to PIP level as
Made day 6 adjusted day 14 weeks 3/4
Wrist −30° Wrist −30° Wrist −30° Wrist −30° Splint only worn
MCPs +40° MCPs +40° MCPs +40° MCPs +70° at night and in busy
PIP 0° DIP 0° PIP 0° DIP 0° PIP 0° DIP 0° PIP 0° DIP 0° places
Fingers— Fingers— X10 hourly X10 hourly X10 hourly—full active
No movement No movement Full active extn. Full active extn. flexion and extension of
x 3 joints then x 3 joints then all joints of fingers
MCP flexn. + 40° MCP flexn. + 70° without splint
PIP/DIP flexn. full PIP/DIP flexn. full
Passively extend joints Passively extend joints to X10 hourly—full active
to neutral if necessary neutral if necessary wrist flexn. and
extension exercises with
the fingers relaxed
If lag persists, fit night From 4 weeks light hand
splint with all joints use—less than 150 gm
straight (full yogurt pot)
Elevate hand Elevate hand above Elevate hand above From 8 weeks—light
above elbow elbow elbow work/driving
Shoulder exercises Shoulder exercises 5x5 Shoulder exercises 5x5 From 12 weeks—heavy
5x5 times per day times per day times per day work/contact sports.
Elbow exercises Elbow exercises 5x5 Elbow exercises 5x5
5x5 times per day times per day times per day
X5 hourly—full thumb X5 hourly—full thumb
active flexion/extension active flexion/extension
X5 hourly—full forearm X5 hourly—full forearm
active supin./pronation active supin./pronation
Adjust pain control as Adjust pain control as
necessary necessary
Hygiene and splint Hygiene and splint
checks—7 & 14 days checks—21 & 28 days
Ultrasound if necessary
from week 3
Appendix 2
Repair of the Thumb: St Andrew’s Centre
for Plastic Surgery, Broomfield Hospital,
Chelmsford, Essex, UK
Zones 1–4 4. 7–14 Days (Week 2)

When resting, the sling remains around the distal
1. Theatre
phalanx.
POP Palmar (volar) splint applied after tendon
X5 hourly, slide sling back under the proximal
repair(s)—
phalanx and actively flex and extend both MCP
Wrist −30° and IP joints together, aiming for the base of the
MCP 0° ring finger ×10 hourly (may need to support the
IP 0° base of the thumb).
2. 0–5 days (Week 1) Elevate hand above elbow at all times.
Rest in POP palmar (volar) splint for 5 days. (Week 1) Shoulder and elbow exercises 5×5 per day (5 exer-
Elevate hand above elbow at all times. cises 5 times per day).
Shoulder and elbow exercises 5×5 per day (5 exer- Full active pronation and supination of the forearm
cises 5 times per day). 5×5 per day.
3. 5–7 Days (Week 1) Full active flexion and extension of all fingers 5×5 per
Day 6—Fabricate thermoplastic dorsal dynamic day.
extension splint with same joint angle of the wrist Adjust pain control as necessary to allow this regime.
and thumb MCP and with the splint lifting off the Hygiene and splint check at 7 days and 14 days.
thumb at the mid-proximal phalangeal level so 5. 14–28 Days (2–4 Weeks)
that a sling can be attached around the distal pha- Active combined MCP and IP flexion/opposition,
langeal palmar (volar) surface. aiming for the base of the little finger ×10 hourly
When resting, the sling remains around the distal (may need to support the base of the thumb).
phalanx. Ultrasound from week 3 if needed.
X5 hourly, slide sling back under the proximal Elevate hand above elbow at all times.
phalanx and actively flex and extend the IP joint Shoulder and elbow exercises 5×5 per day (5 exer-
alone. cises 5 times per day).
X5 hourly, actively flex and extend the MCP joint Full active pronation and supination of the forearm
alone, with the sling under the distal phalanx and 5×5 per day.
the base of the thumb supported with the other Full active flexion and extension of all fingers 5x5 per
hand. Aim thumb tip for the base of the middle day.
finger during this maneuver. Adjust pain control as necessary to allow this regime.
Elevate hand above elbow at all times. Hygiene and splint check at 21 days and 28 days.
Shoulder and elbow exercises 5×5 per day (5 exer- 6. 28+ Days (4–8 Weeks)
cises 5 times per day). Continue X10 hourly—active combined MCP and IP
Full active pronation and supination of the forearm flexion/opposition, aiming for the base of the little
5×5 per day. finger x10 hourly (may need to support the base of
Full active flexion and extension of all fingers 5×5 per the thumb)
day. + add active thumb abduction/adduction/
Adjust pain control as necessary to allow this regime. opposition.
438.e3
X10 hourly—active wrist flexion and extension exer- Full active flexion and extension of fingers 5×5 per day.
cises with the fingers relaxed (fingers in the posi- Full forearm active supination and pronation 5×5 per
tion of the fingers in the wrist tenodesis day.
manoeuvre—wrist flexion with fingers loosely From 4 weeks – light hand use but not lifting any-
extended and wrist flexion with fingers loosely thing more than 150 gm (6oz) = a full yogurt pot.
flexed). 7. 8 weeks onwards
Also start active radial and ulnar wrist movements. Continue all exercises as above.
Passive extension of wrist and fingers to neutral. Passive finger flexion if required.
Gradually increase active combined wrist and finger Dynamic flexion splinting if required.
extension as comfortable. From 8 weeks – return to light work and driving.
Add active combined wrist and digit flexion exercises From 12 weeks – return to heavy work and contact
at 6 weeks post-op if needed. sports.
Thumb splint worn at night and in busy places to 8 If there is extensor tendon tethering – forced passive
weeks. flexion exercises + massage dorsal skin of digit and
Shoulder and elbow exercises 5×5 per day (5 exer- dorsum of hand with finger held in flexion +
cises 5 times per day). ultrasound.
Days 0–5 Days 5–7 Days 7–14 Days 15–28

In Theatre Week 1 Weeks 1–2 Weeks 1–2 Weeks 3–4 Day 28+ Weeks 4–8
POP Rest in POP Thermoplastic Thermoplastic Thermoplastic Splint only worn at night/in
Palmar Splint Splint Splint fitted on Splint worn at Splint worn at busy places
day 6* all times all times
Wrist −30° Wrist −30° Wrist −30° Wrist −30° Wrist −30° Wrist −30°
MCP 0° MCP 0° MCP 0° MCP 0° MCP 0° MCP 0°
IP 0° IP 0° IP 0° IP 0° IP 0° IP 0°
X5 per hr X5 per hr X10 per hr X10 per hr
Thumb Thumb Thumb Thumb Exercises****
Exercises** Exercises*** Exercises****
Ultrasound from + add active abd/add/opp.
week 3 as nec.
Elevate hand Elevate hand Elevate hand Elevate hand Elevate hand above elbow
above elbow above elbow above elbow above elbow
Adjust pain
control as nec.
Finger Finger Finger Finger Finger Finger
Exercises Shoulder Shoulder Shoulder Shoulder Shoulder
immediately Elbow Elbow Elbow Elbow Elbow
Forearm Forearm Forearm Forearm Forearm
exercises Exercises Exercises Exercises Exercises
5x5 times daily 5x5 times daily 5x5 times daily 5x5 times daily 5x5 times daily
X10 hourly—full active wrist
movements with fingers relaxed
Hygiene/Splint Hygiene/Splint Increased Activity*****
Checks–7&14d Checks-21&28d
*The Thermoplastic Dorsal Dynamic Extension Splint is made with the same joint angles of the wrist and thumb MCP and with the splint
lifting off the thumb at the mid-proximal phalangeal level so that a sling can be attached around the distal phalangeal palmar (volar)
surface. When resting, the sling remains around the distal phalanx.
**Five times hourly, the sling is slid proximally, under the proximal phalanx, and the IP joint alone actively flexed and extended. Five times
hourly, the MCP joint alone is actively flexed and extended, with the sling under the distal phalanx and the base of the thumb supported
with the other hand. The thumb tip is aimed for the base of the middle finger during this maneuver.
***Five times hourly, the sling is slid proximally, under the proximal phalanx, and both the MCP and the IP joint are actively flexed and
extended, with the thumb tip aimed for the base of the ring finger.
****Ten times hourly, the sling is slid proximally, under the proximal phalanx, and both the MCP and the IP joint are actively flexed and
extended, with the thumb tip aimed for the base of the little finger. After 28 days, the same exercises are continued without the splint.
*****From 4 weeks light hand use—less than 150 gm (full yogurt pot).
From 8 weeks—light work/driving.
From 12 weeks—heavy work/contact sports.
Appendix 3
Repairs of Fingers: Mid Essex Hospital
Services, St Andrew’s Centre-Hand
Therapy, Essex, UK
ST ANDREW’S CENTRE – HAND THERAPY
EXTENSOR TENDON REPAIRS – FINGERS

Stone Splint – Weeks One to Four
This splint is to reduce the risk of the tendon(s) rupturing.
Weeks 1-4. A plastic splint will be made approximately 5 – 7 days after surgery. It is worn
continuously (24 hours) until 4 weeks after your surgery during which time you must
exercise your hand as instructed by your therapist. Do not use your hand, even unaffected
finger(s) and thumb.
Weeks 4-8. The splint is then worn for a further 4 weeks at night and when you are in
crowded places (e.g., shopping, using public transport). Do not drive until 8 weeks following
surgery. Your tendons are not strong enough and your insurance is invalid because of
your hand injury.
At 4 weeks after surgery you can begin to use your hand for very light activities only, not
lifting anything heavier than 6oz (150 grams) (e.g., yogurt pot).
At 8 weeks after surgery you can return to light work and driving.
From week 12 onwards you can return to heavy work after advice from your the surgeon
and the therapist.
EXERCISES FOR THE FIRST WEEK
You are required, as part of your treatment, to exercise as directed by your therapist
within the splint.
By gently exercising your hand, as instructed, these tendons will heal and are less likely to
become stuck or tightly caught in the scar.
1. Elbow and shoulder exercises – see separate sheet.
2. Straighten your thumb fully then bend it across your palm.

Repeat slowly 10 x each hour.
438.e5
3. Bend your fingers at all joints over the edge of the splint.
DO NOT push with other hand.
Then fully straighten your fingers.

The therapist may ask you to assist by straightening your fingers with your other hand.
Repeat slowly 10 x each hour.
• DO NOT bend or grip strongly with your fingers/thumb.

• DO NOT try to pick anything up with your injured hand.
• DO NOT let your hand hang down.
• DO NOT remove any of the splint or bandages. If you take the splint off against our
advice and it is lost or left at home, it will not be replaced!
You should ring us if:

• You feel pain, swelling, or discomfort
• The splint feels loose or is not fitting well
• You have any worries
Make sure you bring the splint with you to every appointment.
If any problems do occur please telephone the Hand Therapy Department at

01245 516009 between 8:30 a.m. and 2:00 p.m. Monday to Friday, ask for _____________.
It is very important that your hand and splint are checked by your therapist regularly.
It is your responsibility to attend your appointment.
Please telephone to cancel or change appointments.
Chapter 40: State of the Art of Extensor Tendon Rehabilitation 438.e7
ST ANDREW’S CENTRE – HAND THERAPY
EXTENSOR TENDON REPAIRS – FINGERS

Stone Splint - Weeks Four to Eight
You must continue to use your splint for protection (i.e., at night, outside the house, and at
times when your hand may get accidentally knocked) (e.g. by dogs, cats, and young
children).
Light activities can be started, you can lift 6 oz/150grams (e.g., a small yogurt pot), but
avoid straining (e.g., tying shoe laces, pulling on tight clothing/belts, tight taps, tops of
bottles, door handles).
EXERCISES
1. Continue all your hand exercises hourly, out of the splint (as advised by your
therapist).
2. Gently bend your wrist forwards with your fingers relaxed and straight. Hold for 5
seconds.
Gently bend your wrist backwards, keeping your fingers relaxed and slightly bent.
DO NOT push. Hold for 5 seconds.
Repeat slowly 10x each hour.
Make sure you bring the splint with you to every appointment.
If any problems do occur please telephone the Hand Therapy Department at

01245 516009 between 8:30 a.m. and 2:00 p.m. Monday to Friday, ask for _____________.
It is very important that your hand and splint are checked by your therapist regularly.
It is your responsibility to attend your appointment.
Please telephone to cancel or change appointments.
Appendix 4
The Manchester Regimen for
Postoperative Rehabilitation After Finger
Extensor Tendon Repairs, Manchester, UK
Timing Regimen
Zone 1 tendon avulsion, tear, avulsion-fracture, zone 1–2 surgical repair
Week 1 • Apply thermoplastic splint to immobilize DIP joint in full extension or slight hyperextension to be worn
full time.
• No active or passive DIP joint motion.
• Monitor regularly and ensure skin hygiene and compliance.
Week 6 • Following surgical repairs and avulsion fractures wean from splint at 6 weeks slowly over 2 weeks and
commence active DIP joint flexion and extension exercises.
Week 8 • After tendon avulsion and substance tears wean from splint at 8 weeks slowly over 2 weeks and
commence active DIP joint flexion and extension exercises if good active extension.
Week 12 • Continue to wear splint at night until 12 weeks.
• Commence passive flexion stretch at 12 weeks if flexion slow to recover.
Zone 3 and distal zone 4 surgical repair
Week 1 • Apply thermoplastic cylinder or gutter splint to immobilize DIP and PIP joint in full extension.
Week 2 • If lateral bands are uninjured shorten splint to allow active and passive DIP joint flexion and extension
exercises.
• No PIP joint flexion until 3 weeks.
Week 3 • Continue with splint but remove to commence 0°–30° active PIP joint flexion and extension exercises.
10 repetitions hourly progressing to 20 repetitions when comfortable.
• Continue DIP joint exercises in splint.
Week 4 • Progress to 0°–40° active PIP joint flexion if there is no loss of active extension. 20 repetitions every 2
hours replacing cylinder splint between exercise periods.
• Continue DIP joint exercises.
Week 5 • Progress to 0°–50° active PIP joint flexion. Continue with splint.
Week 6 • Remove splint and commence light functional activity and free active PIP and DIP joint flexion and
extension exercises.
• Continue with cylinder splint at night in presence of extensor lag.
• Commence passive flexion stretching.
Week 12 • Return to normal activity.
Zone 4 (proximal), 5, and 6 surgical repair
Week 1 • Apply 2 part thermoplastic forearm based splint. Wrist in 45° extension, MCP joints 0°, IP joints in full
extension. Include only affected digits but in Zone 6 include adjacent digit if tendon linked by juncturae.
Removable digital plate allows IP joint flexion and extension exercises (Figures 40-10 and 40-11).
• Commence active IP joint flexion and extension exercises. 10 repetitions hourly. Digital plate to be
replaced between exercises periods.
438.e8
Chapter 40: State of the Art of Extensor Tendon Rehabilitation 438.e9
Timing Regimen
Week 3–6 • Remove splint every 2 hours and commence active wrist flexion and extension exercises with digits
relaxed. Commence active MCP joint flexion and extension with wrist in flexion and IP joints extended.
Continue active IP joint flexion and extension exercises with MCP joints at 0°. 10 repetitions each
exercise. No composite flexion until 6 weeks.
Week 6 • Remove splint and commence composite flexion and extension exercises. Commence composite passive
flexion stretching. Allow light functional activity.
• Continue to wear splint at night in cases of extension loss.
• Return to normal activity once composite flexion regained.
Zone 7
Week 1 • Apply 2 part thermoplastic forearm based splint. Wrist in 21° extension, MCP joints 0°, IP joints in full
extension. Removable digital plate allows IP joint flexion and extension exercises.
• During weeks 1 and 2 IP joint flexion and extension exercises performed. 10 repetitions hourly.
Week 3–6 • Remove splint every 2 hours and commence gentle wrist motion with digits relaxed. No forced wrist
flexion.
• Commence active MCP joint flexion and extension with wrist at 0°.
• Continue IP joint active flexion and extension with MCP joints at 0°. 10 repetitions each exercise. No
composite flexion until 6 weeks.
Week 6 • Remove splint and commence composite flexion and extension exercises.
• Commence composite passive flexion stretching.
• Commence light functional activity.
• Continue to splint at night in presence of extensor lag.
Zone 8
Week 1 • In combination tendon and muscle belly injuries or muscle bellies only apply high forearm based
thermoplastic splint. Wrist 45° extension. MCP joints 0°. IP joints in full extension. Immobilize for
3 weeks.
Week 3 • For muscle bellies only remove splint and commence slow return to composite flexion.
• In cases of concomitant wrist tendon injury at 3 weeks reduce splint to allow unimpeded active MCP
and IP joint flexion and extension exercises. Remove splint 2 hourly for careful active wrist flexion and
extension exercises. 10 repetitions hourly.
Week 6 • Remove splint and commence composite active flexion and extension exercises.
• Commence composite passive flexion stretching.
The Manchester Regimen for the Postoperative Rehabilitation Following Surgical Repair of Extensor Pollicis
Longus: Manchester, UK
Timing Regimen
Zone T—1 surgical repair, avulsion fracture, and substance tear if treated conservatively
Week 1 • Apply thermoplastic splint to immobilize the IP joint only in full extension. To be worn full time for
6 weeks for avulsion fracture and post surgical repair and 8 weeks for substance tear.
• No active IP joint flexion or extension.
• Monitor regularly and ensure skin hygiene and compliance.
Week 6 • Following surgical repairs or avulsion fracture with large fragment wean from splint slowly over 2
weeks and commence 0°–30° active IP joint flexion and extension exercises. Gradually increase
range of active IP joint flexion if there is no loss of active extension.
• No passive flexion stretch.
• In avulsion or substance tear continue with splint.
Timing Regimen
Week 8 • Following avulsion or substance tear wean from splint slowly over 2 weeks and commence active IP
joint flexion and extension exercises. Gradually increase range of IP joint flexion if there is no loss of
active extension.
• All types to continue with splint at night in presence of extensor lag.
Week 12 • All types commence passive flexion stretch if required.
• All types return to normal activity.
Zone T—2 post surgical repair
Week 1 • Apply thermoplastic splint forearm splint with MP and IP joint in 0°. Thumb comfortably abducted
and extended.
Week 3 • Modify splint adding removable plate to commence 0°–30° active IP joint flexion and extension
exercises. 10 repetitions hourly.
Week 3–5 • Splint to be worn full time.
• Progress active IP joint flexion exercises increasing slowly 0°–60°.
Week 5 • Remove splint and commence light function. Increase active flexion and extension exercises.
• Continue with splint at night in presence of extensor lag.
Week 6 • Commence passive flexion stretch if required.
Weeks 10–12 • Return to normal activity.
Zones T—3–5 post surgical repair
Week 1 • Apply 2 part forearm based thermoplastic splint with wrist at 30°, MCP and IP joint at 0°. Thumb
comfortably abducted and extended. Removable plate to allow 0°–60° IP joint flexion and extension
exercises (Figs. 40-4, 40-5, and 40-6).
• Commence IP joint active flexion and extension exercises progressing to 60° flexion during the first
3 weeks.
• Splint to be worn full time and immobilize at night.
Week 3 • Remove splint to perform careful wrist flexion and extension with thumb relaxed to encourage
tenodesis action and promote tendon glide especially in Zone T5 where there is risk of adhesions
under retinaculum.
Week 5 • Remove splint continue with active IP joint flexion and extension exercises.
• Commence composite active MCP and IP joint motion to restore opposition.
• Continue to wear splint at night in presence of extensor lag.
Week 6 • Commence passive flexion stretch if slow to regain flexion.
Weeks 10–12 • Return to normal activity.
Appendix 5
Protocols of Exercise After Repair
of Extensor Tendon Injuries,
Queen Mary Hospital, The University
of Hong Kong, Hong Kong, China
Day Rehabilitation Program

Day 0 Extensor tendon injury rehabilitation program
Operation
Day 2 Dressing changed
Extension dynamic splint (Fig. 2) applied in occupational therapy department
Position: wrist 30° extension. MPJ and PIPJ full extension
Exercise program by physiotherapists
a. passive extension of MPJ and IPJ
b. active flexion of MPJ to 30°. IPJ to full flexion 1 against resistance of dynamic bands (with broad finger
straps at middle phalanx) 10 times hourly
c. no active extension
Discharged from hospital to hand class for alternate day treatment
Day 7 Splint adjusted to allow MPJ active flexion to 45° against traction system
Day 14 Splint adjusted to allow MPJ active flexion 1 to 60° against traction system
Sutures removed
Day 21 Splint adjusted to allow full active flexion of MPJ
Day 28 Should be able to regain full grip within splint
Day 35 Off splint
Exercise program
a. free active flexion and extension of fingers
b. gentle passive flexion of fingers
c. strong passive extension of fingers
d. wrist mobilization
Week 7 Active flexion and extension of finger against resistance
Passive flexion and extension of fingers
Gradual simultaneous active finger and wrist flexion
Week 8 Strengthening exercise
438.e11
Appendix 6
Extensor Tendon Rehabilitation Program, Queen
Mary Hospital, The University of Hong Kong,
Hong Kong, China
Zone IV → VIII
Thumb Zone I → V
Date *D1 1/52 *D8 2/52 *D15 3/52 *D22 4/52 *D29 5/52 *D36 6/52 *D43 7/52 *D50 8/52
Splintage Wrist 30° ext. Wrist 30° Wrist 30° Wrist 30° Wrist 30° ext. Off splint for wrist mobilization
MCP 15°–30° ext. ext. ext. *Off outrigger
+ outrigger MCP MCP MCP 0°
(dynamic band 15°–45° 15°–60° - full
at MP level, IP + outrigger + outrigger + outrigger
fully ext)
Active Extension No active fingers extension is allowed Free active fingers Free active Gentle Strong resistive
Movement extension within fingers resistive extension
cock up splint extension extension→
Flexion Active fingers flexion within splint & outrigger 10 times Free active fingers Free active Resistive Strong resistive
hourly flexion within fingers fingers flexion
cock up splint flexion flexion→
Passive Extension Passive extension of MCP & IPJs within the splint Strong passive extension of fingers
Movement
Flexion No passion flexion of fingers is allowed Gentle Strong Allow simultaneous
passive passive passive flexion of
flexion of flexion of fingers & wrist
fingers fingers
Remarks D14 Off Pressure Glove for scar as Work rehab in Occ
Stitches indicated Therapy as indicated
Appendix 7
Repair, Springfield, Mass, USA
Zone of
Injury Immobilization Passive Mobilization Active Mobilization
1–2 • 6–8 weeks full-time DIP — —
extension cylinder cast or
splint if not pinned.
• Gradually wean out of splint
(first for exercise only, then for
increasing time) and initiate
active flexion and extension.
3–4 • 3 weeks in IP extension if • Prefer not to use – if patient • 4 weeks Short Arc Motion (SAM)
referred too late for early can perform, can probably with resting splint full extension,
mobilization. also do well with Short Arc exercise template splint allowing
• Wean out of splint as above Motion (SAM) (Evans, 1992). 30° PIP flexion (Evans, 1992).
and initiate AROM. • See Active Mobilization. • Modify exercise splint to increase
• Focus on full extension and allowed PIP flexion weekly, and
initiate passive flexion discontinue at 4 weeks.
cautiously after 7 weeks.
5–6 • 3 weeks in wrist and IP • 3 weeks in dynamic • Except for border digits, Immediate
extension, 15–20° MP flexion. extension splint with wrist at Controlled Active Mobilization
May leave IPs free for Zone 6. 40–45° and active flexion (ICAM) (Howell et al, 2005).
• Wean out of splint as above without block to flexion • 1st 3 weeks: Yoke splint holding
and initiate AROM. Focus on (similar to Evans and MP(s) of involved finger(s) in
attaining full extension while Burkhalter, 1986). 15–20° greater extension relative
increasing MP and composite • Wean out of splint and to adjacent uninjured fingers.
flexion. initiate AROM. Worn with separate 20–25° wrist
• Prefer Immediate Controlled extension splint. Full motion as
Active Mobilization (ICAM) allowed by splints.
(see Active Mobilization) • From 3–5 weeks wean out of wrist
when a border digit not splint and initiate wrist ROM
involved. slowly.
• 5–7 weeks, yoke splint only.
Discontinue by 7 weeks.
7 • 3 weeks wrist extension and • None for wrist extensors. • None for wrist extensors. For
15–20° MP flexion. • Dynamic extension as for digits, have considered but not
• Wean out of splint and initiate Zones 5–6. tried Evans (2002) combination of
active ROM. Focus on dynamic extension with protected
differential glide between short arc active extension in
extensors. therapy only.
438.e13
Zone of
Injury Immobilization Passive Mobilization Active Mobilization
T-1 • As for Zones 1–2 (IP extension • 3–5 weeks dynamic thumb —
fulltime 6–8 weeks). Wean out extension with MP extension
of splint slowly and initiate block, outrigger cuff at DIP
AROM. joint (Elliot, 2005).
• Blocked MP and IP flexion
first week.
• Thumb opposition to middle
finger tip second week.
• Full opposition third week.
Wean out of splint thereafter
as indicated.
T-2 to • 3 weeks in wrist extension, • Dynamic thumb extension —
5 thumb in extension and with MP extension block
abduction as determined by (Elliot, 2005). Protocol above
structures repaired.
References
Elliot D, Southgate CM: New concepts in managing the long Callahan, T. M. Skirven, L. H. Schneider and A. L. Osterman.
tendons of the thumb after primary repair. J Hand Ther 18: St. Louis, C.V. Mosby. 1: 542–582, 2002.
141–156, 2005. Evans RB, Burkhalter WE: A study of the dynamic anatomy of
Evans R, Thompson D: An analysis of factors that support early extensor tendons and implications for treatment. J Hand Surg
active short arc motion of the repaired central slip. J Hand Ther (Am) 11:774–779, 1986.
5:187–201, 1992. Howell JW, Merritt WH, Robinson SJ: Immediate controlled active
Evans RB: Clinical management of extensor tendon injuries. Reha- motion following zone 4–7 extensor tendon repair. J Hand
bilitation of the Hand and Upper Extremity. E. J. Mackin, A. D. Ther 18:182–190, 2005.
Appendix 8
Protocols of Sydney Hand Therapy &
Rehabilitation Centre, Sydney, Australia
Exercises Out Time in

Zone Protocol Type Splint Exercises in Splint of Splint Therapy
3–4 SAM Splint position: Full extension, Immediately start Generally this is Total time in
template splints or other exercises following started at 6 therapy is
devices to limit flexion SAM protocol as weeks, but may be about 3
initially to 30 degrees. described by Evans. sooner at 4 weeks months, if
Some cases (e.g., crush Avoid stress on repair if the joint is stiff, difficulties
injuries) may switch to for 6 weeks. always monitoring maybe 4
Capener at 2 or 4 weeks. However if the to ensure months.
Splint stays on for: 6 weeks, joint is stiff and extension to 0 is
splinting may be longer thick and glide maintained.
if there is a lag and the poor more vigorous Graded resisted
splint may be changed to exercises may be exercises are
Capener or neoprene in the commenced at 4 commenced
day and static digit at night weeks. week 6.
Comments We use a “custom made” Capener that has very low tension (less than 300 g) that can be adjusted and
measured in order to facilitate the therapy program for Zone 3 PIP joint level injuries. Sometimes this works
better than taking splints on and off, but not always. An OFF the shelf Capener is ENTIRELY NOT appropriate
as they are all too strong (600 g plus). It is good to have some different options for different or difficult
situations.
Zone 5–6 Merrit or Merrit: Exercises as As described in the Total time in
Norwich Wrist extension splint in 45 described in original articles, therapy
(Depending on deg original articles graded resisted 3–4
referring plus hand piece with involved exercise is months
surgeon) digit 15 deg more commenced at 6
extension than adjacent weeks
digits
Norwich:
POSI type splint with wrist 45
deg ext
MP 45 deg flexion and IPs in
full ext
The splint stays on for 6
weeks and then 2 wks at
night and for travel
Comments The protocols used are generally reported but are sometimes changed depending on the healing of the
tissues, the patients scar and the mobility of the joint(s), and also what the surgeon found at the time of the
repair eg was it tight or was the tendon really mashed up. Also other factors like patient compliance, other
injuries to other structures in the hand can influence the protocol.
Zone 7 Immobilization Wrist in 40 degrees extension Active exercises start More vigorous active Total time in
Splinting is for 6 weeks then at 3 weeks exercises started therapy 3
weaned over 2–4 weeks at 6 weeks months
438.e15
Appendix 9
Therapy Protocols from Royal Free
Hampstead NHS Trust, London, UK
Exercises Out Total Time

Zone Protocol Type Splint and Positions Exercises in Splint of Splint in Therapy
3–4 Immobilization for Cylinder splint for PIP Active MCP/DIP 6–8 weeks unless
the first 3 joint which is joint flexion/ complications
weeks then extended, DIP free extension from
controlled unless lateral bands day 1
mobilization repaired PIP joint motion
MCP joint free commenced at
2–3 weeks full time 2–3 weeks as
until edema long as central
controlled and some slip can extend
extension central back to neutral
slip control visible 4–6 weeks increase
From 3–6 weeks range of PIP joint
splint full time in flexion as long as
extension coming extension good
out for gentle PIP Passive flexion and
joint exercises. Splint commence some
stopped 6 weeks gripping after 6
unless complications weeks
Comments We delay PIP active mobilization protocol slightly especially if the PIP joint is swollen or the wound infected.
Zone 5-6 Active–Norwich Position: First appointment 4 wks post op: 8–10 weeks on
Wrist joint 20 start passive ext exercises out average
extension from splint of splint and
MP 30 flexion unless Active ext from start moving
extension lag noted: splint wrist joint
MCP in extension Active ext fingers Increase flexion
IP neutral from splint and if fingers
Splint full time 4 weeks extension good towards
with exercises within then gentle palm as long
splint flexion of fingers as extension
Splint for protection towards splint good
4-8 weeks as NB patient must be Light activities
required depending able to maintain with hand
on age/occupation/ extension MCP allowed
hand dominance, etc. joints before
Splint week 4–8 flexion is allowed
reducing gradually
Stop splinting at 8 wks
438.e16
CHAPTER
41
CURRENT STATUS AND FUTURE
A Current Status and Future of

Flexor Tendon Surgery
Peter C. Amadio, MD
for many of them, joint contractures and loss of motion

CURRENT STATUS OF FLEXOR
are unsightly at best, and functionally awkward for
TENDON SURGERY
many. In short, while the current state of tendon surgery
Tendon surgery has certainly advanced over the past is better than it has ever been, it is not nearly as good
century. Our repairs are stronger and more reproduc- as those with injured tendons want it to be.
ible; most surgeons who deal with these injuries have
THE FUTURE OF FLEXOR TENDON SURGERY
had some sort of training in the management of tendon
injuries, and within the past 60 years hand surgery has What does the future hold for tendon surgery? A good
developed as a specialty, while within the past 30 years place to start is current research. These focus on two
hand therapy has joined it as a recognized field of spe- general areas—accelerating the pace of tendon healing
cialization. There are hand surgeons in nearly every and reducing adhesion formation. Along the way,
country on the planet; in the larger and more developed researchers in both areas must address a common
countries, there are literally thousands of trained hand pitfall—too much load, too soon, will result in tendon
surgeons and therapists. rupture, and a need for the patient to start all over again.
One might think that, with all this progress, tendon Speeding up tendon healing has already run down
injuries would be a solved problem. But, despite our one blind alley: once a tendon is moving, there is no
best efforts, this is not the case. The average result after evidence that more load on a repair speeds healing or
surgery restores perhaps 80% of normal finger motion reduces adhesions—all it can do is break the repair.
when both tendons are cut in zone 2, and that assumes Thus, the only reason to create ever stronger repairs is
a sharp laceration and a cooperative patient. Ragged to permit a bit more of a margin of safety for early
cuts, multiple injuries, and patients who are not able or mobilization, while at the same time not creating so
willing to cooperate with an early mobilization rehabili- much bulk as to impede healing or gliding. In my
tation program still frequently end up with adhesions, opinion, there is little more we can practically do in this
ruptures, infections, contractures, and other forms of regard—current repairs are “good enough.”
unsatisfactory results. What is needed to shorten tendon healing time? Two
Why is this? Primarily because while our under things—cells, and matrix, and these are interrelated,
standing of tendon healing, biomechanics, and physiol- because making matrix requires cells—specifically,
ogy has grown dramatically, our ability to improve fibroblasts initially, and then tenocytes. Tendons are not
upon Mother Nature remains where it was in Sterling very cellular, and the cells that are there are often trapped
Bunnell’s day—or, for that matter, Galen’s. We may in a dense collagen matrix. Adding cells from outside
sometimes be able to avoid slowing down the healing the tendon should help, and there are several studies
process, by better techniques, but we have not yet found now underway in animal models that should be trans-
a method to speed things up. And we must face reality— latable to humans soon, delivering differentiated cells
tendon injuries are most common in those who can or stem cells, either via a cell-seeded patch of some sort
least afford time away from work for rehabilitation and between the cut tendon ends, or by literally attaching
protection—mostly adolescents and young adults, the cells to the tendon suture. Add in the right mix of
mostly male, and mostly in occupations where heavy cytokines, or perhaps even platelet-rich plasma, and we
use of both hands is an expectation. And, while our should be able to develop a cocktail that can cut down
patients are often satisfied with less than normal motion, total healing time, and even better, accelerate the early
441
442 Section 6: Current Status and Future
healing phase, so that repair strength grows faster in the cause? Here, tissue engineering may help. While build-
first few weeks, when the repair is in greatest jeopardy. ing a tendon from scratch is daunting, it may be pos-
Reducing adhesions has always been possible, but at sible to manipulate allograft tissue, seeding it with host
a price—aggressive mobilization may result in tendon cells, and specialized surfaces in the middle for gliding,
rupture, and adhesion barriers are usually also healing and at the ends for attachment to tendon, muscle, or
barriers. New research into more permeable barrier, bone. Such work is already proceeding.
and ones that biodegrade over the critical first week In short, I think that the future for tendon surgery is
or two, when most adhesions begin to form, may do bright. With a decade, or two at the most, we should
the trick. have solved the remaining vexing problems of healing
Finally, what to do when no tendon is available, and function and have begun to apply those solutions
due to extensive injury, tumor resection, or some other clinically. The best is yet to come.
B Current Status and Future

A reasonable starting point for considering the future overrated (or underrated) and that cyclic load tests
for tendon surgery would be to consolidate what we would give more reliable information. Further con-
know of best practice today, and to ensure that this trolled studies comparing static and cyclic load testing
knowledge is as widely known as possible. Other chap- are indicated, and perhaps we should adopt cyclic load
ters in this book cover this in detail and as previously tests for all laboratory studies.
reported in surgical history practitioners will choose Recent studies have shown that different mammalian
which bits of advice are most believable and applicable. tendons have different physical characteristics. The com-
There now appears to be very strong evidence that mul- monly used and readily available pig flexor tendon
tistrand tendon repairs give a more reliable outcome to appears to be less like human flexor tendon than, for
acute tendon division. Hopefully, the use of two-strand example, sheep flexor tendon. The wide use of pig flexor
core sutures is diminishing for it appears important that tendon could have produced some inaccurate informa-
at least a four-strand core suture should be used. This tion and it may be better to use sheep tendon in
should be combined with, at least, a simple peripheral preference.
suture but a crossed or interlocked peripheral suture Many other technical problems in medicine and
adds further strength and gap resistance. A six-strand surgery have been resolved by a gadget using the special
core suture further improves repair strength, but it is properties of a physical material and clever engineering.
debatable whether addition of a crossed or interlocked The tendon repair would seem ripe for such a develop-
peripheral suture is beneficial. All these elements give a ment but currently we only have some relatively crude
repair that is, in the main, sufficiently robust to with- barbed suture techniques and screw devices. Further
stand the controlled active motion program and to development of these ideas on a more refined scale
reduce the chance of rupture in the healing phase. might yield something practical and strong.
In laboratory testing, traditionally single static tests Developments in post surgical rehabilitation may be
have been used to describe the quality of a tendon found, which combined with improved repair quality,
repair, but they do not mimic real life where a repair is could lead to less restrictive and shorter splintage regi-
subject to repeated loads. Single static load tests are rela- mens. As a parallel there are other aspects of trauma
tively straightforward to perform in a laboratory and surgery in which multipoint fixation; for example, distal
clearly give a reasonable evaluation of a repair’s quali- radius fractures, has enabled mobilization of the wrist
ties, but it is possible that tendon repairs have been before the fracture has healed. We have not reached a
Chapter 41C: Future of Tendon Surgery of the Hand 443
point where repair strength is sufficient to discard the within the flexor tendons of the injured finger yet allow-
splint immediately after surgery, although possibly this ing it to move.
could come about, but presumably another means of Other ideas will emerge!
restricting finger activity would be required. A theoreti- Biological research may identify methods of acceler-
cal idea for reducing power to one finger could be devel- ating tendon healing and reducing adhesion. Current
oped: the injured finger would be held slightly more tried techniques include grafts and locally applied
flexed than the neighboring fingers reducing the tension agents.
C Future of Tendon Surgery

of the Hand
Jin Bo Tang, MD
The repair of injured tendons is a fascinating field that involving serious damages to multiple structures (such
has attracted the particular attention of hand surgeons as fractures or soft tissue defects), though not related to
over the past century. In the early 1970s, Verdan wrote the quality of tendon repair only, frequently result in
a classic review: “Half a century of flexor-tendon surgery. distinct loss of function. In many such cases, extensive
Current status and changing philosophies” (J Bone adhesions form; arduous staged reconstruction is neces-
Joint Surg [Am] 52:472–491, 1972). In 1987, Hunter, sary. There is still no guarantee of functional recovery to
Schneider, and Mackin edited the book Tendon Surgery the level desired by both patients and surgeons. Fortu-
in the Hand to summarize the progress. nately, the number of such cases declined drastically
The authors of the current book and our predecessors after the inception of primary tendon repair in the
have witnessed major paradigm shifts in both funda- digital sheath area. Though relevant to surgery of the
mental concepts and the practice of tendon repair. The tendon per se only partly, tendon transfers do not
content of this book reflects the growing body of knowl- restore full, or sometimes, major hand function after
edge and advances over the past 25 years. After almost a nerve palsies.
century of efforts by basic scientists and surgeons, our It is difficult to precisely or inclusively predict future
accumulated knowledge of basic scientific knowledge developments in a field. Scientific and technical innova-
offers both useful and meticulous guidance for clinical tions are by their nature unpredictable. Nevertheless, we
practice, making it much more feasible to restore the can summarize those areas where work is under way and
function of the hand. Principles of primary repair and those that await answers and continuing efforts.
secondary reconstruction have been established; surgical We will probably see the following changes in the
and postoperative care methods have been developed. near future:
Armed with current guidelines for surgical repair and
postoperative care, well-trained hand surgeons can 1. More widespread use of stronger surgical repairs.
expect to restore near-normal function of the hand and We already see a trend towards use of stronger
digits after repair of injuries chiefly involving the tendons. surgical repairs. However, the speed of change
It appears that major scientific and technical obstacles varies with the resources of the hospital and with
on the path to nearly optimal primary tendon repair geographic region. I expect that strong surgical
have been eliminated, except in a few specific instances. repairs will become the method of choice for the
Nevertheless, tendon injuries with delayed presenta- vast majority, if not all, of surgeons, particularly in
tion, injuries in a complex wound setting, and injuries digital areas and for flexor tendons.
444 Section 6: Current Status and Future
2. Early combined passive-active motion. It is clear the future, efforts to accelerate tissue healing and
to me that combined passive-active motion is an repair will find the tendon a perfect test ground
ideal way to rehabilitate repaired fingers. However, for transferring some basic scientific concepts to
regimens incorporating this principle can vary the clinic, because tendons are composed mainly
enormously. I believe that rubber band traction of uniform collagen building blocks with aston-
should be abandoned in digital flexor tendon ishingly little vascularization. Compared with
rehabilitation and that passive-only motion tissues rich in vasculature, enhancement of tissue
reserved for patients who fail to comply with repair in tendons may be more attainable. We
active motion regimens. Generally, in each exer- expect that injection or implantation of bioactive
cise session, passive motion should precede active agents will fortify weak tendon healing capacity.
motion to lessen resistance to tendon gliding. Currently, approaches with such potentials include
3. Simplification of motion protocols. We currently gene therapy, controlled release systems, or coated
see a variety of protocols in different units, and surgical sutures; certainly novel methods would
some are quite complex. The variation in proto- emerge and will bring us even closer to this goal.
cols that produce comparable clinical outcomes 2. Reducing adhesion formation. Reducing adhe-
indicates that some protocol details are of second- sions has been a constant theme in tendon surgery
ary importance. We should be cognizant that and imputes for investigations. Limiting adhe-
current protocols are largely experience-based and sions is important not only for primarily repaired
in fact constitute “expert opinions.” My opinion is tendon, but also after secondary tendon grafting
that workload of patients and therapists may be or tenolysis. Broadly, avoiding adhesion or scar is
reduced, without lowering rate of success. For desirable after all surgical interventions, but it is
example, hourly exercise of repaired tendons particularly necessary for tendons, which glide
may not be necessary; four or five sessions of exer- within a restrictive sheath. Surface modifications
cise in a day would probably suffice. The number of tendons, which have been the goal of Peter
of repetitions is increased in each session. This Amadio and his colleagues for a decade, are impor-
would relieve the patients from hourly exercise tant to reduce not only gliding resistance but
of the repaired fingers. In addition, it appears adhesions as well. Such efforts likely offer great
unnecessary to actively move the finger through a potential for decreasing adhesions arising from
full range of motion, particularly in the initial 1 the tendon surface. Another fertile research area is
to 2 weeks. It is vital to keep in mind that the most molecular methods to regulate tendon healing
extreme portion of active finger flexion carries the and inhibit key mediators of scar formation.
greatest risk of disrupting the repair. Partial active However, we must be prepared to understand the
finger flexion not only reduces the chance of over- complex nature and interactions of molecular
loading the tendon, but also diminishes pain and events, and recognize the complexity of interven-
discomfort. Nevertheless, passive finger motion tions at the molecular level. Such approaches may
does need to be executed over the entire range. not prove easy and straightforward, particularly
4. Loosely controlled postoperative motion. In when aimed at simultaneously maintaining
patients whose tendon has been repaired with a healing strength.
strong method, and after proper measures (such 3. Engineered tendons for reconstruction of tendon
as pulley release) have been taken to diminish defects. This is certainly a worthwhile future direc-
tendon gliding resistance, the finger can be tion. The work of researchers in James Chang’s lab
expected to actively move under less stringent pro- leads me to expect that decellularized allogenic
tection or a substantially simplified protocol, pro- tendons will serve as a good scaffold clinically,
vided such motion is not against resistance. providing structural supports for cell seeding in
Employment of such hand motion perhaps will be vitro before implantation or cellular ingrowths
a major advance in the future. from surrounding tissues in vivo. These tendons
bypass the major obstacle in generating scaffolds
The following changes may not occur in the near future, that mimic the flexibility and loading capacity of
but are likely in the years or decades to follow: intrasynovial tendons. In contrast, it is hard to
speculate whether or how soon a “tendon” made
1. Biological approaches to increase intrinsic of biomaterials incorporated with cells in vitro or
tendon healing. Recent years have seen growing in vivo will be used to replace a tendon graft; there
realization of the impact of molecular biotechnol- is a long road ahead of us. There is the open ques-
ogy on medicine. Molecular therapy catches public tion of whether we can ever produce materials
imagination of future medicine, and offers thera- with the superb mechanical properties of natural
peutic promise to regulating tendon healing. In intrasynovial tendons. If we ever do reach that
Chapter 41C: Future of Tendon Surgery of the Hand 445
goal, I expect it to happen in the quite distant Finally, future development of our field includes the
future. education of qualified hand surgeons. This remains a
4. Novel materials and methods to promote tendon great concern and is also a pressing task. Scientific
healing or a manufactured tendon substitute. advances have cleared the major obstacles encountered
Basic scientific developments always offer novel 50 years ago in repairing injured tendons. Nevertheless,
tools to battle against frustrating problems. Lately close-to-ideal outcomes are expectable only when sur-
emergent options constantly replace old ones, geons have been well-trained in tendon repair and abide
though only very few among these may offer actual by up-to-date surgical and postsurgical care guidelines.
solutions. Each innovation creates energy and Unfortunately, tendon injuries may have disastrous
enthusiasm for tackling the problem. I expect that clinical results if treated by unqualified surgeons.
novel materials and methods will be used to In most regions of the world, it is not the current state
produce tendon substitutes (or enhancing the of scientific and technical knowledge that limits return of
healing process). Nevertheless, tendons have many clinically acceptable function after tendon injury; rather, it
unique requirements as a viable biologic tissue— is the lack of both trained surgeons and adequate rehabilita-
bearing both compressive and pulling forces tion systems that prevents functional restoration of the injured
during motion, being firm enough to sustain com- hand (Injury 37:1036–1042, 2006).
pression and flexible enough to accommodate Therefore, in countries where hand surgery is not
angular motion, while surrounded by a restrictive fully recognized as an established surgical subspecialty,
sheath in some parts. The tendon should not be surgeons should be encouraged to become specialists in
bulky, but smooth and free of restraining adhe- the hand. It should be realized that, development of
sion. Any manufactured tendon substitute must techniques and expansion of knowledge on treating
possess these biological and mechanical qualities. hand disorders make a general orthopedic or plastic
surgeon less likely to treat a tendon injury in the hand
The following issues are unlikely to be overcome in proficiently. Poor mastery of surgical techniques and
foreseeable future, and will thus continue to affect out- lack of sufficiently precise knowledge of anatomy jeop-
comes: (1) less-qualified surgeons still repair a propor- ardize treatment outcomes. Ideal repair of lacerated
tion of cases; (2) particular injuries, such as those in the tendons is based on understanding of hand anatomy
little finger, will continue to be a problem; (3) severe and biomechanics, possession of fine surgical skills, and
injuries involving multiple structures, whose outcomes knowledge of hand rehabilitation or cooperation with
do not chiefly depend on treatment of tendon injuries, hand therapists. Improving education and training is
limit the extent of recovery, and (4) socioeconomic con- one of the most momentous tasks among all that we
ditions limit the availability and affordability of surgery will have in the future.
and postoperative rehabilitation.
CHAPTER
42
CHEMICAL MODIFICATION OF
TENDON GLIDING SURFACE
Yu-Long Sun, PhD, and Peter C. Amadio, MD
Phospholipase C selectively removes certain types of

TENDON LUBRICANTS
phospholipids, such as phosphatidylcholine, without
The flexor digitorum profundus (FDP) tendon glides destroying the extracellular matrix network.14 The
within tendon sheath, which consists of annular liga- increase in friction after treatment with phospholipase
ments or pulleys, during the movement of fingers. This C suggests that phospholipids are present on the surface
tendon-pulley system has a low coefficient of friction of the FDP tendon, and that phospholipids help to
(0.04), which is similar to that of articular cartilage lubricate FDP tendon (see Figure 42-1). This conclusion
(0.014).1 was further confirmed by the increase in friction after
Lubrication mechanism of articular cartilage has been treatment with lipid solvent. The increased effect of
widely investigated.2,3 Hyaluronic acid (HA), lubricin, lipid solvent compared to phospholipase C suggests
and phospholipids are thought to be involved in the that phospholipids other than phosphatidylcholine
lubrication of the cartilage–cartilage interface, acting may also affect tendon lubrication.
alone or in combination. HA is a polyanionic polysac- Trypsin can digest lubricin as well as other extracel-
charide, present in the intercellular matrix of most ver- lular matrix proteins except collagen, the principal
tebrate connective tissues, especially in synovial fluid. protein in tendon. Trypsin digestion resulted in a sig-
The unique properties of HA result in a molecular nificant increase of friction of the FDP tendon (see
network that, in highly hydrated conditions, is extremely Figure 42-1). Although the increase of friction could
viscoelastic and pseudoplastic, favorable rheological contribute to phospholipids, which could be carried by
properties for a potential lubricant. Lubricin, also known lubricin and/or other extracellular matrix proteins, it
as superficial zone protein and proteoglycan 4, is a gly- was found that the friction of the FDP tendons could
coprotein which has been identified in synovial fluid4,5 be further increased with trypsin after the elimination
and the superficial zone of articular cartilage.6 It has of phospholipids with lipid solvent (see Figure 42-1).
been noted to lubricate articular cartilage with the same Hence, the effect on friction could be due to a removal
lubricating properties as normal synovial fluid. Lubricin of protein components, especially lubricin, a glycopro-
is widely considered to be the principal lubricant in tein both known to have lubricating ability, although it
joints.3,7 Furthermore, phospholipids, the major compo- cannot exclude an effect from other proteins on the
nent of all biological membranes, are known to contrib- tendon surface.
ute to joint lubrication and to lubricate other gliding Many factors appear to contribute to the lubrication
surfaces as well.8,9 mechanism of the FDP tendon. The research findings
HA and lubricin have been identified on the surface are strongly suggestive of the presence of, and a role for,
of the FDP tendon.10-12 While phospholipids have not proteins, HA, and phospholipids in tendon lubrication.
been sought in tendon, it is reasonable to assume that Phospholipids, HA and lubricin, may serve as boundary
some are present, as phospholipids are found in all lubricants in FDP tendon lubrication.
living tissues. To assess the effect of HA, lubricin, and
CHEMICAL SURFACE MODIFICATION
phospholipids on tendon lubrication, the enzymatic
OF TENDON IN VITRO
and chemical treatments were applied to remove them
from the surface of canine FDP tendons.13 Tendons attach muscle to bone and transfer the power
Hyaluronidase can effectively digest HA. The effect of of the muscle to bone over a distance. The structure of
the hyaluronidase digestion on the friction between tendon is directly related its physical and physiological
FDP tendon and its associated pulley was measured. The function. The surface of tendons well adapts to their
friction between the FDP tendon and its pulley increases mechanical environments.15 Tendons are characterized
after the FDP tendon is treated with hyaluronidase based on their anatomic location as either intrasynovial
(Figure 42-1).10,13 Therefore, HA has been assumed to or extrasynovial.16-18 The intrasynovial tendons, such as
play a role in lubricating the surface of the FDP tendon. the FDP tendon, have parietal and visceral synovial
This chapter does not appear in the print edition. e1

e2 Chapter 42: Chemical Modification of Tendon Gliding Surface
0.15 OH OH
O
0.12
O O
Friction (N)
* * * * O HO
0.09 O
HO
OH NH
0.06
0.03 O n
0 Figure 42-2 The chemical structure of hyaluronic acid.

Control HAase PLC LipSol Trypsin LipSol-
Try
Treatment HA Paratenon
HOOC HOOC
Figure 42-1 The friction of FDP tendons treated with
COOH CONH
control solution (Control), hyaluronidase (HAase), COOH COOH
NH2
phospholipase C (PLC), lipid solvent (LipSol), trypsin, and the COOH
combination of lipid solvent and trypsin (LipSol-Try). NH2 EDC CONH
CONH
NH2 COOH
sheaths that form a closed compartment that contains

synovial fluid for lubrication and nutrition. In extrasy-
novial tendons, such as the peroneus longus (PL) Tendon
tendon, there is a peritendinous sheet of loose fibrillar Figure 42-3 Chemical surface modification of
tissue, the paratenon, which functions as an elastic extrasynovial tendon with cd-HA. EDC is 1-ethyl-3-
sleeve, permitting limited movement of the tendon (3-dimethylaminopropyl)carbodiimide.
against the surrounding tissue. The extrasynovial auto-
graft, intrasynovial allograft, and the repaired flexor
tendon are the accepted procedures in flexor tendon disaccharide that consists of N-acetyl-D-glucosamine
surgery. The chemical surface modification of these and D-glucuronic acid linked by a β1–4 glycosidic bond
tendons is described later. (Figure 42-2).25 The disaccharides are linked by β1–3
bonds to form the HA chain. Each disaccharide has one
Extrasynovial Autograft carboxyl group, which can be activated by carbodi-
Tendon graft plays an important role in reconstruction imides at physiological condition to form an amine-
to restore finger function in the cases of severe flexor reactive O-acylisourea intermediate that quickly reacts
tendon damage, adhesion formation, and primary with an amino group to form an amide bond and
tenorrhaphy rupture. As the potential sources of intra- release an isourea. As amino group universally exists in
synovial tendons available for use as tendon autografts the protein components, such as collagen, the major
are limited, the most donor tendons, such as palmaris extracellular matrix in tendon, with the activation of
longus tendon, plantaris tendon, and long extensor carbodiimides, HA could cross-link paratenon and
tendon, come from extrasynovial tendon sources in tendon and keep paratenon resist abrasion. Further-
clinical settings. Extrasynovial tendons have rougher more, HA is a lubricant of tendon. The chemical reac-
surfaces than intrasynovial tendons.19,20 The coating of tion can tightly bind HA on the surface of tendon and
paratenon on the surface of extrasynovial tendon is play a role in lubrication (Figure 42-3).
extremely susceptible to damage as the tendon repeti- We performed a study to evaluate HA and carbodi-
tively glides against the pulley. Extrasynovial tendons imide derivatized HA (cd-HA) on the gliding of canine
create higher friction against a pulley compared to intra- PL tendon, an extrasynovial tendon.26 We found that
synovial tendons, particularly after multiple repetitive the gliding resistance of normal PL increased with the
motion.20-22 Animal models have shown that extrasyno- increase of cycle of repetitive motion (Figure 42-4).
vial tendon grafts are associated with more adhesions The administration of exogenous HA (1%) resulted in
to the surrounding tissue than intrasynovial tendon the nonchange of gliding resistance in the first cycle of
grafts.19,23,24 Therefore, outcomes of extrasynovial grafts motion after the administration. However, the gliding
may be improved by keeping paratenon intact as well resistance of PL treated with HA increased significantly
as low friction of the grafts. over five cycles of repetitive motion than normal PL did.
HA is a linear, unbranched polysaccharide with a The quick discharge of the lubricating ability of exoge-
high molecular weight. It is composed of a repeating nous HA indicates the weak attachment of HA on the
Chapter 42: Chemical Modification of Tendon Gliding Surface e3
1.2 1.4
Saline 1.2
1
HA
Gliding resistance (N)

0.8 cd-HA 1
0.8
0.6
0.6
0.4
0.4
0.2
0.2
0
Normal 1 5 10 20 50 100 0
Cycles 0 100 200 300 400 500
Cycles
Figure 42-4 Gliding resistance of PL tendon treated with
saline, exogenous HA, or cd-HA over 100 cycles of repetitive FDP cd-HA
motion against pulley. Saline cd-gelatin
Gelatin cd-HA-gelatin
surface of the tendon. cd-HA, which is composed of Figure 42-5 Gliding resistance of FDP tendons and PL
1% HA with 1% 1-ethyl-3-(3-dimethylaminopropyl) tendons treated with saline, gelatin, cd-HA, cd-gelatin, or
carbodiimide hydrochloride (EDC) and 1% N- cd-HA–gelatin at different cycles of simulated motion.
hydroxysuccinimide (NHS), significantly decreased the
gliding resistance of the PL tendon compared with that
of normal PL tendon or the PL tendon treated with HA between the PL tendon treated with cd-gelatin and the
only, at each corresponding cycle of repetitive motion. PL tendon treated with cd-HA–gelatin (p < 0.05), with
This finding indicates the chemical modification the latter group having a lower gliding resistance at
improves the attachment of HA and/or paratenon on comparable cycles of simulated flexion/extension. At
the surface of the PL tendon. the 500th cycle, the increase in gliding resistance of
Although cd-HA improves the gliding of the PL the cd-HA–gelatin treated PL tendons was roughly 4
tendon, the gliding resistance decreased significantly times that of the FDP tendon, compared to a 20-fold
only in the first cycle of motion after the administration difference for the saline treated PL tendon. The gliding
and increased over 20 cycles of repetitive motion. of the PL tendon treated with cd-HA–gelatin almost
Gelatin, which serves as a carrier of HA and a cross- approached that of the FDP tendon. The chemical mod-
linker and a cross-linker, was introduced to further ification of the surface of the PL tendon with cd-HA–
improve the gliding of the PL tendon. It was found that gelatin also significantly improved its resistance to
all PL tendons treated with saline, 10% gelatin, or cd-HA abrasion. After 500 flexion/extension cycles, the surface
(1% HA, 0.25% EDC, and 0.25% NHS) showed similar of untreated PL tendons was roughened, and the col-
trends up to 500 cycles of repetitive motion22,27 (Figure lagen fibers covering the PL tendon surface were twisted
42-5). Over the first 200 cycles, the gliding resistance into large strands. In contrast, the surface of the PL
increased linearly and then reached a plateau. There was tendon treated with cd-HA–gelatin was still smooth
no significant difference in gliding resistance between after 500 cycles of repetitive motion, and the normal
the saline-, gelatin-, and cd-HA–treated PL tendons for collagen fibers on the PL tendon surface remained
any given number cycles of motion. For the PL tendon intact, similar to the FDP tendon.
treated with cd-gelatin (10% gelatin, 0.25% EDC, and The formula of cd-HA–gelatin and the curing time
0.25% NHS) and cd-HA–gelatin (1% HA, 10% gelatin, were further optimized to improve the surface gliding
0.25% EDC, and 0.25% NHS), the gliding resistance of extrasynovial tendon grafts.28,29 cd-HA–gelatin with
increased at a much more gradual rate over the 500 1% HA, 10% gelatin, 1% EDC, and 1% NHS showed
cycles. Beginning at 100 cycles of simulated flexion/ the best improvement of gliding of extrasynovial tendon
extension, the gliding resistance of tendons treated with grafts. Meanwhile, it was found the curing time could
cd-HA–gelatin was significantly lower than that of the be as short as 5 minutes for this formula of
saline-treated tendons. Starting at 200 cycles, the gliding cd-HA–gelatin.
resistance of tendons treated with cd-gelatin was also In addition to HA, lubricin also is believed a lubri-
significantly lower than that of the saline-, gelatin-, and cant of tendon. Can lubricin improve the gliding of
cd-HA–treated PL tendons. Starting at 300 cycles, there extrasynovial tendon grafts by itself or a chemical
was also a significant difference in the gliding resistance approach? A study compared the lubricating ability of
1.2 0.9
0.8
1.0
0.7
0.8
0.6
0.6 0.5
0.4
0.4
0.3
0.2
0.2
0.0 0.1
0 200 400 600 800 1000
0.0
Cycles
0 200 400 600 800 1000
Saline cd-HA-gelatin Cycles
Lubricin cd-gelatin
cd-gelatin + lubricin Saline cd- cd-HA-
cd-HA- gelatin + gelatin +
gelatin lubricin lubricin
Figure 42-6 Gliding resistance of PL tendons treated with
saline, lubricin, cd-gelatin, cd-HA–gelatin, or cd-gelatin/
lubricin at different cycles of tendon motion. Figure 42-7 Gliding resistance of PL tendons treated with
saline, cd-HA–gelatin, cd-gelatin/lubricin, or cd-HA–gelatin/
lubricin at different cycles of tendon motion.
canine PL tendons that were treated with saline, bovine

lubricin (260 µg/mL), cd-gelatin (10% gelatin, 1% EDC, significantly lower than that of the saline-treated control
and 1% NHS), cd-HA–gelatin (1% HA, 10% gelatin, 1% after 1000 cycles (Figure 42-7). The gliding resistance
EDC, and 1% NHS), or cd-gelatin plus lubricin (260 µg/ in these treatment groups decreased within the first 50
mL lubricin was applied after cd-gelatin treatment).30 cycles and then increased at a much more gradual rate
There was no significant difference in the gliding resis- over the 1000 cycles, with the cd-HA–gelatin plus lubri-
tance between the tendons treated with saline solution cin group being most stable. The results indicate that
and those treated with lubricin alone or between the the chemical modification can be applied in a variety of
tendons treated with cd-HA–gelatin and those treated extrasynovial tendons.
with cd-gelatin plus lubricin (Figure 42-6). However, HA, lubricin, and phospholipids exist in native syno-
the gliding resistance of the tendons treated with vial fluid and also are found to play the role of tendon
cd-gelatin plus lubricin was significantly lower than that lubrication. Instead of using purified HA and lubricin,
of the tendons treated with saline solution, lubricin native synovial fluid may serve as a lubricating material
alone, or cd-gelatin alone. The results indicate that to improve the gliding of extrasynovial tendon. Canine
lubricin does have an important effect on tendon lubri- PL tendons were treated with either saline, 1% EDC/1%
cation. Like HA, lubricin may preferentially adhere to NHS, cd-gelatin, synovial fluid, synovial fluid plus 1%
tendon surface pretreated with cd-gelatin and when so EDC/1% NHS, or cd-gelatin–synovial fluid. The gliding
fixed in place. resistance was measured for 1000 cycles of simulated
The gliding of the canine PL tendon can be improved flexion/extension motion. Same as HA and lubricin
with the chemical treatment of cd-gelatin, cd-HA– only, synovial fluid alone did not improve the gliding
gelatin, and cd-gelatin plus lubricin. The feasibility of of the tendon (Figure 42-8). The gliding resistance of
these approaches was tested with human ipsilateral the tendons treated with synovial fluid plus 1% EDC/1%
palmaris longus tendon, an extrasynovial tendon often NHS, cd-gelatin, or cd-gelatin–synovial fluid was signifi-
used for tendon grafting clinically. Human palmaris cantly lower than the control group after 1000 cycles of
longus tendons were treated with either saline, cd-HA– tendon motion. The gliding resistance of the tendon
gelatin, cd-gelatin plus lubricin, or cd-HA–gelatin plus treated with cd-gelatin–synovial fluid was significantly
lubricin. After treatment, tendon gliding resistance lower than that of the tendon either treated with syno-
was measured during up to 1000 cycles of simulated vial fluid plus 1% EDC/1% NHS or cd-gelatin. No sig-
flexion and extension motion.31 The gliding resistance nificant difference was found in the gliding resistance
of the PL tendons in the cd-HA–gelatin, cd-gelatin plus between first cycle and 1000 cycles for the gliding resis-
lubricin, and cd-HA–gelatin plus lubricin groups was tance of the tendon treated with cd-gelatin–synovial
1.00
Gliding resistance (N) 0.80
0.60
0.40
0.20
0.00
0 100 200 300 400 500 600 700 800 900 1000
Gliding times
cd-SF-gelatin EDCNHS
cd-gelatin cd-SF
Control SF
Figure 42-8 Gliding resistance of PL tendons treated with saline, cd-HA–gelatin, cd-gelatin/lubricin, or cd-HA–gelatin/
lubricin at different cycles of tendon motion.
fluid. The results indicate that synovial fluid can be 0.6

applied by chemical approach to improve the gliding of *
extrasynovial tendon. 0.5 *
* †‡
Intrasynovial Allograft 0.4
Friction (N)
Intrasynovial tendon autografts may have better out- ** ‡

comes than extrasynovial autografts do. The autologous 0.3
†
intrasynovial tendons are rarely available for tendon *
grafts. However, intrasynovial tendon allografts are 0.2
more available and can be potentially used as flexor
0.1
tendon graft. In order to reduce immunogenicity and to
facilitate storage, allografts may be subjected to repeti-
0
tive freeze/thaw cycles and lyophilization.32 We found
First cycle 1000 cycles
that frictional force of the flexor digitorum profundus
Cycle
tendon, which was lyophilized and rehydrated in a
saline solution, was significantly increased in compari- Before Lyophilized After cd-HA
son with that of the normal FDP tendon (Figure 42-9).
*, **; p <0.05
With the surface modification of FDP tendon allograft †, ‡; p <0.05
with cd-HA–gelatin (1% HA, 10% gelatin, 1% EDC,
“and 1% NHS), the frictional force of the lyophilized Figure 42-9 The gliding resistance for the groups of
FDP tendon was significantly decreased in comparison normal tendons, untreated lyophilized tendons, and
with the untreated lyophilized tendon even after 1000 lyophilized tendons treated with cd-HA–gelatin.
cycles of repetitive motion in vitro (see Figure 42-9).
The results indicate that tendon surface modification
with cd-HA–gelatin can improve the gliding ability of 0.40

lyophilized flexor tendons and therefore may improve
Increase in average gliding resistance (N)

the utility of lyophilized tendon allografts as a tendon 0.30
graft substitute.
0.20
Flexor Tendon Primary Repair
With the development of surgical techniques and post- 0.10
operative controlled mobilization, the primary repair
after injury has been the mainstream in flexor tendon 0.00
surgery. Stronger repairs have been advocated to permit
early active mobilization and to reduce adhesion forma- –0.10
tion,33 but tendon adhesions and tendon repair rupture
remain a problem even with stronger repairs.34 The role
–0.20
of friction as a source of adhesions has been investi-
gated. The data suggest that many strong repairs also
–0.30
have higher friction35-37 and that this higher friction is 0 200 400 600 800 1000
associated with poorer results in an animal model.38
Gliding cycles
The repair constantly increases the gliding resistance
of the flexor tendon.39 A number of suture techniques Saline cd-HA-gelatin
were investigated to repair FDP tendon.35-37 The modi- cd-gelatin cd-HA-gelatin
fied Kessler and modified Pennington techniques are + Lubricin + lubricin
satisfied with relatively high breaking strength and low
gliding resistance. However, gliding resistance of the Figure 42-10 Increase in average gliding resistance of
FDP tendon repaired with these two techniques is sig- repaired FDP tendon in the four treatment groups at
nificantly higher than the intact FDP tendon. different cycles of tendon motion.
The effects of chemical surface modification on
gliding and repair integrity were investigated during
simulated repetitive motion of a repaired tendon in
vitro.40 The gliding resistance between the FDP and the
proximal pulley was measured before laceration. After
the repair with modified Kessler technique, the tendons at much more gradual rate over the 1000 cycles (Figure
were treated with saline, 1% HA, or cd-HA–gelatin (1% 42-10). In these groups, the mean and peak gliding
HA, 10% gelatin, 0.25% EDC, and 0.25% NHS). Then resistance after 1000 cycles was still lower than the
the gliding resistance of the tendons was measured up initial gliding resistance before treatment, while the
to 500 cycles of repetitive motion. The results showed, gliding resistance in the saline control tendons increased
from the first cycle to the 10th cycle, no significant dif- significantly over the 1000 cycles of testing. The repaired
ferences in gliding resistance between the three testing tendons treated with cd-HA–gelatin plus lubricin had
groups. From the 50th cycle onward, the friction was the lowest gliding resistance comparing the tendons in
significantly lower in the cd-HA–gelatin group than other three groups at same cycle of repetitive motion.
in the control group. Neither breaking strength, nor The surfaces of the repaired tendons appeared smooth
tendon stiffness, nor resistance or gap formation of the after 1000 cycles of tendon motion for the tendons
repairs, was significantly different with the treatment of treated with cd-HA–gelatin, cd-gelatin plus lubricin,
cd-HA–gelatin. and cd-HA–gelatin plus lubricin, while that of the saline
The effects of lubricin chemical modification on the control appeared roughened. These results suggest that
gliding of repaired FDP tendons were also investigated tendon surface modification can improve tendon gliding
in vitro.41 Canine FDP tendons were completely lacer- ability, with a trend suggesting that lubricin fixed on the
ated, repaired with a modified Pennington technique, repaired tendon may provide additional improvement
and treated with one of the following solutions: saline, over that provided by HA and gelatin alone.
cd-HA–gelatin (1% HA, 10% gelatin, 1% EDC, and 1%
EVALUATION OF CHEMICAL MODIFICATION
NHS), cd-gelatin plus lubricin (260 µg/mL), or cd-HA–
IN ANIMAL MODELS
gelatin plus lubricin. After treatment, the gliding resis-
tance was measured up to 1000 cycles of simulated The chemical surface modification succeeded in improv-
flexion/extension motion. The gliding resistance of the ing the gliding ability of extrasynovial tendon, intrasy-
repaired FDP tendons in the cd-HA–gelatin, cd-gelatin novial tendon allograft, and the repaired flexor tendon
plus lubricin, and cd-HA–gelatin plus lubricin groups in vitro. It was also applied to improve digit function in
decreased within the first 50 cycles and then increased the canine models in vivo.42-45
Table 42-1 Adhesion Scores in Extrasynovial Tendon Autografts

1W 3W 6W
Adhesion Score Saline Modified Saline Modified Saline Modified
0 1 7 0 1 0 0
1 2 1 0 5 0 5
2 5 0 2 2 0 2
3 0 0 6 0 8 1
cd-HA–Gelatin: Extrasynovial GLIDING RESISTANCE OF TENDON GRAFT

Tendon Autograft
0.6
The canine PL tendons were harvested and transplanted
Normal
to replace the FDP tendons in the second and fifth digits 0.5
cd-HA
of one forepaw.42,43 Prior to grafting, one of the PL
Saline
tendons was coated with cd-HA–gelatin (1% HA, 10% 0.4
Resistance (N)
gelatin, 0.25% EDC, and 0.25% NHS), while the other
was immersed in saline solution only. Adhesion and 0.3
digital normalized work of flexion were evaluated
0.2
after surgery at 1, 3, and 6 weeks. The adhesion score
of cd-HA–gelatin treated tendons was significantly
0.1
less than the saline treated tendons at all time points
(p < 0.05) (Table 42-1). All saline-treated graft digits at 0
6 weeks had severe adhesions at both the pulley and A 1-week 3-week 6-week
tendon bed, including the entire zone 2 area. The adhe-
sion score at 1 week in both groups was significantly less NORMALIZED WORK OF FLEXION (nWOF)
than at 3 and 6 weeks in their respective groups (treated
7
or control), with no significant difference between the
3- and 6-week results. In consistence with adhesion Normal
6
cd-HA
score, the normalized work of flexion of the tendons
nWOF (N-mm/degree)
5 Saline
treated with cd-HA was significantly lower than that of
the saline-solution-treated controls at each time point 4
(Figure 42-11). In addition, the gliding resistance of the
cd-HA group was significantly lower than that of the 3
saline-solution group at 3 and 6 weeks. The chemical 2
surface modification of an extrasynovial tendon auto-
graft with cd-HA–gelatin decreases adhesion formation 1
and improves the digital function in flexor tendon auto- 0
graft model in vivo. B 1-week 3-week 6-week
cd-HA–Gelatin: Intrasynovial Figure 42-11 The gliding resistance (A) and normalized
Tendon Allograft work (B) of flexion in the normal, cd-HA–gelatin–treated,
A primary repair failure model was first created by lac- and saline-solution–treated groups at 1, 3, and 6 weeks. A
erating and repairing the FDP tendons in zone 2 from difference in symbols denotes a significant difference
between values (p < 0.05), with the triangle being
the second and fifth digits of dogs.44 The dogs were
significantly less than the circle.
allowed free active motion postoperatively. Six weeks
later, the tendons were reconstructed with use of FDP
allografts. In each dog, one allograft was treated with
cd-HA–gelatin (1% HA, 10% gelatin, 1% EDC, and 1% of flexion of the allografts treated with cd-HA–gelatin
NHS) and the other was treated with saline solution, as were significantly less than those in the saline-solution
a control. The dogs were restricted from free active control group (Figure 42-12). This study indicates the
motion, but daily therapy was performed beginning on chemical modification with cd-HA–gelatin can improve
postoperative day 5 and continued until 6 weeks after the digital function in flexor tendon allograft model
the operation. The gliding resistance and mean work in vivo.
cd-HA–Gelatin/Lubricin: Tendon Repair ((260 µg/mL). Passive synergistic motion therapy was

In this study, dogs were randomly assigned to either a started on the fifth postoperative day and continued
chemical treatment group or an untreated control until the dogs were killed on day 10, day 21, or day 42.
group.45 The second and fifth FDP tendons from each The prevalence of severe adhesions was decreased in the
dog were lacerated fully at the zone 2 area and then tendon treated with cd-HA–gelatin plus lubricin (Table
repaired. Following repair, the tendons in the chemical 42-2). The normalized work of flexion of the repaired
treatment group were treated with cd-HA–gelatin (1% tendons treated with cd-HA–gelatin plus lubricin was
HA, 10% gelatin, 1% EDC, and 1% NHS) plus lubricin significantly lower than that of the nontreated repaired
tendons at all time points (Figure 42-13). The results
indicate treatment with cd-HA–gelatin plus lubricin
appears to be an effective means of decreasing postop-
erative adhesions after flexor tendon repair.
GLIDING RESISTANCE
SUMMARY
*
0.5 Flexor tendon injuries are a frequent clinical problem.
n = 10
*
Restoration of tendon function after flexor tendon lac-
0.4
eration especially in zones 1 and 2 has been difficult.
The introduction of chemical surface modification and
Force (N)
0.3 n=8
the development of carbodiimide-derivatized gelatin
0.2
n = 18
0.1
0 * * * *
A Normal CHG Saline 5
nWOF (N-mm/degree)
* *
4 *
NORMALIZED WORK OF FLEXION
* * *
* 3
* *
1.6 n = 10 *
2 *
nWOF (N-mm/degree)
1.4
1.2 1 *
*
1
0
0.8
n=8 D-10 D-21 D-42
0.6
0.4 Normal FDP
n = 18 CHL
0.2
Repair-control
0
B Normal CHG Saline
Figure 42-13 The work of flexion normalized by the
Figure 42-12 The gliding resistance (A) and normalized proximal interphalangeal and distal interphalangeal angle
work (B) of flexion in the normal, cd-HA–gelatin–treated, (nWOF) of repaired FDP tendons with or without cd-HA-
and saline-solution-treated groups at 10, 21, and 42 days. gelatin plus lubricin (CHL) treatment and of the normal,
CHG, cd-HA-gelatin. contralateral digit at days 10, 21, and 42.
Table 42-2 Adhesion Scores in the Repaired FDP Tendon

10 Day 21 Day 42 Day
Adhesion Score Saline Modified Saline Modified Saline Modified
0 10 11 9 12 5 9
1 3 5 3 0 4 3
2 4 0 2 2 4 3
3 1 0 3 1 7 2
incorporation of HA and lubricin successfully improved digital function after flexor tendon autograft, allograft,
the gliding ability of the extrasynovial tendon, intrasy- and direct end-to-end tendon repair in vivo. Chemical
novial tendon allograft, and the repaired flexor tendon surface modification with cd-HA–gelatin derivatives is
in vitro. The methods of chemical surface modification likely able to provide hand surgeons a new and useful
also reduced adhesion formation and improved the method to improve the quality of flexor tendon surgery.
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CHAPTER
43
TENDON GLIDING: THE ROLE
AND MECHANICAL BEHAVIOR
OF CONNECTIVE TISSUES
OUTLINE hypodermis, the vessels, the aponeurosis, and the

muscles. Present everywhere are structures that allow
The work and experiments of the author and his col- sliding to take place.
leagues, including surgeons, histophysiologists, and We present a view of physiology of tendon sliding in
biomechanical engineers, have convinced them that human tissues, based on microanatomical observations
current understanding about tendon physiology is to that we made with the aid of video recording and analy-
be moved ahead. After carrying out in vivo dissections sis. We present new hypotheses concerning the organi-
and video-recording of the tissues existing between zation of these subcutaneous tissues.
the skin and tendons in carpal tunnel and forearm
areas, the author and his colleagues questioned some MATERIALS AND METHODS
basic mechanics of the tendon sliding. This chapter
presents a new approach of morphological studies, In Vitro Study of the Paratenon
and the author attempts to explain the existence of the This study was carried out on 30 human upper limb
multimicrovacuolar collagenous dynamic absorbing biopsies of flexor digitorum superficialis (FDS) and pro-
system. This system enables easy and extensive sliding fundus (FDP) with their surrounding sheaths, and 26
of the tendons without interference from surrounding animal samples including the flexor carpi radialis from
tissues, facilitating tissue interdependence. The multi- cattle where the organization is very similar to that of
microvacuolar collagenous dynamic absorbing system, the human flexor profundus (Figure 43-2).
which initially seems chaotic and complex, is based The preparation was treated with potassium bichro-
on the vacuolar concept, which is found in many parts mate, placed in formalin, and finally in caustic soda,
of the human body, and is structurally composed of allowing for a softer and more complete hydrolysis
multiple interconnected fibrous tissues organized to (Prof. J. P. Delage, INSERM Laboratories, Bordeaux,
facilitate functional adaptation of the tendon during France). It was then frozen and freeze-dried under stan-
movement. dard conditions for dehydration. Afterward, it was dis-
sected under a binocular loupe at ×3.5 magnification.
For many years, the scientific explanations concerning Samples were taken, given a gold-metallic finish, and
the natural mechanism of flexor tendon mobility in the then observed under the electron microscope. The
fingers were limited to the notion of a virtual space or INSERM Laboratories (Prof. Herbage, Lyon, France)
the existence of loose connective tissue organized in helped us to analyze the chemical components of this
layers, but the biomechanical foundations for these connective tissue.
theories were vague.1-3
The biomechanical characteristics and histological In Vivo Study of Digital Zones 3, 4, and 5 by
findings of the structures around the tendons are some- Microanatomical Video Endoscopic
times confusing, and the roles and the definitions of the Observation
paratenon, mesotendon, peritendon, and sheaths and The tendon gliding system was observed and recorded
have largely varied among authors and their described on video in 65 cases of tendon revascularization in
surgical procedures4-9 (Figure 43-1). Kleinert’s zones 3, 4, and 5 after releasing the
When surgical dissection is performed in vivo, visual tourniquet.
magnification demonstrates the presence of a varied All of the patients gave their consent before surgery.
arrangement of tissue connections; a histological con- Of the 65 cases, 57 procedures were forearm island
tinuum with no clear separation between the skin, the reverse flaps. The remaining eight procedures were
This chapter does not appear in the print edition. e11

e12 Chapter 43: Tendon Gliding: The Role and Mechanical Behavior of Connective Tissues
It is also clear from observing the behavior of the

vessels of the common carpal sheath after revasculariza-
tion and during flexion and extension, that there is
apparent disorder and irregularity of shape of the micro-
vascular network. There are surprisingly complex forms
of vascular distribution, a finesse to the microvascular
network, which is much more complex than a simplistic
mechanistic distribution.10-14
When we observed the area around the tendon, we
noted an apparently circular longitudinal and periph-
eral vascularization, which seemed to represent a real
continuity between the sheath and the tendon, and
A which was not interrupted despite the excursion and
distension occurring during sliding and subsequent
return to the original position.
At first sight, this is not incompatible with classical
anatomical descriptions.
Ten-Fold Microscopic Examination

However, during flexion and extension of the tendon,
tenfold microscopic examination of zones 3, 4, and 5
enabled us to observe vascular patterns in different
planes of excursion and with different speeds of vessel
progression due to modifications in the capillary
network and depending on variations in tendon
movements (Figure 43-3). Small vessels are subjected
B
to deformation during movement but do not follow
Figure 43-1 When the tendon moves, the movement is any logical or rational sequence. Some vessels pro-
barely discernible. There is an absorbing system surrounding gress quickly, while others move more slowly, and
the tendon. The capillary network around the tendon some overtake other vessels. The diameter of the vessel
changes as the tendon moves. Vascular network observed seems to be of no importance in this process. There
during flexion (A), and during extension (B). is dynamic progression with no apparent order or
proportionality.
Very little research has been done to study this
axillary flaps. Static and dynamic observations were mechanical phenomenon, since the issue was consid-
carried out using an endoscope with an attached camera ered by many to have been solved by the concept of a
Tri CCD-HD-Image 1 22220055 Karl Storz endoscopy virtual space (i.e., the tendon slides in the carpal sheath
fiber optic camera and Xenon Nova 201315 light source like a bullet in a gun barrel without touching the sides,
at ×25 magnification. or rather, it slides in membranous or visceral layers or
Continuous sequences were captured on video during by stratification of different coaxial layers).
flexion of the digital flexors to allow for subsequent In vivo observation has rendered this concept unac-
analysis. ceptable partly because it is surgically impossible to
define a clear field of dissection between the paratenon
RESULTS and the tendon (Figure 43-4).
At 10-fold microscopic examination (Figure 43-5),
In Vivo Observations video observation at rest showed an inaccessible micro-
Macroscopic Observations anatomical arrangement, a tissue-continuity, and a gel-
When the flexor tendon moves, its movement is barely like tissue surrounding the tendon. We saw a glossy
discernible in the palm. There is no dynamic repercus- structure stretching across the tendon. Within this
sion of the movement on the skin surface. However, the tissue, collagen fibers can be seen framing the vessels
flexor tendon excursion is at least 2 cm, without any in a random fashion. We were confronted with the
hindrance and without displacing any of the neighbor- notion of global dynamics and continuous matter
ing tissues in the palmar area or along the common between the tendon and the surrounding tissue, radi-
carpal sheath. cally opposing the classical descriptions of sliding struc-
This suggests the existence of some sort of shock- tures based on the notion of tissue stratification and
absorbing system. a virtual space between the tissue layers. Instead, we
Chapter 43: Tendon Gliding: The Role and Mechanical Behavior of Connective Tissues e13
A B
C D
Figure 43-2 MVCAS shown under electron microscope. A, The flexor carpi radialis of cattle was harvested for observation.
B, Preparation frozen-dried samples. C, Appearance of the sliding structure, MVCAS, under the electron microscope (×5).
D, Findings under a higher power magnification. Tissues surrounding the tendon are made of microvacuoles (×25).
found total histological continuity. It therefore became

necessary to investigate this tissue further in order to
gain better knowledge of its properties and its different
roles.
At 25-Fold Magnification
At 25-fold magnification, this glossy system consists of
loose connective tissue situated between the tendon and
its neighboring tissue, and is composed of intertwining
multidirectional filaments creating partitions that form
a new type of vacuole: three-dimensional, structured
microvacuolar volumes (Figure 43-6). Apart from some
adipocytes and fibroblasts, there are few cells in this
A multifibrillar network.
We called it the MultimicroVacuolar Collagenous
dynamic Absorbing System (MVCAS), to emphasize its
functional and architectural impact.15-17
4 This tissue network is a continuous structure com-
3 posed of billions of microvacuolar components that
1 must be considered as a three-dimensional network.
2
The basic component of this sliding framework is the
microvacuole.
The microvacuoles measure from a few microns to a
few hundred microns and are organized in a dispersed
branching fractal pattern. They have a pseudo-geometric
shape forming a basic polyhedron.
A microvacuole can be considered as a microvolume
(Figure 43-7); however, the organization differs accord-
ing to dynamic role—The greater the distance that the
B structure must travel, the smaller and denser are the
vacuoles; when stimulated, the structures can move
freely without anything else moving around them; and
under physical constraints, the structure is resistant,
adapting, and yet able to maintain shape. Its apparent
major role is to ensure the dynamics of movement and
absorb the shocks that this creates. The structure also
4
has a memory, so it returns to its initial position, pre-
1 3
2 serving its form and volume. Slight traction on this
microvacuolar system reveals mini air explosions that
prove the existence of a tissular pressure, which is dif-
ferent from atmospheric pressure.
As well as providing efficient movement, shape, form,
and filling space, this microvacuolar tissue plays two
other essential roles18 (Figures 43-8 and 43-9).
As an essential structural element, fibrils serve as a sup-
C
porting frame for the network of the blood supply,
Figure 43-3 A, Cold light variable magnification which accounts for the huge variety of blood supply
endoscope and 3 CCD camera. B, Intriguing vascular shapes. This frame constitutes the continuum of tissues
patterns that change in the capillary network depending between the mobile tendon and the neighboring tissues,
on the direction of tendon movements during flexion and ensuring the collagenous, vascular, lymphatic, and
extension. C, Vessels are not all going at the same speed nervous continuity between the tendon, epitenon, and
and are in different planes. paratenon. Tissue continuum is total.
As a biomechanical and dynamic system, it has a
mixed role of combined transmission and absorption
of the stress. Thanks to this dynamical behavior, the
microvacuolar system permits the transmission and
A B
C D
Figure 43-4 A, Traction on the paratendon during surgery. B, Searching for a space over the tendon surface. C, Network
between the tendon and the surrounding tissues: the MVCAS. D, The movable, elastic sliding tissues, MVCAS.
A B
C D
Figure 43-5 A, Peritendinous sliding system. B, Tissue continuity between tendon and microvacuolar distribution. C, 3D
MicroVacuola. D, Apparent fibrillar distribution in the dispersed branching pattern.
A
Collagen I
Collagen VI
Collagen I
Collagen I
Co
lla
ge
B
nI
Polysaccharides, hyaluronan
Network of gly licans
colicans
Network of glycolicans of glyco
N etwork
C
Figure 43-7 A, Diagrams showing the microvacuoles
inside the MVCAS. B, Real microvacuole with a hexagonal
shape at the beginning of dissection. C, Microvacuole
hyperpressure after atmospheric pression exposure filled
D with GAG and the collagen type I, III, and IV framework.
Figure 43-6 A, Fibrils composed of collagen and elastin
delimit the microvacuoles. B, Magnification MVCAS under
the electron microscope. C, A microvacuola with a hexagonal
shape. D, Diagram of the basic building brick of the MVCAS:
the microvacuola filled with GAG and the frame contains
collagen types I, III, and IV.
Figure 43-8 Collagen frameworks along with fibrils provide

support and nutrition.
Figure 43-9 Chaotic dynamic system showing a tendency
of pseudo-geometric arrangement.
absorption of the constraint across the tissue while at can recover its initial form by returning to its initial
the same time the surrounding tissues are not affected. position (Figure 43-11). This mechanism seems to be
During progressive traction (2 N/cm2) (Figure 43-10), involved in minor forms of tension.
the fibers rearrange themselves in response to the local Second, the fibers undergoing mechanical stimula-
stress. As the stress increases, the fibers become more tion can divide in space into several other fibrils, which
aligned in the direction of the stress. All of the compo- enables an immediate dispersion and distribution of
nent parts then turn so as to be oriented as much as the forces across the tissue space (Figure 43-12).
possible in the direction of the applied force. However, Third, the fibers are able to glide past each other
this set of movements is difficult to analyze, so certain around a mobile focal point along the entire length of
fibers have to be selected for analysis on an arbitrary both fibers (Figure 43-13). Because classic linear models
basis. We therefore stained some fibers yellow and based on straight lines cannot account for these move-
observed their behavior. ments, we are required to use fractal and nonlinear
Other internal factors need also be taken into account: mathematics to explain them.
The fibrillar struts behave in a very peculiar manner. These three dynamic abilities always coexist, which
First, in response to stretching a fibril becomes longer allows the structure to move in three-dimensional space
by resembling a wormlike chain or a spring, which and to respond optimally no matter what direction in
means that it is capable of molecular rearrangement and which it is stretched (Figure 43-14).
A B C
D E F
Figure 43-10 A 200-fold magnification of fibrillary movements during traction. Time span between photographs A and F is
2 seconds. Diameter of fibrils = 10 µm. Two-dimensional analysis of what actually occurs in three dimensions. The fibrils
become oriented in the direction of traction but in a less-organized manner than the rules of linearity would have it.
Figure 43-11 Distention-retraction of a fiber.

Figure 43-12 Division of a fiber into several fibrils that diffuse the stress three-dimensionally.
Figure 43-13 Fiber moves freely along axis of another fiber.

Figure 43-14 Variation of fibrillar movements in the three dimensions of space opens a lot of dynamical opportunities. The
chaotic, pseudo-geometric distribution of the structures in vivo and the different ways in which the fibrils behave require a
specific vision of the system.
We have frequently observed glycosaminoglycan incorporated into this network and are connected with
(GAG) gel movements inside the fibers, the sliding it on their superior and inferior aspects, thereby increas-
of drops along the fibrils, together with dilaceration, ing the shock-absorbing properties of the tissue and
absorption, and reconstitution. It is impossible to ignore allowing the structures to move interdependently.
the role of GAG in response to traction (Figures 43-15 Whether it is in the abdominal, thoracic, dorsal, or ante-
and 43-16). brachial regions or in the scalp, this tissue network is
omnipresent (Figure 43-17).
In Vitro Observations Indeed, there is no space within the body where it is
The sides of the intertwined microvacuoles are com- not found. This fibrillar tissue network surrounds even
posed of collagen fibers (75%, mostly type I, some type structures subject to relatively little movement—such as
III, IV, and VI collagens) and 20% elastin. Type I collagen nerves and the periosteum—although in these cases,
makes up 23% of the microvacuolar unit. Their diameter there are differences in the network itself and in the size
ranges from a few to several dozen microns and they of the vacuoles. Indeed, it would seem that the MVCAS
vary in length, thus giving an overall disorganized occurs everywhere in the body.
chaotic aspect. These microvacuoles contain a highly The notion of tissue continuity provided by the mul-
hydrated proteoglycan gel (70%), which can change timicrovacuolar collagenic absorbing system, MVCAS.
shape during movement but whose volume remains All of our observations support this tissue continuity
constant. Their lipid content (4%) is high. A major issue and the microvacuolar and fibrillar architecture. In tra-
in this system is the presence of water, which is omni- ditional observations of this tissue, the concept of
present as soon as the skin is penetrated (Prof. Herbage, sliding was thought to be due to several coaxial con-
INSERM Laboratories, Lyon, France). For this reason, no joined layers with progressively decreasing diameters
biomechanical explanation for the sliding of subcutane- framing the vascular structures, or to a virtual space
ous structures can disregard the dynamics of the fluids between visceral and membranous layers.
present (e.g., osmotic pressure and superficial tension). The layer closest to the tendon would move the
fastest, while the one farther away would move more
DISCUSSION
slowly. This concept of annular layers sliding between
This sliding tissue with its basic polyhedric shaped units each other based on the theoretical concept of virtual
is to be found in every nook and cranny of our organ- space and a hierarchical tissular distribution seems
ism. The tissue, which used to be referred to as connec- to be incorrect (see Figure 43-5). For this reason, we
tive or areolar tissue, is totally continuous throughout have developed the concept of a tissue continuum. This
the fibers and their prolongations. Even the intermedi- concept supposes that there is an association between
ary structures such as the deep premuscular fascia are the way tissues are organized and how they behave.
This sliding system and its multifibrillar organization

participating simultaneously in movement, restitution,
and the transfer of energy seem to be composed of ele-
ments developed from within this tissue rather than a
superposition of different tissues. We get the impression
of elements united to compose one sole tissue with
genuine continuity between the tendon, the sliding
tissue, and all surrounding tissues. The notion of layers
is replaced by a greater or lesser densification of the
MVCAS with a more or less specific cellularization. In
vivo observation has rendered the notion of tissue layers
unacceptable. This means that we need a new way of
thinking—a way of posing the problem in terms of
global dynamics and continuous matter and a theory
involving the concept of a tissue continuum. This is in
total contradiction with the traditional view of sliding
structures, tissue stratification, and virtual space between
tissue layers.
The microvacuole as the basic structural unit enables
the MCVAS to perform its function of filling space and
preserving form.19-23 This multimicrovacuolar collagenic
absorbing system is made of microvolumes and micro-
fibrils and is focused around the microvacuole, which
we can consider to be the basic framework unit. This
enables us to explain the very notion of form and the
fact that this form adapts to its environment but does
not change. We need to move to three dimensions to
really understand this.
It would seem that the existing polyhedron shape of
the microvacuole is the optimal shape for occupying
space with the most minimal arrangement. It is essential
to grasp that to fill space, living structures tend to adapt
geometrically simple forms such as polygons, spirals, or
cylinders.
By accumulation and superposition, these multimi-
crovacuolar polyhedric patterns under internal tension
Figure 43-15 Three-dimensional sketch showing potential
will build an elaborate form. The concept of the micro-
for interfibrillar movement involving the three dynamic vacuole explains the ability of the tissues to resist com-
capacities of the system. pression and expansion while maintaining a stable
volume.
It is important to highlight that, due to the dispersed Efficient Dynamic Behavior

pattern of the fibrils and the cohesive nature of the MVCAS is highly dynamic, and its components have
extracellular matrix, the sliding system forms a continu- efficient dynamic behavior. Although the arrangement
ous deformable framework performing three major of the structures is chaotic, with a dispersed pattern of
mechanical roles: distribution, this flexible, polyhedric architecture is able
to assume many shapes, thereby providing stability and
 Responding to any kind of mechanical stimulus in efficient sliding.
a highly adaptable and energy-saving manner, We are now confronted with the dilemma of chaotic
ensuring the complete movement of the tendon architecture and optimal efficiency. Because of the exis-
 Preserving peripheral tissue stability, structures, tence of this sliding system, called the paratenon or
and shapes; providing information during action areolar or subsynovial connective tissue (SSCT)5 by
and springing back to its original shape other investigators, the tendon displays optimal sliding
 Ensuring the interdependence and autonomy of and can move smoothly and quickly without any hin-
the various functional units drance and without disturbing anything around it,
Figure 43-16 The multimicrovacuolar system during peritendinous sliding.
A B
C D
Figure 43-17 The sliding system in different sites. A, Forearm subcutaneous area. B, Thoracic wall. C, Thigh region.
D, Abdominal wall.
thus allowing the tendon to move freely without trans- the peritendinous surface to the finest multimicro
ferring the movement to the surrounding structures. vacuolar organization, the ultimate boundary of the
This accounts for the absence of any dynamic repercus- mesosphere, before entering the realm of molecular
sions of the movement on the skin surface. dynamics. The entire dynamic and structural continuum
The essential function of the network is to ensure its may thus be explained and represented (Figure 43-18).
own efficient movement. Every structure component in It may even be that this fundamental system obeys
this network must permit movement while at the same dynamic and biomechanical principles that are subject
time ensuring shock absorption, which is indispensable to influences other than gravity.
to avoid rupture of the mechanical elements within
the network. The question of how the microvacuolar Anatomical Features
network behaves as a shock absorber, including the fact In order to transmit forces, this complex sliding system
that the closest vacuole to the moving structure under- must be resistant and able to adapt to environmental
goes maximal deformation while those farthest away and mechanical requirements. It must be able to con-
hardly change shape, remains to be explained. These serve its mobility while maintaining its architecture and
two apparently conflicting roles must also be accompa- adapting to the mechanical demands imposed on it. As
nied by the spring-back memory function. It appears to the function of different regions differ, its structures
be a very elastic system that accommodates tendon therefore vary by anatomical sites according to changing
movement but does not disrupt the stretched collagen functional needs.
fibers within the normal range of motion of tendon This type of microvacuolar sliding that we described
motion. within a multimicrovacuolar framework has been seen
These highly flexible, stressed or loaded fibrils take in zones 3, 4, and 5 of the flexor tendons. In the digital
various shapes during tendon sliding and movement fibrous sheath area, an efficient change in the subcuta
of extremities. The changes of interlacing, intertwining neous tissue is observed. The digital sheath and the
fibrillar structures are created by the repetition of move- sheath in the carpal tunnel area share some mechanical
ments, including distention, retraction, and compres- characteristics, but each has its own specific morphologic
sion during extremity movement. The system seems to features and function.
function optimally dynamically. The fibril movement
is highly organized and nicely coordinated, without
CONCLUSION
abnormal force distribution within the system, and the
motion of the tendon and other tissues is smooth and The notion of virtual space between the sheath in the
efficient. carpal tunnel area and the flexor tendons or the absence
Due to the natural arrangement of the fibrils in their of any connecting tissue and especially vascular tissue
seemingly chaotic or dispersed pattern and due to the must be reconsidered. The vision described here has
hydrophilic nature of the GAG in the extracellular resulted from anatomical observations performed on
matrix, the microvacuole (which is a microvolume) is fresh or formalin-treated cadavers. A different view of
able to adapt, change form, and return to its original the sliding system is therefore required. Based upon our
form. The MVCAS therefore displays chaotic patterns in vivo studies, a new sliding system can now be pro-
and multiadaptive efficiency. posed. The basic framework of this sliding tissue system
is the nonlinear, interconnecting, multimicrovacuolar
A Global System network, which seems chaotic and complex and yet
This internal multifibrillar and microvacuolar architec- simultaneously shows graceful simplicity with one final
ture is too repetitive not to be taken into account. Seen objective: to promote and facilitate sliding adaptation
in these terms, the whole structure of the body may and mobility. Future research in biology and chemistry
be considered as an immense collagen network. Going must examine the behavior of these basic structures,
from the macroscopic to the limits of the microscopic, which have long been neglected due to their apparently
this network can be seen to stretch continuously from self-evident nature.
A B
C D
E
Figure 43-18 Progressive 50-fold enlargement of peritendinous area from the macroscopic to the pre-molecular conveys an
idea of the total tissue continuity of the sliding system with tendon. (Magnification: A, ×0; B, ×2, C, ×5, D, ×20, E, ×50.)
References
1. Potenza AD: Critical evaluation of flexor-tendon healing and 13. Smith JW, Ellinger CG: La vascularisation des tendons. In
adhesion formation within artificial digital sheaths, J Bone Tubiana IR, editor: Traité de la Chirurgie de la Main, Paris,
Joint Surg (Am) 45:1217–1233, 1963. 1986, Masson, pp 375–380.
2. Lundborg G, Holm S, Myrhage R: The role of the synovial 14. Zbrodowski A: Vascularization of the flexor tendons in
fluid and tendon sheath for flexor tendon nutrition. An exper- the fingers, Chir Narzadow Ruchu Ortop Pol 39:265–270,
imental tracer study on diffusional pathways in dogs, Scand 1974.
J Plast Reconstr Surg 14:99–107, 1980. 15. Guimberteau JC: Journey to the tendon and satellite sheath
3. Littler JW: Free tendon grafts in secondary flexor tendon areas. In vivo anatomical observations of flexor tendon vascu-
repair, Am J Surg 74:315–321, 1947. larization and surrounding sheaths. Brussels International
4. Verdan CE: Half a century of flexor-tendon surgery. Current Symposium Tendon Lesions, Injuries and Repair: Genval-
status and changing philosophies, J Bone Joint Surg (Am) Brussels; 1999.
54:472–491, 1972. 16. Guimberteau JC: New Ideas in Hand Surgery; Island Vascular-
5. Strickland JW, Glogovac SV: Digital function following flexor ized Flexor Tendon Transfers, the Sliding System, France, 2001,
tendon repair in Zone II: a comparison of immobilization Aquitaine Domaine Forestier, pp 210.
and controlled passive motion techniques, J Hand Surg (Am) 17. Guimberteau JC, Panconi B, Boileau R: Mesovascularized
5:537–543, 1980. island flexor tendon: new concepts and techniques for flexor
6. Strickland JW: Results of flexor tendon surgery in zone II, tendon salvage surgery, Plast Reconstr Surg 92:888–903, 1993.
Hand Clin 1:167–179, 1985. 18. Zhao C, Amadio PC, Zobitz ME, et al: Gliding characteristics
7. Hunter JM: Tendon salvage and the active tendon implant: A of tendon repair in canine flexor digitorum profundus
perspective, Hand Clin 1:181–186, 1985. tendons, J Orthop Res 19:580–586, 2001.
8. Paneva-Holevith E: Résultats du traitement des lésions mul- 19. Guimberteau JC, Bakhach J: Subcutaneous tissue function:
tiples des tendons fléchisseurs des doigts par greffe effectuée the multimicrovacuolar absorbing sliding system in hand and
en deux temps, Rev Chir Orthop Reparatrice Appar Mot 58:481– plastic surgery. In Siemonov MZ, editor: Tissue Surgery. New
487, 1972. York, 2006, Springer, pp 41–54.
9. Boyes JH: Flexor-tendon grafts in the fingers and thumb: An 20. Guimberteau JC, Sentucq-Rigall J, Panconi B, et al; Introduc-
evaluation of end results, J Bone Joint Surg (Am) 32:489–499, tion to the knowledge of subcutaneous sliding system in
1950. humans, Ann Chir Plast Esthet 50:19–34, 2005.
10. Colville J, Callison JR, White WL: Role of mesotenon in 21. Ingber DE: Cellular tensegrity: defining new rules of biologi-
tendon blood supply, Plast Reconstr Surg 43:53–60, 1969. cal design that govern the cytoskeleton, J Cell Sci 104:613–
11. Lundborg G, Myrhage R, Rydevik B: The vascularization of 627, 1993.
human flexor tendons within the digital synovial sheath 22. Levin SM: Continuous tension, discontinuous compression.
region—structureal and functional aspects, J Hand Surg (Am) a model for biomechanical support of the body. Available at
2:417–427, 1977. www.biotensegrity.com/tension.html.
12. Schatzker J, Brånemark PI: Intravital observations on the 23. Thompson D: On Growth and Form, Cambridge, 1992, Cam-
microvascular anatomy and microcirculation of the tendon, bridge University Press.
Acta Orthop Scand Suppl 126:1–23, 1969.
CHAPTER
44
MOLECULAR BIOLOGY OF
TENDON HEALING
Chuan Hao Chen, PhD, Ya Fang Wu, MD, and
Jin Bo Tang, MD
The weak healing capacity of the injured tendons, intra- extrinsic. Both intrinsic and extrinsic tendon healing
synovial tendon in particular, is a critical issue underly- mechanisms come into play in a clinical setting. Intrinsic
ing difficulties in achieving optimal outcomes after healing takes place through proliferation of tenocytes
tendon surgery. After surgical repair, tendons ought to and production of extracellular matrix by intrinsic cells.
be able to move to prevent adhesions; the weak healing Extrinsic healing is the healing process brought about by
predisposes tendons to rupture during the early tendon growth of tissues or cell seeding from outside the lacer-
movement. In the early half of the 20th century, the ated tendon. Clinically, the participation of intrinsic
mechanisms of healing of primary end-to-end repair of and extrinsic healing after tendon repair depends on the
the intrasynovial tendon were not of great concern, condition of the tendon and surrounding tissues. Extrin-
because secondary tendon grafting was advocated to sic cells participate minimally in the healing of clean-cut
treat tendon injuries in the digits. In the 1950s and wounds but can dominate healing when the intrinsic
1960s, the healing potential of primarily repaired healing is jeopardized by severe trauma to the tendon.
tendons in the sheath area became an essential question For a typically lacerated tendon, the healing process
facing hand surgeons. In the recent decades, the healing generally consists of three stages: inflammation, colla-
of flexor tendons has been the subject of investigations gen production (or proliferation and repair), and col-
of a great number of investigators. lagen remodeling.
In the 1970s and 1980s, a number of elegant experi- The first stage is manifested with infiltration of
mental investigations demonstrated that cells in the inflammatory cells, such as neutrophils. Monocytes and
intrasynovial tendon segment can proliferate and par- macrophages are recruited to the injury site within the
ticipate in the healing process, establishing the concept first 24 hours, and phagocytosis of necrotic materials
of “intrinsic tendon healing.”1-7 Since 1990s, investiga- occurs. After the release of vasoactive and chemotactic
tions into tendon healing biology have been directed factors, angiogenesis and proliferation of tenocytes are
toward elucidation of molecular events underlying the initiated. Tenocytes then move into the site and start to
healing process and development of molecular thera- synthesize collagen III. The inflammation stage usually
peutic methods to enhance the healing or to decrease lasts for a few days, followed by the collagen production
adhesion formations. These investigations came from stage.
several major laboratories around the world, under In the collagen production stage, which lasts for 5 to
investigators such as Abrahamsson,8-10 Chang,11-14 Gel- 6 weeks, the tenocytes produce large amounts of colla-
berman, Boyer, and Thomopoulos,15-20 McGrouther,21-24 gen and proteoglycans at the repair site. In the early part
Mass,25,26 Tang,27-34 and Wolfe.35 of this stage, tenocytes proliferate dramatically, but in
Currently, laboratory research is focused on uncover- later weeks, inflammation subsides and cell prolifera-
ing gene expression patterns of the healing tendon and tion is less obvious. Collagen I, which increases healing
exploring cellular and genetic therapeutic approaches to strength, is produced abundantly in the later period.
strengthen weak intrinsic healing capacity. Work is also At about 6 weeks after injury, the remodeling stage
aimed at improving the healing strength of the surgi- begins. The first part of this stage is consolidation, which
cally repaired tendon. lasts from about 6 to 10 weeks after the injury. During
this time, synthesis of collagens and glycosaminogly-
TWO MECHANISMS OF INTRASYNOVIAL
cans (GAGs) decreases, as does cellularity. The tissue
TENDON HEALING
becomes more fibrous as a result of increased produc-
It is now generally believed that intrasynovial flexor tion of collagen I, and the fibrils become aligned in the
tendons heal through two mechanisms—intrinsic and direction of mechanical stress. The final maturation
e26 This chapter does not appear in the print edition.

Chapter 44: Molecular Biology of Tendon Healing e27
stage occurs after 10 weeks, and there is an increase in binds to the β receptor. Investigations have focused
cross-linking of the collagen fibrils, which makes the on the roles of PDGF-BB in tendon healing. Exog-
tissue stiffer. enous PDGF-BB stimulates collagen, proteogly-
can, and DNA synthesis of the tenocytes.18
MOLECULAR BIOLOGY OF TENDON HEALING Expression of PDGF-BB is increased after tendon
injuries in canine and chicken models.34,37
Roles of Individual Growth Factors 4. Vascular endothelial growth factor (VEGF).
A variety of molecules are involved in tendon healing.36 VEGF has five isoforms (i.e., 121, 145, 165, 189,
The roles of six growth factors have been studied associ- and 206) distinguished by their number of amino
ated with tendon healing in vivo or tenocyte prolifera- acids. Biological effects of these isoforms are
tion in vitro: similar. VEGF121 and VEGF165 are the predomi-
nant isoforms secreted by most cells. VEGFs bind
1. Transforming growth factor (TGF). This molecule to one of three VEGF receptors (VEGFR 1, 2, and
is secreted by all of cell types participating in the 3) on the cell surface to exert their biologic effects.
healing process and plays a role in wound healing The primary role of VEGF is to induce angiogen-
and scar formation. TGF-β has three isoforms: TGF- esis, including that in pathological conditions. In
β1, TGF-β2, and TGF-β3; they play different roles a canine model, VEGF mRNA expression was
in scar formation. While TGF-β1 and -β2 are known increased in healing flexor tendons.17,38,39 VEGF
to induce fibrotic changes and scar formation, expression may differ between the cells in endo-
TGF-β3 may inhibit scar formation.37 Three iso- tenon and epitenon at the repair site: 67% of the
forms are 60% to 80% homologous and are dimers cells in the endotenon at the repair site express
of 12.5-kDa polypeptides cleaved from larger pre- VEGF, but 10% of epitenon cells express VEGF.
cursors after being secreted from the cells into the Direct injection of VEGF increased the healing
ECM. TGF-β is a master mediator in the pathogen- strength of Achilles tendon in a rat model.
esis of fibrosis and scar formation. Regarding However, the effectiveness of direct use of VEGF in
specific roles of TGF-β in flexor tendon healing, synovial tendons has not been tested. We found
Chang and colleagues found increased levels of that AAV2-VEGF treatment significantly increased
TGF-β1 mRNA in the sheath and the tendon itself the healing strength of the chicken flexor tendons
after tendon trauma. TGF-β receptors 1, 2, and 3 at postoperative weeks 3, 4, and 6.
were upregulated as well. In in vitro studies, TGF- 5. Basic fibroblast growth factor (bFGF). bFGF
β1 induced collagen I production by tenocytes.11 commonly presents as an 18-kDa, single-chain
Chang and colleagues applied TGF-β1 neutralizing polypeptide of 146 amino acids; other forms of
antibodies to injured digital flexor tendons, and greater molecular weights (22, 22.5, and 24 kDa)
this therapy increased the range of digital motion also exist. bFGF has a wide range of biological
of the toes operated upon in a rabbit model.13 effects, including induction of cell proliferation
2. Insulin-like growth factor (IGF). It is a single- and migration as well as stimulation of fibroblasts
chain polypeptide hormone. The primary biologi- to produce collagens and collagenase. There have
cal action of IGF-1 is mitogenic activity for a broad been several specific investigations of the roles of
range of cells. Extracts from the epitenon and bFGF in flexor tendon healing. Duffy and col-
internal compartment of avian flexor tendons leagues detected presence of bFGF in normal intra-
were found to contain IGF-1; these extracts could synovial flexor tendons.16 Chang and colleagues
stimulate DNA synthesis by tenocytes.8 In in vitro found that bFGF levels were increased in flexor
culture of tenocytes, IGF-1 was found to increase tendons and sheath during healing from day 1 to
cell proliferation as well as stimulate synthesis of week 8.12 Tang and colleagues observed that exog-
DNA, collagen, and proteoglycan.9 Both IGF-1 and enous bFGF acts on cultured chicken tenocytes to
IGF-2 were shown to promote proliferation of accelerate cell proliferation and to promote col-
tenocytes in vitro tenocyte culture.8-10 lagen I gene expression.27,28
3. Platelet-derived growth factor (PDGF). PDGF Both direct delivery of bFGF and transfer of
consists of a group of dimers, each of two chains bFGF cDNA via appropriate vectors to the healing
(A and B). Various grouping of these chains form tendons have been tested to enhance tendon
three isoforms (AA, BB, and AB). PDGF acts as a healing.31,40-43 Direct delivery of bFGF was achieved
chemoattractant and mitogen for fibroblasts, with direct injection of the bFGF,40 use of bFGF-
endothelial cells, and smooth muscle cells. The coated suture,41 or bFGF delivery through con-
cell surface contains two kinds of receptors (α and trolled release system.42,43 Direct injection of bFGF
β) for PDGF binding. In fibroblasts, the β receptor did not improve the healing strength of the tendon,
is predominant. Only the isoform BB of PDGF nor did bFGF delivered through controlled release
e28 Chapter 44: Molecular Biology of Tendon Healing
system.40,43 After delivery of bFGF to the tendon, BMP-14 gene therapy increases tendon tensile strength
biological reactions and increases in cellular pro- in a rat model of Achilles tendon injury 2 and 3 weeks
liferation in the healing tendons were observed, after surgery.
but mechanically, the healing strength was not Chhabra and colleagues47 found that GDF-5 defi-
increased.43 Tendon repair with bFGF-coated surgi- ciency delays Achilles tendon healing in GDF-5 −/−
cal suture increased the tendon strength at week 3 mice. After injury, these mice took longer to reach peak
after surgery, but not at week 6, in a rabbit model.41 cell density and GAG and collagen content in the repair
AAV2-bFGF–treated tendons had a significantly site compared with normal control littermates. Aspen-
greater breaking strength than the nontreatment berg and Forslund48 found that implanting GDF-5 and
control at weeks 2, 3, and 4 in a chicken model.31 GDF-6–containing collagen sponge enhanced tendon
6. Bone morphogenetic proteins (BMPs). BMPs are healing strength at 2 weeks after surgery in a rat Achilles
a group of growth factors originally discovered by tendon model. Other studies also identified that exog-
their ability to induce the formation of bone and enous GDFs stimulated healing of the Achilles tendon,
cartilage. BMPs are considered to constitute a but this response was influenced by loading; without
group of pivotal morphogenetic signals, orches- loading, cartilage and bone formation was initiated.
trating tissue architecture throughout the body.
There are BMPs 1 through 15 in this superfamily. Roles of Growth Factors and Cytokines
BMP14 is called growth differentiation factor-5 In Vivo
(GDF-5) as well; this factor was particularly studied Chen and colleagues investigated the differences in
regarding its role in tendon healing and repair. expression levels of six growth factors in lacerated and
Hogan and colleagues44 found that growth differ- surgically repaired flexor tendon in chicken toes.32 Con-
entiation factor-5 (GDF-5, or BMP14) regulates nective tissue growth factor (CTGF) and TGF-β had high
ECM gene expression in murine tendon fibro- levels of gene expression in the early healing period
blasts. They isolated mice Achilles tendon fibro- (Figure 44-1). Levels of expression of VEGF and IGF-1
blasts and treated them with rGDF-5 (0 to 100 ng/ genes were high or moderately high. Expression of the
mL) for 0 to 12 days in cell culture. The temporal TGF-β gene was upregulated after injury, whereas the
effect of rGDF-5 on ECM gene expression was bFGF gene was downregulated at all time points
analyzed for type 1 collagen and aggrecan expres- observed (Figures 44-1 and 44-2) and expressed at the
sion. They found that expression of extracellular lowest levels among six growth factor genes 2 to 3 weeks
matrix (ECM) genes procollagen IX, aggrecan, after surgery. The PDGF-B gene was minimally expressed
matrix metalloproteinase 9, and fibromodulin in injured tendon. Findings in immunohistochemical
were upregulated. Proinflammatory reaction genes staining corresponded to TGF-β, bFGF, and IGF-1 gene
were downregulated. rGDF-5 led to an increase expression (see Figure 44-2).
in total DNA, glycosaminoglycan (GAG), and Schulze-Tanzil and colleagues49 reviewed the reports
hydroxyproline (OHP). rGDF-5 treatment showed of cytokines and growth factors on tendon healing and
improved collagen organization over controls. summarized interrelations known between the interleu-
kin (IL)-1β, transforming growth factor (TNF)-α, IL-6,
No studies have directly investigated expression profile and VEGF in tendon to assess their role in tendon
of BMPs during intrasynovial tendon healing process. damage and healing. Multiple interrelations between
However, studies were performed to determine relation cytokines and ECM synthesis, catabolic mediators such
of BMPs with the healing in rat Achilles tendon. Elias- as matrix-degrading enzymes, inflammatory and angio-
son and colleagues45 investigated how mechanical genic factors (cyclo-oxygenase [COX]-2, prostaglandin
loading influences the gene expression of the BMP sig- [PG]E2, VEGF, nitric oxide [NO]), and cytoskeleton
naling system in intact and healing tendons and how assembly are evident. Proinflammatory cytokines affect
the BMP signaling system changes during healing. They ECM homeostasis, accelerate remodeling, amplify bio-
studied four BMPs (OP-1/BMP-7, GDF-5/CDMP-1/BMP- mechanical adaptiveness, and promote tenocyte apop-
14, GDF-6/CDMP-2/BMP-13, and GDF-7/CDMP-3/ tosis. This multifaceted interplay might both contribute
BMP-12), two receptors (BMPR1b and BMPR2), and the to and interfere with healing, which has relevance for
antagonists follistatin and noggin. The Achilles tendon the development of novel therapeutic strategies.
was transected in rats. Ten tendons were analyzed before
transsection and in the early healing period after surgery. Extracellular Matrix
All genes except noggin were expressed at all time points. Cao and colleagues in our laboratory studied expression
Loading strongly decreased the expression of follistatin. of ECM components from postsurgical day 3 to week
They concluded that BMPs are involved in tendon 12 in a chicken model. Tendons exhibited drastic upreg-
healing, and change after tendon loading. Bolt and col- ulation in the expression of collagens I, III, XII, and XIV
leagues46 showed that adenoviral vector–mediated as early as 3 days after injury. After day 3, expression of
0.4
**
0.35
Levels of gene expression (target/GAPDH) 0.3 VEGF PDGF

TGF-beta bFGF
*
CTGF IGF-1
0.25
0.2
*
0.15 *
0.1
*
*
0.05 ** ** **
0
0 3 9 14 21
Time-points of the early healing period (days)
Figure 44-1 Changes in level of expression of six growth factor genes in the early healing period of a chicken FDP tendon
with real-time PCR analysis. Growth factor expression peaked at day 3, and CTGF and TGF-β expressed in the highest level.
(Modified from Chen CH, Cao Y, Wu YF, et al: Tendon healing in vivo: gene expression and production of multiple growth
factors in early tendon healing period, J Hand Surg [Am] 33:1834–1842, 2008.)
collagen I declined somewhat but remained at moder- during the study period, whereas MMP-3 returned to
ately high levels after week 3. The collagen III gene was normal levels within the first week after injury. TIMP-3
upregulated progressively from day 3, with a drastic was downregulated in the tendon sheaths. Cathepsin K
increase from week 2 to 5. The fibronectin gene was was upregulated in tendons and sheaths after injury.
upregulated from week 2 to 8. Expression of aggrecan Nerve growth factor (NGF) was present in both tendons
and fibromodulin genes did not change after tendon and sheaths, but unaltered. IGF-1 exhibited a late
injury. increase in the tendons, while VEGF was downregulated
Matrix metalloproteinases (MMPs) act to modulate at the later time points. They demonstrated the presence
metabolism of tendon healing. They play an important of NGF in flexor tendons and concluded that MMP-13
role in the degradation and remodeling of the ECM. expression appears to play a more protracted role in
They break down structural proteins of the ECM. Certain flexor tendon healing than MMP-3. The relatively low
MMPs, such as MMP-1, -2, -8, -13, and -14, have colla- levels of endogenous IGF-1 and VEGF mRNA following
genase activity, capable of degrading collagen fibrils. The injury support their potential beneficial role as exoge-
activities of the MMPs are inhibited by endogenous nous modulators to optimize tendon healing and
tissue inhibitors of metalloproteinases (TIMPs), a family strength without increasing adhesion formation.
of four protease inhibitors (TIMP 1–4). Using the same
chicken model, Cao and colleagues investigated levels of Intracellular Signal Pathways
gene expression of MMPs and TIMPs from the early to Only the NFκB pathway was investigated in in vitro
late healing periods in digital flexor tendons. MMP1 of tenocytes treated with exogenous bFGF and in in vivo
the tendon was upregulated and remained high in the flexor tendon healing.38,51 Each of the key factors in the
first 6 weeks after injury and dropped thereafter. TIMP2 NFκB pathway was found to be activated after exoge-
and TIMP3 were downregulated after tendon injury in nous application of bFGF to the tenocytes’ culture
the first 6 weeks after injury but were upregulated later. medium. In the healing flexor tendon in a chicken
Berglund and colleagues50 studied molecular events model, NFκB gene was found to be upregulated.51
during flexor tendon healing in a rabbit model of flexor
TENOCYTE APOPTOSIS DURING
tendon injury. The mRNA expression for the growth
TENDON HEALING
factors, MMPs, and TIMPs were measured in tendon and
tendon sheath tissue at several time points (3, 6, 21, and Apoptotic events in the healing digital flexor tendon
42 days) representing different phases of the healing have been investigated recently.34,52 Nevertheless, teno-
process. They found that MMP-13 remained increased cyte apoptosis can be an important event in the healing
TGF-beta IGF-1 bFGF
Day 0
21
Figure 44-2 Immunohistochemical staining of three growth factors in the healing tendons. Great amount of TGF-β is
present in the tendon. Both bFGF and IGF-1 are present in a much lower amount compared with TGF-β. (Modified from
Chen CH, Cao Y, Wu YF, et al: Tendon healing in vivo: gene expression and production of multiple growth factors in early
tendon healing period, J Hand Surg [Am] 33:1834–1842, 2008.)
digital flexor tendon and can affect healing strength. antiapoptotic effects. Apoptosis of tenocytes peaked at
Investigations of Wu and colleagues have been aimed at day 3 (see Figure 44-3), which is followed about 10 days
elucidating the relationship between cellular apoptosis later by the peak proliferation period. At days 14 to 28,
and proliferation in early tendon healing.34 At postop- the number of apoptotic cells decreased significantly
erative days 3, 7, 14, 21, and 28, Wu and colleagues compared with days 3 and 7, yet numbers remained
quantitatively analyzed the presence of apoptotic cells greater than those at day 0. At days 7 to 14, the number
in tendons using an in situ TUNEL assay (Figure 44-3), of PCNA-positive cells peaked (see Figure 44-4). At days
and performed immunofluorescence staining with anti- 7 and 14, the cells positively stained with Bcl-2 peaked.
bodies to proliferating cell nuclear antigen (PCNA) to These findings indicate that tenocyte apoptosis is accel-
assess proliferation (Figure 44-4), and Bcl-2 to assess erated within several days post-injury, followed by
A B
Figure 44-3 Tenocyte apoptosis is most obvious at day 3 after tendon laceration. The pictures show the cells with dark
brown nucleus stained with TUNEL are apoptotic cells (A ×200, B ×400). Nearly 50% of the tenocytes in the endotenon are
apoptotic at day 3.
40 Bcl 2-positive cells

Positively-stained cells/field
PCNA-positive cells
35
30
25
20
15
10
5
0
0 3 7 14 21 28
Days
Figure 44-4 Tenocyte proliferation peak at postsurgical Figure 44-5 Changes of PCNA- and Bcl-2–positively
day 14. The picture shows positive PCNA-stained tenocytes, stained cells (Bcl-2 is an antiapoptotic protein) in the early
which peak in number at day 14 (×200). Positive PCNA tendon healing period in a chicken model. Numbers plotted
staining indicates proliferation of the cells. in the graph show positively stained cells in the field under
high magnification (×400) over five time-points. (Data from
Wu YF, Chen CH, Cao Y, et al: Molecular events of cellular
increases in cellular proliferation and activation of apoptosis and proliferation in the early tendon healing
molecular events to inhibit apoptosis in 2 to 4 weeks. period, J Hand Surg [Am] 35:2–10, 2010.)
After 4 weeks, tenocyte proliferation persisted, but at a
rather lower level. Tenocyte apoptosis also declined TUNEL assay showed few positive staining cells in the
drastically (Figures 44-5 and 44-6). In the late healing wound at days 4 and 7. The percentages of TUNEL-
period, tenocyte apoptosis persisted, likely in response positive fibroblast-like cells showing morphological
to tendon remodeling, while tenocyte proliferation was characteristics of apoptosis increased sharply and
minimal or undetectable.52 reached the maximum on day 28 (median, 31.4%). No
Lui and colleagues53 found increases in tenocyte fibroblast-like cell was stained at month 6 and the
apoptosis at the end of patellar tendon healing. They healed tissue was similar to that in a normal uninjured
investigated the role of apoptosis in cell turnover in a tendon. A similar trend was observed with active
rat central 1/3 patellar tendon donor site injury model. caspase-3 immunohistochemistry. They concluded that
The observations were made at days 4, 7, 14, and 28 and an increase in apoptosis at the end of tendon healing
months 2 and 6 after surgery. The total fibroblast-like coincided with a decrease in cellularity.
cell density in the center of the wound increased from The findings of Skutek and colleagues54 corroborate
day 4 and thereafter steadily returned to normal. In situ that mechanical stretching directly activates intracellular
of the roles of growth factors and ECM components

Bcl 2-positive cells during tendon healing process is incomplete. Informa-
50
PCNA-positive cells tion obtained thus far reflects several instances of genetic
Positively-stained cells (%)
profiling. In the future, effort should be directed to char-

40
acterizing the molecular events in the in vivo tendon
healing process, under different injury conditions.
30
Enhancing tendon healing strength and preventing
adhesion formation will continue to be major subjects
20
of investigation and be at the center of basic science
investigations of tendon repair.
10 Growth factor–coated suture, controlled-release
system, and gene therapy are appealing approaches to
0 enhancing flexor tendon healing. Delivery of cells
0 3 7 14 21 28 (including stem cells) and genes critical to the healing
Days process would ameliorate weakness in healing strength
Figure 44-6 Changes of percentage of PCNA- and produced by the paucity of cellular components and
Bcl-2–positively stained cells in the field under high insufficient, or inappropriate, production of growth
magnification (×400) in a total population of the cells. factors or ECM. The ideal therapies should not increase
(Data from Wu YF, Chen CH, Cao Y, et al: Molecular events the healing strength at the cost of increasing adhesion
of cellular apoptosis and proliferation in the early tendon formation. We should be able to control the biological
healing period, J Hand Surg [Am] 35:2–10, 2010.) regulation of tendon healing and avoid any detrimental
effects. A controlled-release system is another way to
signaling pathways, which in turn induce apoptosis. provide continuous and controlled supplies of growth
They investigated the response profile of human tendon factors, but its effectiveness in improving healing
fibroblasts in terms of apoptosis in response to cyclic strength remains to be addressed.
stretching. They also found that cyclic mechanical Almost all exogenously applied growth factors are
stretching activated stress-activated protein kinase found to accelerate proliferation of tenocytes to some
(SAPK)/Jun N-terminal kinase (JNK). extent in vitro. However, our understanding of growth
factor activity in tendon healing is incomplete, and not
FUTURE FOR TENDON HEALING BIOLOGY
all of these growth factors have been characterized as to
INVESTIGATION AND APPLICATION
their effects on tendon healing in vivo. Further investi-
The molecular mechanisms underlying tendon healing gations should be able to elucidate the exact roles of
are still poorly understood currently. Our understanding these growth factors in tendon healing.
References
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in vitro, J Jpn Orthop Assoc 48:541–552, 1974. 9. Abrahamsson SO, Lundborg G, Lohmander LS: Recombinant
2. Matthews P, Richards H: The repair potential of digital flexor human insulin-like growth factor-I stimulates in vitro matrix
tendons. An experimental study, J Bone Joint Surg (Br) 56: synthesis and cell proliferation in rabbit flexor tendon,
618–625, 1974. J Orthop Res 9:495–502, 1991.
3. Matthews P, Richards H: The repair reaction of flexor tendon 10. Abrahamsson SO: Similar effects of recombinant human
within the digital sheath, Hand 7:27–29, 1975. insulin-like growth factor-I and II on cellular activities in
4. Lundborg G: Experimental flexor tendon healing without flexor tendons of young rabbits: experimental studies in vitro,
adhesion formation—a new concept of tendon nutrition and J Orthop Res 15:256–262, 1997.
intrinsic healing mechanisms. A preliminary report, Hand 8: 11. Chang J, Most D, Stelnicki E, et al: Gene expression of trans-
235–238, 1976. forming growth factor beta-1 in rabbit zone II flexor tendon
5. Katsumi M, Tajima T: Experimental investigation of healing wound healing: evidence for dual mechanisms of repair, Plast
process of tendons with or without synovial coverage in or Reconstr Surg 100:937–944, 1997.
outside of synovial cavity, J Niigata Med Assoc 95: 532–567, 12. Chang J, Most D, Thunder R, et al: Molecular studies in flexor
1981. tendon wound healing: the role of basic fibroblast growth
6. Lundborg G, Rank F, Heinau B: Intrinsic tendon healing. A factor gene expression, J Hand Surg (Am) 23:1052–1058, 1998.
new experimental model, Scand J Plast Reconstr Surg 19:113– 13. Chang J, Thunder R, Most D, et al: Studies in flexor tendon
117, 1985. wound healing: neutralizing antibody to TGF-beta1 increases
7. Manske PR, Gelberman RH, Vande Berg J, et al: Flexor tendon postoperative range of motion, Plast Reconstr Surg 105:148–
repair: A morphological study in vitro, J Bone Joint Surg (Am) 155, 2000.
66:385–396, 1984. 14. Kryger GS, Chong AK, Costa M, et al: A comparison of teno-
8. Abrahamsson SO, Lundborg G, Lohmander LS: Long-term cytes and mesenchymal stem cells for use in flexor tendon
explant culture of rabbit flexor tendon: effects of recombinant tissue engineering, J Hand Surg (Am) 32:597–605, 2007.
15. Gelberman RH, Amiel D, Harwood F: Genetic expression for 34. Wu YF, Chen CH, Cao Y, et al: Molecular events of cellular
type I procollagen in the early stages of flexor tendon healing, apoptosis and proliferation in the early tendon healing
J Hand Surg (Am) 17:551–558, 1992. period, J Hand Surg (Am) 35:2–10, 2010.
16. Duffy FJ, Seiler JG, Gelberman RH, et al: Growth factors and 35. Henn RF 3rd, Kuo CE, Kessler MW, et al: Augmentation of
canine flexor tendon healing: initial studies in uninjured and zone II flexor tendon repair using growth differentiation factor
repair models, J Hand Surg (Am) 20:645–649, 1995. 5 in a rabbit model, J Hand Surg (Am) 35:1825–1832, 2010.
17. Boyer MI, Watson JT, Lou J, et al: Quantitative variation in 36. Hsu C, Chang J: Clinical implications of growth factors in
vascular endothelial growth factor mRNA expression during flexor tendon wound healing, J Hand Surg 29A:551–563, 2004.
early flexor tendon healing: An investigation in a canine 37. Chan KM, Fu SC, Wong YP, et al: Expression of transforming
model, J Orthop Res 19:869–872, 2001. growth factor beta isoforms and their roles in tendon healing,
18. Thomopoulos S, Harwood FL, Silva MJ, et al: Effect of several Wound Repair Regen 16:399–407, 2008.
growth factors on canine flexor tendon fibroblast prolifera- 38. Tsubone T, Moran SL, Amadio PC, et al: Expression of growth
tion and collagen synthesis in vitro, J Hand Surg (Am) 30:441– factors in canine flexor tendon after laceration in vivo, Ann
447, 2005. Plast Surg 53:393–397, 2004.
19. Thomopoulos S, Das R, Sakiyama-Elbert S, et al: bFGF and 39. Bidder M, Towler DA, Gelberman RH, et al: Expression of
PDGF-BB for tendon repair: controlled release and biologic mRNA for vascular endothelial growth factor at the repair site
activity by tendon fibroblasts in vitro, Ann Biomed Eng of healing canine flexor tendon, J Orthop Res 18:247–252,
38:225–234, 2010. 2000.
20. Thomopoulos S, Das R, Silva MJ, et al: Enhanced flexor 40. Chan BP, Fu S, Qin L, et al: Effects of basic fibroblast growth
tendon healing through controlled delivery of PDGF-BB, factor (bFGF) on early stages of tendon healing: A rat patellar
J Orthop Res 27:1209–1215, 2009. tendon model, Acta Orthop Scand 71:513–518, 2000.
21. Khan U, Kakar S, Akali A, et al: Modulation of the formation 41. Hamada Y, Katoh S, Hibino N, et al: Effects of monofilament
of adhesions during the healing of injured tendons, J Bone nylon coated with basic fibroblast growth factor on endoge-
Joint Surg (Br) 82:1054–1058, 2000. nous intrasynovial flexor tendon healing, J Hand Surg (Am)
22. Akali A, Khan U, Khaw PT, et al: Decrease in adhesion forma- 31:530–540, 2006.
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tendon injury, Plast Reconstr Surg 103:151–158, 1999. PDGF-BB for tendon repair: controlled release and biologic
23. Jones ME, Mudera V, Brown RA, et al: The early surface cell activity by tendon fibroblasts in vitro, Ann Biomed Eng 38:
response to flexor tendon injury, J Hand Surg (Am) 28:221– 225–234, 2010.
230, 2003. 43. Thomopoulos S, Kim HM, Das R, et al: The effects of exog-
24. Wong JK, Cerovac S, Ferguson MW, et al: The cellular effect enous basic fibroblast growth factor on intrasynovial flexor
of a single interrupted suture on tendon, J Hand Surg (Br) tendon healing in a canine model, J Bone Joint Surg (Am)
31:358–367, 2006. 92:2285–2293, 2010.
25. Mehta V, Kang Q, Luo J, et al: Characterization of adenovirus- 44. Hogan M, Girish K, James R, et al: Growth differentiation
mediated gene transfer in rabbit flexor tendons, J Hand Surg factor-5 regulation of extracellular matrix gene expression in
(Am) 30:136–141, 2005. murine tendon fibroblasts, J Tissue Eng Regen Med 5:191–200,
26. Mehta V, Mass D: The use of growth factors on tendon inju- 2011.
ries, J Hand Ther 18:87–92, 2005. 45. Eliasson P, Fahlgren A, Aspenberg P: Mechanical load and
27. Tang JB, Xu Y, Ding F, et al: Tendon healing in vitro: promo- BMP signaling during tendon repair: A role for follistatin?
tion of collagen gene expression by bFGF with NF-κB gene Clin Orthop Relat Res 466:1592–1597, 2008.
activation, J Hand Surg (Am) 28:215–220, 2003. 46. Bolt P, Clerk AN, Luu HH, et al: BMP-14 gene therapy
28. Tang JB, Xu Y, Wang XT: Tendon healing in vitro: activation of increases tendon tensile strength in a rat model of Achilles
NIK, IKKα, IKKβ, and NF-κB genes in signal pathway and tendon injury, J Bone Joint Surg (Am) 89:1315–1320, 2007.
proliferation of tenocytes, Plast Reconstr Surg 113:1703–1711, 47. Chhabra A, Tsou D, Clark RT, et al: GDF-5 deficiency in mice
2004. delays Achilles tendon healing, J Orthop Res 21:826–835, 2003.
29. Wang XT, Liu PY, Tang JB, et al: Tendon healing in vitro: 48. Aspenberg P, Forslund C: Enhanced tendon healing with GDF
adeno-associated virus-2 effectively transduces intrasynovial 5 and 6, Acta Orthop Scand 70:51–54, 1999.
tenocytes with persistent expression of the transgene, but 49. Schulze-Tanzil G, Al-Sadi O, Wiegand E, et al: The role of
other serotypes do not, Plast Reconstr Surg 119:227–234, pro-inflammatory and immunoregulatory cytokines in
2007. tendon healing and rupture: new insights, Scand J Med Sci
30. Zhu B, Cao Y, Xin KQ, et al: Tissue reactions of adenoviral, Sports 21:337–351, 2011.
adeno-associated viral, and liposome-plasmid vectors in 50. Berglund ME, Hart DA, Reno C, et al: Growth factor and pro-
tendons and comparison with early-stage healing responses tease expression during different phases of healing after rabbit
of injured flexor tendons, J Hand Surg (Am) 31:1652–1660, deep flexor tendon repair, J Orthop Res 29:886–892, 2011.
2006. 51. Tang JB, Xu Y, Ding F, et al: Expression of genes for collagen
31. Tang JB, Cao Y, Zhu B, et al: Adeno-associated virus-2-medi- production and NF-κB gene activation of in vivo healing flexor
ated bFGF gene transfer to digital flexor tendons significantly tendons, J Hand Surg (Am) 29:564–570, 2004.
increases healing strength. An in vivo study, J Bone Joint Surg 52. Wu YF, Zhou YL, Mao WF, et al: Cellular apoptosis and pro-
(Am) 90:1078–1089, 2008. liferation in the middle and late intrasynovial tendon healing
32. Chen CH, Cao Y, Wu YF, et al: Tendon healing in vivo: gene periods, J Hand Surg (Am) 37:209–216, 2012.
expression and production of multiple growth factors in early 53. Lui PP, Cheuk YC, Hung LK, et al: Increased apoptosis at the
tendon healing period, J Hand Surg (Am) 33:1834–1842, late stage of tendon healing, Wound Repair Regen 15:702–707,
2008. 2007.
33. Chen CH, Zhou YL, Wu YF, et al: Effectiveness of microRNA 54. Skutek M, van Griensven M, Zeichen J, et al: Cyclic mechani-
in down-regulation of TGF-β gene expression in digital flexor cal stretching of human patellar tendon fibroblasts: activation
tendons of chickens: in vitro and in vivo study, J Hand Surg of JNK and modulation of apoptosis, Knee Surg Sports Trau-
(Am) 34:1777–1784, 2009. matol Arthrosc 11:122–129, 2003.
CHAPTER
45
MOLECULAR METHODS TO
PREVENT ADHESION
FORMATION
Armin Kraus, MD, and James Chang, MD
OUTLINE immediate tendon repair in zone 2 was considered to

be generally possible by a skillful surgeon. Nevertheless,
Tendon adhesions are a significant problem, especially the results have since remained often less than
after repair in zone 2. Tendon healing undergoes three satisfactory.
different phases—inflammation, proliferation, and From clinical experience, it can be seen that three
maturation—which can all be altered to reduce adhe- factors (“quality of repair,” “motion” in the sense of
sions. Intrinsic healing without contact to surrounding early exercise, and “inflammation”)1 have an impact on
tissue and therefore low adhesive potential can be the degree of adhesion formation. While the quality of
distinguished from extrinsic healing, where cell inva- a tendon repair is still up to the surgeon, strategies from
sion and vascularization take place from the surround- the toolbox of molecular medicine are under investiga-
ing with concomitant adhesions. Motion has shown tion to modulate tendon healing on the molecular or
to decrease adhesions by mechanical disruption of cellular levels, to decrease those inflammatory effects
adhesions and by molecular alteration of tendon cells. that are responsible for adhesion formation, and to find
Artificial tendon grafts can be seeded with cells to form new ways to prevent loss of tendon gliding.
an epitenon layer that could enhance gliding. Adding
PATHOPHYSIOLOGY
or blocking various cytokines can reduce adhesion for-
mation, but cytokine interaction has shown to be In its healing process, the tendon undergoes three
complex. Gene transfer or RNA interference are further distinct phases: inflammation, proliferation, and
methods under investigation. Mesenchymal stem cells maturation/remodeling. The inflammatory phase is
have anti-inflammatory effects and may have the characterized by the migration of T-lymphocytes and
potential to differentiate into a tenocyte-like pheno- phagocytotic cells into synovial sheath and epitenon.
type, so that they could contribute to adhesion free Platelets adherent at the injury site release a variety of
tendon healing. Despite promising results in the field cytokines such as platelet-derived growth factor (PDGF),
of molecular research, many of these insights remain transforming growth factor (TGF)-β, or insulin-like
to be translated into clinical application. growth factor (IGF) that activate the migrating cells.2
These migrating cells are responsible for phagocytosis
CLINICAL SIGNIFICANCE
of cell debris and for deposition of a preliminary extra-
In the repair of flexor tendons, hand surgeons attempt cellular matrix.
to achieve two main goals: stability of the repair and In the proliferation phase, collagen synthesis and vas-
gliding of the tendon. The problem of adhesion forma- cularization are enhanced.3 The remodeling phase is
tion has been a challenge since the beginning of the characterized by rearrangement and organization of col-
20th century. Initially this lead to the concept of a “no lagen fibers.4 At this state, adhesions become more
man’s land” in the area of zone 2, a zone were primary apparent.
tendon repair was not indicated. As the tendon is gliding In contrast to many other tissues, there are two dif-
through a tight fibro-osseus canal in this area, the likeli- ferent mechanisms involved in tendon healing: the
hood of adhesion formation was considered so high extrinsic and the intrinsic pathway. In extrinsic healing,
that no direct tendon repair was recommended. As a extracellular matrix producing cells are invading the lac-
secondary procedure, tendon continuity was restored by erated tendon from its periphery. This pathway described
grafting. With the advent of more sophisticated suture by Potenza and colleagues5 was for some time consid-
materials and surgical techniques and particularly with ered to be the prevailing and maybe only mechanism
more aggressive methods of early mobilization, an of healing in a lacerated tendon.

Chapter 45: Molecular Methods to Prevent Adhesion Formation e35
Lundborg and others, however, have shown that showed a reduction of adhesions at the plantar site, but
tendon healing is also possible independent from the mild to moderate adhesions both at the ends of the
adjacent tissue. When a sutured tendon was kept inside sheaths and at the plantar contact site to the bone. Ishi-
the knee joint space of a rabbit without contact to a yama and colleagues reported a phospholipid polymer
tendon sheath or other connective tissue surfaces, the hydrogel to effectively prevent adhesion formation in a
tendon healed without forming adhesions. This intrin- rat and in a chicken model.10 They explained this by a
sic healing process allows a restitution of tendon conti- microstructure with a pore size less than 8 to 10 µm that
nuity by cells out of the epitenon and endotenon is capable of preventing extrinsic inflammatory cells
without forming adhesions to its surrounding.6 from getting into contact with the tendon surface but
McGrouther and colleagues showed in vitro that the allowing the passage of cytokines and growth factors
extrinsic pathway naturally is the more active one and required for healing. Tenenhaus and colleagues11
starts to be active at an earlier time-point.7 This means claimed a similar mechanism to be active in adhesion
that tendon healing naturally tends toward forming prevention when they wrapped tendon repair sites with
adhesions and that a therapeutic approach should aim a collagen-GAG membrane (Integra) in a chicken model.
at enhancing the intrinsic pathway and suppressing the This material has been used particularly in burn surgery
extrinsic. and is known to possess good biocompatibility.
Motion
TREATMENT
From clinical experience, it is known that early active
Quantification of Tendon Adhesions motion treatment helps to prevent adhesion formation
Measurement of the degree of adhesion formation is after tendon repair. Various explanations for this obser-
mainly semiquantitative. In addition to macroscopic vation can be conceived. First, it might be due to
observation, investigators use either biomechanical mechanical reasons that newly forming adhesions are
testing or image analysis of histologic sections to quan- interrupted by motion. Recent research, however, has
tify the degree of adhesions. Biomechanical testing is also shown an effect of motion on a molecular level.
also dependent on factors such as joint stiffness. Histol- Strain and shear forces can be exerted onto cultured cells
ogy is dependent on section location and direction and by using a cell bioreactor, which is simulating the condi-
cannot quantify the rigidity of adhesions. Therefore, the tions of motion.12 By exercising mechanical shear stress
ideal measurement for the quantitative analysis of adhe- on tenocytes in vitro (Figure 45-1), Fong and colleagues
sion formation remains elusive. showed an “antifibrotic” gene expression pattern—that
is, an upregulation of matrix-metalloproteinases and
Conventional Pharmacological Treatment a downregulation of collagen I and III as well as of
Before the era of molecular medicine, various pharma- TGF-β.13 Not only cells in culture but also cell-seeded
cological agents have been investigated. Local and sys- grafts made from acellularized cadaver tendons can be
temic steroids, nonsteroidal anti-inflammatory drugs, treated by mechanical force before implantation. Ange-
hyaluronic acid, 5-fluorouracil, and others have been lidis and colleagues used a cell bioreactor to exert a
used. However, none of these substances have been suit- cyclic load of 1.25N on cell-seeded tendon scaffolds
able for routine clinical use. Lubricin, a mucinous gly-
coprotein responsible for the boundary lubrication of
articular cartilage, has been used to prevent adhesion
formation in a canine model of tendon repair.8 The
application of this substance led to a decreased adhe-
sion formation, although it is at the expense of repair
strength. Clinical value of this agent therefore is yet to
Rotating cone Tissue culture plate
be elucidated.
Biomaterials to Prevent Adhesion Formation

As described earlier, the majority of adhesion formation
is considered to be caused by extrinsic rather than by 0.5°
intrinsic healing. Therefore, attempts with blocking
materials and membranes have been made to prevent
Tenocytes
adhesion formation caused by the exterior. Before the
area of molecular treatment, attempts have been made Figure 45-1 Tenocytes may be exposed to shear forces
to use materials such as silicone or gelatin sponge. Using induced by a cone viscometer to simulate tendon motion in
hydroxyapatite or alumina sheaths for covering a tendon vitro. An “antifibrotic” gene expression pattern can thereby
suture site in the chicken model,9 Siddiqi and colleagues be obtained.
e36 Chapter 45: Molecular Methods to Prevent Adhesion Formation
for 5 days. Subsequent biomechanical testing showed susceptible to adhesion formation. Furthermore, the
higher tensile strength of the bioreactor-treated tendons function of artificial grafting materials has been poor.
compared to untreated controls. Moreover, the seeded On the other hand, the use of allografts or xenografts is
cells (adipoderived stem cells and skin fibroblasts) limited due to immunological reasons, as these anti-
showed an orientation parallel to the direction of force genic stimuli generally lead to excessive fibrosis, a fact
on the scaffold. Further studies will have to show that is most detrimental in the gliding region of zone
whether this orientation also helps to prevent adhesion 2.14 Acellularization of cadaver tendons could be a way
with the surroundings. to obtain a nonimmunogenic scaffold for tendon repair
The concept of mimicking the molecular events with the right mechanical properties. Zhang and col-
induced by motion stress seems appealing, as this could leagues acellularized rabbit tendons by treating them
increase repair strength, decrease the formation of adhe- with trypsine/EDTA + Triton-X solution.15 These acel-
sions, and minimize the risk of dehiscence caused by lularized scaffolds could be repopulated with epitenon
motion therapy. and endotenon cells. Reseeding the acellularized
tendons with tenocytes has been shown to improve
Prevention of Adhesions in Tendon Grafting their biomechanical properties, mainly ultimate tensile
The formation of adhesions is an even greater problem strength and elastic modulus.16 It may be speculated
in tendon grafting than it is in tendon repair. Com- that the newly formed epitenon layer (Figure 45-2) can
monly used grafts such as the palmaris longus tendon also inhibit adhesion formation, which has to be proved
lack an extrasynovial sheath and are therefore highly in further preclinical studies.
A B
C D
Figure 45-2 Acellularized tendon scaffolds seeded with various cell types after 6 weeks in vivo. A, Epitenon tenocytes.
B, Sheath fibroblasts. C, Bone marrow–derived MSCs. D, Adipocyte-derived stem cells. Note preservation of collagen
framework, single epitenon-like layer on surface (individual cells indicated by black arrows), and distribution of endotenon-like
cells in center of grafts (individual cells indicated by white arrows).
FLEXOR TENDON WOUND HEALING CASCADE RANGE OF MOTION

40
Range of motion (degrees)

INFLAMMATORY PROLIFERATIVE REMODELING *
35
30
Neutrophil and Angiogenesis Collagen 25
macrophage reorganization 20
chemotaxis VEGF
bFGF 15
PDGF PDGF
TGF-β 10
5
Cell proliferation 0
IGF-1 *p <0.05 1
bFGF
PDGF Control Low-dose M6P
Low-dose Decorin High-dose M6P
High-dose Decorin
Collagen synthesis and
extracellular matrix deposition
TGF-β Figure 45-4 Range of motion of rabbit forepaws treated
bFGF with the TGF-β antagonists decorin and mannose-6-
PDGF phosphate (M6P). Significant improvement (*) was achieved
by local administration of low-dose M6P (1 mg/100 µL).
Figure 45-3 Although the interaction of cytokines is highly
complex, each cytokine is supposed to make a major
contribution to one or several certain aspects of tendon Insulin-Like Growth Factor
healing in the three distinct phases.
IGF is a cytokine also of interest in the process of tendon
healing. It has been shown to posses anti-inflammatory
properties19 and to increase the production of collagen
and proteoglycan as well as DNA synthesis in flexor
Cytokines tendon specimens in vitro.20 However, the ultimate
As a variety of cytokines are active in the process of proof of whether IGF is effective in preventing intrasy-
tendon healing (Figure 45-3), blocking the “proadhe- novial tendon adhesions is yet to be determined.
sion” and substituting the “antiadhesion” ones could be
a powerful strategy in preventing tendon adhesions. Transforming Growth Factor-β
However, there are several obstacles to overcome before TGF-β is a cytokine that is related to various processes
this approach will come to fruition. The number of pos- in wound healing. Because TGF-β was upregulated espe-
sible cytokines involved is large, and there may be cially in the inflammatory cells of the tendon sheath,21
several cytokines that are still unidentified. Second, the this cytokine has become a target in the effort to prevent
above classification into “proadhesion” and “antiadhe- adhesion formation.
sion” is overly simplified. A cytokine may perform con- By using mannose-6-phosphate as an inhibitor of
tradictory effects depending on the time and location of TGF-β production in an in vivo model of tendon repair
its activity. The exact regulation of cytokine secretion in rabbits, Bates and colleagues could achieve a signifi-
and activation is regulated by various paracrine feed- cantly improved range of motion in the operated digits
back loops that will be very difficult to simulate. Never- (Figure 45-4).22 Similarly, mannose-6-phosphate has
theless, promising results already have been obtained been shown to be effective in blocking TGF-β–induced
when certain cytokines were either substituted or production of collagen I in tenocytes in vitro.23 Because
blocked. mannose-6-phsophate is nontoxic, nonimmunogenic,
and easy to produce, it will be an interesting agent for
Platelet-Derived Growth Factor and future clinical applications.
Fibroblast Growth Factor In the intracellular pathway triggered by TGF-β, the
By exogenous application of the cytokines PDGF-BB Smad proteins play a vital role. Katzel and colleagues
and bFGF, Gelberman and colleagues have shown an showed decreased scarring after FPL repair in Smad3-
increased expression of lubricin and hyaluronic acid, deficient mice.24 By using a blocking agent of the Smad
which promote gliding.17 By local administration of pathway, likewise, Au and colleagues found diminished
PDGF to a tendon repair site in a canine model, the connective tissue deposition and a decreased number of
same group showed an increase in cell proliferation and myofibroblasts in rat skin wound healing.25
matrix maturation without an increase of adhesion Smad 2 and 3 are phosporylated by TGF-β receptors
formation.18 while Smad 1, 5, and 8 are phosphorylated by bone
morphogenetic protein (BMP) receptors and mediate of medical research where gene silencing offers promise,
BMP signals.26 The group of BMPs is characterized by such as in HIV therapy, cancer treatment, or the therapy
high complexity of their signaling functions. BMP-12 is of neurological disorders, protective treatment against
known to play a role in the differentiation of stem cells tendon adhesion by gene silencing may be possible.
into tenogenic cells.27 It further has been shown to Because the site of tendon repair is easy to access, selec-
increase proliferation of tenocytes and the production tive local administration could rule out systemic adverse
of procollagen I and III and to decrease the production events. By coupling silencing RNA with target-selective
of decorin.28 A role in the formation of adhesions there- carriers such as ligand-coated nanoparticles, an even
fore is likely for BMP-12, but the exact mechanisms are more specific way of delivering the agent to its domain
yet to be elucidated. could be provided. Adverse effects of silencing RNAs
such as unspecific downregulation of genes and compe-
Vascular Endothelial Growth Factor tition with endogenous silencing RNAs36 are still to be
There is evidence from in vivo studies that tendon overcome. Unlike in chronic diseases that would require
healing is possible without vascularization, but just by lifelong administration of RNA interference, short-term
mere diffusion.29 If neovascularization should contrib- treatment during the period of tendon healing should
ute to adhesion-free tendon healing, it would have to be more easily tolerated.
occur from intratendinous vessels. Gelberman and col-
leagues have shown that this type of neovascularization Stem Cells
takes place in a canine model of tendon repair.30 New With the knowledge that scarless healing is possible
blood vessels were formed in tendon regions during the in the fetal stage,37 one might conceive that stem cell
healing process that were previously avascular. However, mechanisms are a key to adhesion free tendon healing.
vascular endothelial growth factor (VEGF), a cytokine From embryonic stem cells, pluripotent cells that
playing a role in angiogenesis, has not been found to can renew indefinitely in vitro can be derived. These
improve tendon vascularity and adhesion prevention cells are capable of differentiation into tissues of all
yet. In an in vitro model, VEGF gene transfer led to an three germ lines. The use of donor embryonic stem
increase in TGF-β production, which was related to cells raises various ethical concerns in humans and
increased adhesion formation.31 The authors concluded involves the drawback of immune rejection by the
that VEGF was not a critical factor to substitute in order recipient.
to promote tendon strength or to decrease adhesion Recent research has shown that somatic cells can also
formation. be altered to become pluripotent. These cells are called
“induced pluripotent stem cells” (iPS). Takahashi and
Epidermal Growth Factor colleagues transfected adult human fibroblasts with the
Epidermal growth factor (EGF) is another cytokine that developmental genes Oct3/4, Sox2, Klf4, and c-Myc and
plays a role in tendon healing. It has been shown to be could thereby successfully transform these cells into a
present not in tenocytes but in migrating inflammatory phenotype that was similar to embryonic stem cells in
cells during the healing process.32 Another study showed morphology, proliferation, surface antigen profile, gene
EGF to have a stimulatory effect on tenoblast migration expression, epigenetic status of pluripotent cell-specific
in culture.33 Further studies must elucidate whether EGF genes, and telomerase activity.38 Theoretically, this
would increase or decrease adhesion formation in zone method could produce a self-renewing cell for every
2 tendon repair. individual with a capacity to transform into every
favored tissue type without the problem of immune
Gene Silencing rejection. Thus, tendon healing free of scars and there-
In addition to blocking the effect of a cytokine by an fore free of adhesions may be conceived in the future as
antagonist protein or natural inhibitor, blocking the this technology is further developed.
gene expression of an adhesion-causing protein such as Despite these groundbreaking achievements, various
TGF-β is another strategy. The use of micro-RNA obstacles are still to be overcome before clinical use of
(miRNA) or small interfering RNA (siRNA) is a method this technology is possible. When retroviral transfection
to silence gene expression.34 miRNA typically consists of is used, this will yield high efficiency but contains the
single-stranded RNA at a length of 19 to 25 nucleotides risk of tumorigenesis as the viral genome is incorpo-
that binds to a corresponding sequence of messenger rated into the genome of the host cell. This problem
RNA and inhibits the translation of the respective could be overcome by modern vectors completely
protein. siRNA binds to complementary RNA and leads devoid of prokaryotic elements such as plasmids or
to degradation of this complex by endonuclease cleav- linear dumbbell-shaped expression cassettes, as their
age. Chen and colleagues showed an effective decrease integration rate into the host genome is far below the
in TGF-β production using miRNA directed against spontaneous mutation rate.39 Furthermore, iPS seem to
TGF-β RNA both in vitro and in vivo.35 As in other fields be highly susceptible for tumor induction themselves.
In Takahashi and colleagues’ experiments, subcutane- Despite these difficulties, recent studies on nonhu-
ous implantation of iPS into mice lead to teratoma man cells give promising evidence that a tenogenic dif-
formation in 25% of the cases. ferentiation of mesenchymal stem cells toward tenocytes
Conversely, multipotent adult stem cells do not raise may be achieved. In vitro studies in animal models have
the same ethical concerns as do embryonal stem cells, shown the expression of the tenogenic genes decorin and
immunogenic reactions can be avoided by taking the tenomodulin, Collagen Ia1, six1, six2, scleraxis, eya1, and
cells from the recipient individual, and their teratoge- EphA4 after exogenous exposure to BMP-12.47 After
nous potential seems to be far lower than that of embry- BMP-12 gene transfer, an upregulation of collagen type
onal stem cells.40 Mesenchymal stem cells (MSCs) were I and scleraxis in rhesus monkey MSCs could be shown.27
initially derived from the bone marrow, but that method There is also some evidence that interaction with teno-
of harvest is a major procedure. Adipocyte-derived stem cytes could induce mesenchymal stem cells toward a
cells are an interesting alternative as they are abundant tenogenic line. Luo and colleagues co-cultured rat bone
in adipose tissue and are easier to harvest by marrow MSCs and tenocytes in an indirect co-culture
liposuction. system that allowed passage of soluble factors.48 They
MSCs have been successfully used in various disor- noted an increased expression of the tendon-related
ders such as myocardial infarction, meniscus repair, or genes collagen I, collagen III, tenascin C, and scleraxis
treatment of spinal cord injury. Concerning their use in compared to the control group. This gives evidence that
tendon healing, MSCs exert two main functions that can no direct cell contact is needed for tenogenic differentia-
be important for adhesion free healing. tion of MSCs. The soluble factors that play the key role
First, stem cells are known to possess immunosup- in this process remain to be identified.
pressive capabilities.41 Their ability of homing at a site Further evidence is required to prove whether these
of inflammation by chemotaxis toward inflammatory differentiated cells will be able to overtake the relevant
cytokines makes them particularly suitable for suppres- functions of tenocytes at a site of tendon repair and
sion of local inflammatory processes. Initially, MSCs contribute to scarless and adhesion-free healing.
are activated by immune cells that are secreting pro
inflammatory cytokines such as interferon (IFN)-γ, Gene Therapy
tumor necrosis factor (TNF)α, interleukin (IL)-1α, or Gene therapy is a strategy that may deliver the cytokine
IL-1β.42 Subsequently, MSCs produce soluble mediators genes to the tendon repair site. For the insertion of genes
such as nitric oxide, prostaglandin E2, indoleamine into a recipient cell, nonviral and viral vectors are avail-
2,3-dioxygenase, IL-6, and human leukocyte antigen able. Nonviral gene transfer includes chemical methods
(HLA)-G. These mediators have an influence on a variety such as lipofection and physical methods such as elec-
of immune cells. Particularly, regulatory T cells are troporation, microbubble-enhanced ultrasound, ballis-
induced and dendritic cells are directed toward an anti- tic delivery (“particle gun”), magnetofection, and laser
inflammatory phenotype. poration.
Second, MSCs are known to be able to differentiate Nonviral methods are nonpathogenic but have lower
into various cell lines—bone, cartilage, muscle, bone efficiency than viral methods. Furthermore, chemical
marrow stroma cells, adipose tissue, and connective nonviral vectors may be toxic, and physical manipula-
tissue. A differentiation of MSCs toward mature teno- tion may be harmful to the cells. On the other hand,
cytes could therefore be conceived. Characterization of viral vectors are more efficient but have the potential
the mature tenocyte phenotype is difficult, as a defini- risk of immunogenicity and of causing genetic muta-
tive marker is missing. Various markers have been pro- tions in the host cell. Various attempts of gene transfer
posed by different groups, such as collagen I, collagen to tendons have been made. Nakamura and colleagues
III, tenascin C, tenomodulin, scleraxis, decorin, aggre- successfully transferred the PDGF gene into rat tendons
can, elastin, thrombospondin 4, thrombospondin 5 in a liposome-mediated manner.49 Despite a transfec-
(also called cartilage oligomeric matrix protein, COMP), tion rate of only 2%, there was enhanced angiogenesis
and others.43 Scleraxis, a basic helix-loop-helix tran- and collagen I synthesis over a period of 4 weeks. As this
scription factor, is regarded to be highly specific for was not a model of intrasynovial tendon repair, further
tenocytes by some authors44,45 and is thought to regulate studies will have to show whether PDGF is a suitable
the expression of tenomodulin, a transmembrane gly- cytokine to prevent adhesion formation in such a
coprotein with an antiangiogenetic C-terminal domain. setting. In another model of extrasynovial tendon
However, scleraxis also has been detected in other cell healing (gap formation in the medial collateral liga-
types such as osteocytes and chondrocytes.43 Tenascin is ment of the rabbit, no suture), the same group admin-
an extracellular matrix protein that is highly expessed in istered antisense-oligonucleotide against decorin
musculoskeletal tissues mainly during regenerative and mRNA.50 They noted a higher abundance of larger col-
healing processes.46 It is upregulated by mechanical lagen fibrils, higher tensile strength, and better biome-
strain but is also not exclusively tendon specific. chanical properties compared to the control group.
inflammation and fibrosis. Embryonal stem cells have

CONCLUSIONS
the ability to promote scarless wound healing, but their
The repair of flexor tendons that is free of adhesions in utilization is limited by ethical concerns, the potential
zone 2 of the hand is a very complex problem. Various of tumorigenesis and various technical difficulties. MSCs,
efforts have been made in the past with pharmacologi- on the other hand, could be harvested from the potential
cal agents, mainly to reduce inflammation, and with recipients themselves in large amounts. They could con-
physical barriers to reduce adhesion formation. More tribute to adhesion-free tendon healing by their capaci-
recent attempts have used various cytokines with prom- ties of homing and their potential ability to differentiate
ising results. The blockade of TGF-β seems to effectively into a tenogenic phenotype. Furthermore, they possess
reduce adhesion formation in the experimental setting. immunosuppressive and anti-inflammatory properties,
For more specific cytokine delivery, genetic modification which could be useful in adhesion prevention.
strategies at a tendon repair site are possible, but obsta- Despite the great potential that these molecular strat-
cles such as vector toxicity, low transfection efficiency, egies have to offer, they yet have to be tested in routine
unstable transfection, and the possibility of mutagene- clinical use. Research at the interface of surgery and
sis remain to be overcome. molecular biology will bring further insights into the
To solve the problem of adhesion formation after pivotal mechanisms of adhesion formation. Together
tendon grafting, seeding of a graft with recipient cells with sound surgical technique, surgeons will hopefully
could prevent adhesion formation by providing a gliding be able to restore full finger motion in the area once
layer and by reducing immune response with subsequent considered to be the “no man’s land.”
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1180, 2010. J Orthop Res 18:517–523, 2000.
CHAPTER
46
TENDON REPAIRS IN
REPLANTATION SURGERY
Ren Guo Xie, MD, Jun Tan, MD, and Jin Bo Tang, MD
Tendon injuries are an integral part of complex tissue 46-5). In our unit, we use a cruciate or an U-shaped
injuries involved in the digital and forearm amputation. four-strand repairs (Figures 46-5 and 46-6). We do not
Recovery of active movement of the hand and wrist after repair the FDS tendon. The FDS tendons are excised,
replantation of digits or forearm depends on ample because it is not possible to obtain good gliding and
tendon gliding. Tendon injuries in the amputation can prevent adhesions after injuries to multiple tissues
present as tidy cut or avulsion injuries of the tendons, including bones involved in digital amputation. During
caused by knife or machine cuts, or by crush avulsion surgery, we attempt to preserve the annular pulleys and
injuries, respectively. Loss of a segment of bones or a synovial sheath as much as possible. Frequently, we
part of soft tissues in the trauma area is very common. incise or left open the sheath around the area of digital
After patients are brought into the hospital, the amputation. It is not possible to perform complicated
patients should be thoroughly evaluated regarding the pulley reconstruction during the replantation surgery, as
conditions of entire body and degrees of tissue loss or this is not possible and lengthen the surgery. It is a
contusion locally. The wound should be carefully practical way to leave completely disrupted annular
assessed about severity of contamination and potential pulleys open without surgical repair or reconstruction.
of infection. It is not infrequent that we see that the A2 pulley is
almost entirely damaged by the trauma, or is signifi-
SURGERIES AND TENDON REPAIRS cantly shortened during surgery. In the case of thumb
amputation, the FPL tendon must be repaired.
Digital Replantation As for extensor tendon repair, shortening of the digits
Surgery has great impact on function of extensors. We usually
Digital amputation after clean-cut injuries does not manage to repair the extensor tendon with running con-
have loss of tendon substance (Figure 46-1), but the tinuous or locked running stitches or figure-of-eight
level of tendon cut may not be the same as those in the suture. When phalanges are shortened, extensor tendons
tendons, particularly the flexor tendon. The proximal can be sutured with some overlapping of the cut
tendon ends retracted to the proximal phalanx or the portions.
palm. During crush and avulsion injuries, both flexor
and extensor tendons can be avulsed from more proxi- Postoperative Care
mal parts of the tendon (Figures 46-2 and 46-3). Addi- To avoid disturbance to vascular circulation and ensure
tional incisions are needed to find the proximal ends stable fixation of phalanges, replanted digits do not
and do end-to-end repair. In the thumb, both flexor undergo early mobilization. For the first 3 or 4 weeks,
pollicis longus (FPL) and extensor pollicis longus (EPL) the reattached digits are immobilized. After 3 or 4
tendons are usually cut without loss of tendon sub- weeks, the patients can be instructed to perform light
stance (Figure 46-4), and tendon avulsion from the passive motion of the digits. Active motion of the fingers
thumb is also sometimes seen. Surgical priority should can be started from 4 or 5 weeks (or even later) after
be given first to the bony fixation and re-establishment surgery. Therapies should be given to lessen digital
of vascular circulation. Ideally, tendons are repaired in edema and improve digital circulation when the digit
all the cases. During replantation surgery, though slightly motion starts.
shortening of phalanges are necessary, tendons do not
usually require shortening. Trimming the rugged tendon Outcomes
ends is required, which usually only produces about Recovery of active range of finger motion after digital
0.5 cm shortening of the tendon substance. replantation is generally poor. Many replanted digits
Both 2-strand Kessler and cruciate repair methods are have only limited active flexion. The specific reports that
now used popularly for flexor tendon repair (Figure discussed digital motion range after digital replantation

Chapter 46: Tendon Repairs in Replantation Surgery e43
A
Figure 46-3 Both the flexor and extensor tendons were
pulled out after disruption at the palm and wrist levels. The
tendons were repaired through additional incision in the
palm and wrist.
are rare. In our experience, we observed total range of

active motion of the distal and proximal interphalan-
geal (DIP and PIP, respectively) joints of about 60° to
80° degrees of digital flexion. These degrees of motion
in IP joints provide the hand with rather practical func-
tion for making a light grip or picking up. Powerful grip
B is usually not possible and making a full fist is rarely
Figure 46-1 A clean-cut total amputation through the achievable. Joint stiffness occurs to a great percentage of
middle phalanx of the index finger, presenting an ideal the replanted digits. In our unit, we note varied degrees
indication for repair of the flexor and extensor tendons. In of finger joint stiffness (i.e., limitations in passive digital
this kind of tidy digital amputation, the phalanx was not motion) in almost all the cases. Limitations of digital
shortened, and flexor and extensor tendons were repaired motion and function are actually due largely to the loss
in the same way as usually do for clean-cuts of flexor or of passive digital motion range, rather than impaired
extensor tendons. tendon function.
A few reports indicated effectiveness of tenolysis after
digital replantation. In 1989, Jupiter and colleagues
reported 37 replanted digital units and four thumb
replantations with a flexor tendon tenolysis at an average
of 10 months after replantation.1 The results were
assessed by measuring total active range of motion
(TAM), potential active motion, and by the Strickland
criteria. The TAM increased from a mean pretenolysis of
72° to 130°. The potential active motion increased from
a mean of 43% to 70% after tenolysis. Both of these
improvements were statistically significant. By Strick-
land criteria, 13 digits were rated excellent, 11 good, 6
fair, and 11 poor. The thumbs had two fair results and
two poor results. Poor results were also seen in crush or
avulsion amputations, hands with more than two digits
amputated, and those requiring a PIP joint capsulotomy.
Complications included tendon rupture and infection.
The results support flexor tendon tenolysis after replan-
tation of fingers but not replanted thumbs.
Figure 46-2 A crush-avulsion amputation of the index Ross and colleagues (2003) specifically reported
finger. the tendon function after digital replantation.2 They
e44 Chapter 46: Tendon Repairs in Replantation Surgery
B
Figure 46-5 Two methods often used in flexor tendon
repair during replantation surgery. A, Two-strand modified
Kessler repair. B, Four-strand cruciate repair.
C
Figure 46-6 A four-stand repair method, i.e., the U-shaped
repair, the senior author developed using a looped suture.
A–C, Method of repair is shown. This is used to repair the
C FDP tendon during replantation.
Figure 46-4 A, Thumb amputation distal to the IP joint.

B and C, Both FPL and EPL tendons were repaired directly
and the replanted thumb has good cosmetic appearance injury. TAM values were not affected by age, type of
and function after surgery. bone fixation, number of arteries repaired, or number
of digits injured. Digits with both the FDP and FDS
tendons repaired had significantly better TAM values
relative to one-tendon fingers. Similarly, fingers treated
retrospectively reviewed 48 patients (103 digital rays) with an “early” mobilization regimen also exhibited
who underwent replantation. Average TAM (sum of the better movement.
DIP, PIP, and MCP joints) for all digits was 129°. Zone
1 and zone 5 injuries had better TAM than injuries in Secondary Tenolysis
zones 2, 3, and 4, which had TAM values not signifi- Tenolysis is indicated for the patients who have suffi-
cantly different from one another. Avulsion injuries ciently ample passive motion of the digits but whose
fared significantly worse than other mechanisms of degrees of active digital flexion are markedly smaller.
Therefore, only a very limited number of patients are lead to amputation through palm. At this level, the
ideally indicative of secondary tenolysis because loss of amputation involves multiple flexor and extensor
passive digital motion is common. Tenolysis is usually tendons, and intrinsic muscles. Chances of infection
carried out about 6 months or one year after surgery. increase in palm amputation. Thorough irrigation and
Postoperative 3 months are too early for this surgery. débridement are important. Similarly, surgical priority
Most patients seen in our department who needs should be given to stable fixation of the metacarpal
secondary tenolysis are operated one year after replanta- bones and reestablishment of vascular circulation.
tion surgery. When passive motion is restricted, a con- Both core and peripheral repairs are used for flexor
siderable number of patients may not want to accept a tendons, but for extensor tendons, a running or cross-
secondary operation to improve passive joint motion stitch suture of sufficient suture purchase or a core
followed by tenolysis. Under this circumstance, we do suture (mostly two-strand repair) should be used.
not strongly urge the patients to have the surgery, Peripheral sutures can be loosely added for flexor
because the improvement after tenolysis is not as great tendons. This is less important in the palm area than in
in these patients. Adhesions in extensor tendons are the digital area, because this area accommodate more
common, but they are not as problematic as for flexor space for the bulky repair site. Strength of the flexor
tendons. Should these cases undergo the tenolysis, tendon remains important; we recommend four-strand
simple release of the extensor tendon adhesions usually repair made with 4-0 or 3-0 sutures rather than two-
is required. Care should be given especially to the pres- strand repair in the flexor tendons of the palm. Using a
ervation of integration of reattached vessels, and the looped suture or a system with one needling leading
dissection should not extend too far away. Early passive two suture strands greatly simplify the surgery and
and active motion of the digit should be initiated after reduce operation time. In our unit, we also use a cruciate
tenolysis if the tendons are not found frayed. four-strand repair. The FDS tendons are excised and
Yu and colleagues (2003) reported that 79 digits of not repaired; some surgeons attempt to repair one or
55 patients received 102 secondary procedures follow- two FDS tendons in the palm, which is also a feasible
ing replantation.3 They divided the procedures into two option. Palm amputation may not involve a FPL tendon
groups, occurring before or after 2 months following cut. If the FPL tendon is lacerated, the FPL must be
replantation. The procedures in the early group were repaired.
mainly for soft tissue coverage (92%), and those in that
late group were mainly for tendon (67%) to improve Postoperative Care
function. Factors associated with higher incidence of After surgery, the hand is placed in protective cast with
early secondary procedures included multiple-finger the wrist in slight extension and the MCP joint slightly
injury, avulsion or degloving injury, and level of injury flexed and IP joints extended. Some surgeons place the
proximal to zone 3 in finger replantation. However, wrist in slight flexion. For the first 3 weeks, the hand is
younger patients and those with proximal level replan- immobilized. Passive digital flexion can be prescribed,
tation in fingers had more late secondary procedures. but generally motion range should be limited and
Flexor tenolysis procedure significantly improved the should be initiated after 10 days or 2 weeks when edema
digital function after replantation. subsides. Light active motion over a very limited range
Eggli and colleagues (2005) reported 23 patients can be ordered as well, just producing mild finger
with restricted motion after 32 combined digital injuries motion. Starting passive motion of the digits prevents
or amputations in zone 2 treated with tenolysis.4 With digital stiffness. Motion also helps reduce persistent
an average follow-up of 5 years, significant functional edema of the hand and digits. After 3 weeks, the patients
improvement was achieved in 28 of 32 digits (88%). can be instructed to perform passive motion of the
TAM improved on average 51° after dorsal tenolysis, 55° digits, together with active motion of the fingers. Hand
after palmar tenolysis, and 63° after combined dorso- edema can be serious in the first days after surgery, and
palmar tenolysis. Using Buck-Gramcko’s criteria, 15 when persistent, therapies should be given to lessen
digits were rated excellent, 8 good, 4 fair, and 5 poor. digital edema and improve digital circulation when the
Complications consisted of 16% flexor tendon ruptures digit motion starts.
after palmar or combined tenolyses. In contrast, dorsal
tenolysis proved to be a safe procedure. Prerequisites for Outcomes
success are compliant patients who are willing to After palm replantation, the hand can be expected to
undergo therapy for at least 3 months postoperatively. recover to rather realistic hand functions. Ample active
digital flexion can expected if no serious adhesions
Palm Replantation occur. The overall digital function is better after surgery
Surgery of palm than digital replantation. Stiffness in the digital
Amputation through palm is rarely caused by clean cuts. joints does not usually develop if the passive motion
Most often, machine cutting or crush-cutting injuries therapies are properly initiated. Nevertheless, when
e46 Chapter 46: Tendon Repairs in Replantation Surgery
postsurgical therapy guidelines are not established or FPL must be repaired and major wrist flexors (flexor
timely ordered, the hand with successfully replanted carpi radialis and ulnaris, FCR and FCU) should be
palm may end up with very limited function. Due to the repaired. Almost all the extensor tendons are worth
damage to intrinsic muscles, function of the digital MCP repairing, except for the extensor indicis proprius (EIP)
joint can be affected, and grip and pinch strengths and extensor digiti minimi (EDM). Preferably the EPL
reduce substantially. Therapies should continue to post- tendon should be repaired with a stronger surgical
surgical 6 months or over one year. method.
Tenolysis Postoperative Care

Tenolysis in the palm can be much more safely done After surgery, the hand is placed in a well-padded pro-
than in the replanted digits. The passive motion of the tective cast with the hand in the functioning position or
digits and wrist are usually ample. Consequently, a neutral position, with the thumb web widely opened.
higher percentage of the patients with palm replanta- For the first 3 weeks, the hand is immobilized. After 1
tion are indicative of secondary tenolysis. The palm pro- week, after serious hand edema subsides, passive digital
vides greater space to release the tendon from adhesions flexion can start, but generally only a mild range of
with less danger to damage the reestablished vascular passive motion should be prescribed. Light active
supplies, although surgeons should still take great care motion over a very limited range can be ordered as well.
not to hamper the vessels. Tenolysis is carried out about Motion helps reduce persistent edema of the hand.
6 months after surgery and should be under the condi- Early dynamic splinting and digital motion can be initi-
tion that solid union of the metacarpus is achieved. ated in selected patients who can follow the instruction
After tenolysis, the patients are instructed to perform of the therapist in a setting with well-established reha-
early active motion to prevent reoccurrence of the adhe- bilitation guideline. After 3 weeks, the cast fixation
sion, and the motion therapies should continue for 2 should be continued, with the hand in functional posi-
or 3 months. tion. Passive and active finger motion programs can be
upgraded gradually. Similarly, hand edema is serious in
Foream Replantation the first week after surgery and, if persistent, therapies
Surgery should be given to lessen digital edema and improve
Amputation through forearm, especially distal forearm, digital circulation when the digit motion starts. After 6
is caused by work-related injuries or crushing during to 8 weeks, when the radiograph confirms that bony
accidents. At this level, the amputation involves multi- healing is solid, the amplitude of motion and repetition
ple flexor and extensor tendons, major arteries, and of the motion can be increased. For the patient with
nerve trunks. Bony fixation should be accomplished first forearm replantation, much progress can be expected
during the surgery, followed by vascular anastomosis to even months after surgery, and continuation of thera-
establish circulation. The radius and ulna are usually pies to 6 months or one year is worthwhile.
shortened for 2 to 3 cm.
There is no need to particularly shorten the tendon, Outcomes
but the rugged tendon parts are excised to obtain healthy Outcomes of the forearm replantation vary greatly,
tendon substance for surgical repair. A core suture depending on the degree of injuries, structures repaired,
(mostly two-strand repair or a four-strand repair) should and, in particular, the recovery of nerve function. Passive
be used for both extensor and flexor tendons. Peripheral motion of the hand may not be impaired, but hand
sutures can be loosely added. Whether the repair site is function may be greatly reduced due to usually partial
bulky or not is not a great concern, because this area or poor recovery of nerve function. Grip and pinch
accommodates more space for tendon to glide. The strengths reduce substantially.
surgeons should pay particular attention not to mis- Scheker and colleagues (1995) reported that the
match the tendon ends. Strength of the flexor tendon results of replantation at the wrist and distal forearm are
remains important; we recommend four-strand repair better than at the metacarpal level.5 Their study evalu-
such as cruciate repair or U-shaped repair (see Figure ated a new postoperative protocol for replantation at
46-5 and Figure 46-6), made with 4-0 or 3-0 sutures. the metacarpal, wrist, and distal forearm levels. Three
Our colleagues (Zun Shan Ke, MD) used the U-shaped days after replantation, the patient was placed in a
4-strand repair made with looped nylon suture, supple- dynamic crane outrigger splint with MCP joint control,
mented with locking running peripheral suture in cases compensating for intrinsic muscle function loss. From
of forearm replantation, followed by early tendon mobi- 4 to 12 weeks, an anticlaw splint alternated with the
lization. They impressively obtained good function. outrigger splint. After 12 weeks, a dynamic wrist exten-
Repair of the FDS tendon is not a necessity. To reduce sion orthosis was added to the anticlaw splint. Eleven
operation time, the FDS tendon may not be repaired or patients (4 replantations at the transmetacarpal level,
may be connected with simpler suture. The lacerated 3 at the wrist area, and 4 in the distal forearm) had
this protocol. For distal forearm replantations, TAM of

FUNCTIONAL EVALUATION
fingers averaged 216°, grip strength 42 lb, and pinch
strength 7.2 lb with 75% good or excellent results. For In the early days of digital replantation, flexor tendons
wrist replantations, TAM of fingers averaged 243°, grip were not repaired, and secondary tendon reconstructed
strength 37 lb, and pinch strength 10.6 lb with 100% was preferred.6,7 The treatment guidelines for the tendon
good or excellent results. For transmetacarpal replanta- repairs in replantation have been changed. Currently,
tions, TAM of fingers averaged 189°, grip strength 37 lb, under favorable conditions, repairs of both extensors
and pinch strength 5.6 lb, with 75% good and excellent and flexor tendons are an integral and important part
results. of replantation surgery.8,9
Functional evaluations of patients after digital replan-
Tenolysis tation include (1) range of motion, passive and active;
Tenolysis can improve function of most patients after (2) recovery of sensation; (3) muscle power; (4) grip
replantation in the forearm. Surgery can be performed strength; (5) pain; (6) cold tolerance; (7) ability to
from 6 months to several years after surgery. Function resume previous or new occupation; (8) ability to inte-
of both extensor and flexor tendons can be improved grate the replanted parts into daily life and functional
after surgical release. Similarly, tenolysis should not be use; (9) patient satisfaction with the replanted part; and
performed within 6 months after surgery, and before (10) cosmetic appearance.10 While all the above criteria
solid union of the radius and ulna is achieved. After are important to the normal life, Buncke and colleagues11
tenolysis, the patients are instructed to perform early stated that among all factors influencing outcomes,
active motion immediately after surgery, and the motion “experience has shown that the two most critical issues
therapies should continue for months. are sensibility and tendon gliding.”
References
1. Jupiter JB, Pess GM, Bour CJ: Results of flexor tendon tenoly- 6. Komatsu S, Tamai S: Successful replantation of a completely
sis after replantation in the hand, J Hand Surg (Am) 14:35– cut-off thumb, Plast Reconstr Surg 42:374–377, 1968.
44, 1989. 7. Tamai S: Digit replantation: analysis of 163 replantations in
2. Ross DC, Manktelow RT, Wells MT, et al: Tendon function an 11 year period, Clin Plast Surg 5:195–209, 1978.
after replantation: prognostic factors and strategies to enhance 8. Meyer VE, Chen ZW, Beasley RW: Basic technical consider-
total active motion, Ann Plast Surg 51:141–146, 2003. ations in reattachment surgery, Orthop Clin North Am 12:871–
3. Yu JC, Shieh SJ, Lee JW, et al: Secondary procedures following 895, 1981.
digital replantation and revascularisation, Br J Plast Surg 9. Morrison WA, O’Brien BM, Macleod AM: Digital replantation
56:125–128, 2003. and revascularization: A long term review of one hundred
4. Eggli S, Dietsche A, Eggli S, et al: Tenolysis after combined cases, Hand 10:125–134, 1978.
digital injuries in zone II, Ann Plast Surg 55:266–271, 10. Steichen JB: Management of flexor tendon injury associated
2005. with digital replantation or revascularization. In Hunter JM,
5. Scheker LR, Chesher SP, Netscher DT, et al: Functional Schneider LH, Mackin EJ, editors: Tendon Surgery in the Hand,
results of dynamic splinting after transmetacarpal, wrist, and St Louis, 1987, CV Mosby, pp 156–169.
distal forearm replantation, J Hand Surg (Br) 20:584–590, 11. Buncke HJ, Alpert BS, Johnson-Giebink R: Digital replanta-
1995. tion, Surg Clin North Am 61:383–394, 1981.
Appendix
SYMPOSIUM DISCUSSION 1 Peter Amadio: How about treatment of the partially

lacerated FDP tendon and the FDS tendon? I repair
Symposium of Flexor Tendon Injury, The 10th a partial cut of the FDP when the cut is over 60% to
Congress of International Federation of Societies 70% of the cross-section. If the cut is less than 50%
for Surgery of the Hand (IFSSH) to 60%, trimming the tendon wound is an option.
March 12, 2007 This reduces the chance of triggering, but does not
The Sydney Convention Center, Sydney, Australia reduce the tendon strength. I repair the FDS tendon
(Figure 1) if possible, but prefer to remove a slip of the FDS
tendon when the gliding of the FDP appears tight
The discussion followed the symposium presentations with the sheath or pulleys.
by panelists. Michale Riccio: I agree that we may not need to repair
Panelists: Robert Savage, Jin Bo Tang, Michale Riccio, the FDS tendon in all occasions. In some cases, it is
and Peter Amadio very difficult to repair this tendon; we have to leave
Moderators: Peter Amadio and Stephen Coleman it unrepaired. Otherwise, the both tendons would be
bulky, but whether not repairing the FDS reduces the
Peter Amadio: Let’s start the discussion of this session. flexion power of the finger is a concern, which
It seems all of us are moving towards venting a certain remains uncertain.
part of the important pulleys and using strong repairs. Audience: This is a question for Dr. Tang. First I appreci-
What do you think about importance of individual ate the incredibly excellent work done in flexor tendon
annular pulley? from Dr. Tang. One thing I did not understand in the
Robert Savage: If other pulleys are intact, the A2 pulley work you’re doing: how far to place the grasping
may not be as important as thought in terms of suture. To my knowledge, the grasping and locking
preventing bowstringing and maintaining normal suture should be placed 3 or 4 mm away from the cut
mechanics of the tendon gliding. I think partial inci- edge of the tendon. As to the traditional technique,
sion or partial removal of the A2 pulley has no too much of the distance will bring about more tissues
adverse influence; I leave such partial defects of the within the suture, which will affect tendon gliding.
pulley unrepaired. The lack of importance of other Jin Bo Tang: Our original speculation is if a suture is
individual pulleys in the presence of a mainly intact placed with sufficient grasping or locking area, these
pulley system has been proven biomechanically in repairs would produce equal strength. However,
the past more than 10 years. during the test, the repair with shorter suture pur-
Peter Amadio: How about the A4 pulley? chase had much lower repair strength. This may
Robert Savage: It may not be important as well if others relate to the stiffness of the tendon and grasping
are intact. I would not repair it if it is the only annular power of the suture. With smaller suture purchase,
pulley injured. the stiffness may be much less and easy to deform
Peter Amadio: What method do you use for tendon and gap. Also the length of core suture purchase will
repairs? affect the share of the loads among the core suture
Jin Bo Tang: My colleagues and I use the latest modi- and peripheral sutures. If the core suture is very short,
fication of 6-strand repair with looped suture for the the load can be largely loaded into peripheral sutures,
profundus tendon. For FDS tendon, it cannot afford which is disrupted more easily, then the load will be
more than 4-strand core suture, so a four-strand on the core suture entirely; core suture will be dis-
repair using one group of looped suture is used to rupted. This is my explanation. We also found that if
make a U-shaped repair. the core suture purchase is beyond 7 mm, such effects
Peter Amadio: What kind of suture material? do not exist; almost equal repair strength was found
Jin Bo Tang: 4-0 nylon. from 7 mm to 12 mm.
Peter Amadio: Dr. Riccio, what sutures are you Audience: We have just heard about venting, removal,
using? or not repairing a part of important pulleys, such as
Michale Riccio: Pretty similar, I use 4-0 or 3-0 sutures the A2. I think this is a dangerous idea. Removal of
to make core stitches, but in children, I use a 5-0 the pulley may cause bowstringing and this is oppo-
suture instead. It is not necessary to do early motion site to traditional suggestions of not violating these
of the digit in children. important structures, such as A2 and A4 pulleys.
446
Appendix: Symposium Discussion 2 447
SYMPOSIUM DISCUSSION 2
Symposium of Flexor Tendon and Carpal

Disorders, The Pre-Congress of The 11th
Congress of International Federation of Societies
for Surgery of the Hand (IFSSH)
October 28, 2010
Affiliated Hospital of Nantong University,
Jiangsu, China (Figure 2)
Panelists: Daniel Mass, Michael Sandow, Robert Savage,

Steve K. Lee, and Jin Bo Tang
Moderator: Jin Bo Tang
Michael Sandow: Bad repair leads to bad outcomes.

Good repair does not guarantee good outcomes, but
Figure 1 Symposium of flexor tendon injury in The 10th it helps. I used modified Kessler repair (two-strand)
Congress of the IFSSH, Sydney, March 12, 2007. On the using 4-0 nylon or similar, Kleinert traction, and
podium (from left to right): Stephen Coleman, Peter Amadio,
flexed wrist splint. We failed to obtain satisfactory
Robert Savage, Jin Bo Tang, and Michale Riccio. (Courtesy of
Bin Wang.)
results in some cases. We then changed to a four-
strand single cross grasp repair (“Adelaide repair”)
using 3-0 braided polyester (Ethibond or similar)
Jin Bo Tang: We perform simple venting of the A2 with immediate active mobilization, extension block
pulley when other annular pulleys are not injured. splint with the wrist extended. I reviewed the results
With the other parts of the sheath intact, partial between 1996 and 2002, 89% follow-up, 71% good
venting of the A2 pulley is acceptable. Clinically, if or excellent results, 4.5% rupture rate. Modified
we see a wound limited to the area of the A2 pulley, Kessler is a simple repair of poor biomechanics. Its
or not extending to another annular pulley, we leave core suture has inherent grapping potential; its grasps
a part of injured A2 pulley unrepaired, or more often, are easily deformable. The transverse passes in the
we incise or remove a part of the A2 pulley to allow tendon may not be a good design.
repair or smooth tendon gliding. If the wound is Michael Sandow: I have some concern for definitions
extensive, with other pulleys, such as A1, PA, injured, of “grasp” and “loop.” I looked up the dictionary:
we should take great care to preserve the A2 pulley. “Grasp” denotes function, to hold onto something,
In those cases of tendon injury with A1 and PA lac- but “loop” denotes form, shape. “Locking grasp” and
erations, the tendon is usually cut proximal to the “looping grasp” appear more appropriate.
A2. It does not interfere with tendon motion, thus Jin Bo Tang: I probably would not change these terms,
not needing venting. because most hand surgeons are familiar with them,
Peter Amadio: What is the length you vent the pulley? but we need to give them clearer definitions.
Jin Bo Tang: I incise the A2 pulley to 2/3 of the length Michael Sandow: In Green’s textbook about the grasp-
of this pulley. ing, the suture is looped around the tendon sub-
Peter Amadio: How about Dr. Riccio? stance, and is pulled to the opposite direction. The
Michale Riccio: About the same. grasping loop slips over the tendon substance in the
Jin Bo Tang: The important message is that we really illustration. The difference between “grasp” and “lock”
need to know the detail of anatomy of the A2 pulley. is that if the suture changes its form by tension to the
In the adult middle finger, this pulley is quite long, tendon, it has a poor hold on the tendon and the
about 2 cm. This pulley even has different density in strength of repair is decreased. If the suture does not
its middle, distal, or proximal parts. The diameters of change its form, it is a lock, and the strength does
these parts are also different. I think either distal, not decrease as the hold gets stronger under load.
proximal, or their combination with the middle part, Jin Bo Tang: No suture techniques in clinical use actu-
can be incised or excised to free the tendon motion, ally have grasping suture pulled at two opposite
without any clinical problems. I have done it over directions. The techniques in use have grasp being
years, and still continue to do it. I do not suggest the pulled in one direction parallel to the longitudinal axis
incision of the entire A2 pulley. of the tendon, and in the other side another pull vertical
Peter Amadio: We are at the right time to end this to the long axis of the tendon. This is the way the grasp-
session now. Great discussion of the panelists and ing loops act in the Kessler and other grasping repairs.
from the audience! Thank you. The drawings in that textbook need to be modified.
448 Appendix: Symposium Discussion 2
splint after surgery. With 3-0 Ethibond suture, we had

no rupture at all in our recent series. I think adding
Silfverskiöld will unnecessarily complicate the repair
of the four-strand core repair. It is much more com-
plicated when we do it.
Jin Bo Tang: I have never used Silfverskiöld suture, as
we can easily increase the strength of core suture.
Complex peripheral suture brings about a lot of
suture over the tendon surface and this repair is also
difficult to perform. Is that very difficult to perform
such cross-stitch on the dorsal surface of the tendon?
Michael Sandow: Our discussion here is quite gentle;
actually we had quite hot discussion in Adelaide with
Figure 2 Panelists touring the Biomechanics Laboratory
Dr. Silfverskiöld. He works in Adelaide and he pub-
of the Hand Surgery Research Center in the Hospital of lished the method when he was in Sweden, and then
Nantong University immediately before the Symposium. came back to work in Australia.
From the left to the right: Robert Savage, Steve K. Lee, Jin Bo Tang: How about the tension of your core
Daniel Mass, Michael Sandow, Ya Fang Wu, and You Lang suture?
Zhou. Michael Sandow: The tension is sufficient to maintain
the cooptation of tendon ends. I do not mind having
some gap between the ends, so no bunching or catch-
ing by the sheath.
Michael Sandow: I agree. We put modified Kessler Jin Bo Tang: Would other panelists maintain some
repair in porcine flexor tendon and observed the tension across the repair site of the tendon, or leave
deformation of the tendon after preloading. The gaps between the ends?
transverse passes of the Kessler repair shortened and Michael Sandow: I mean I will add some tension at the
tendon was narrowed remarkably. With two single time of repair when temporary fixation is in place,
cross placed into the tendon, without a transverse but after removal of the fixation, it is best to see that
arm across the tendon end, we see little narrowing of the tendon is smooth and not bunching, but it is fine
the tendon. if there are small gaps between the ends. I do not
Steve K. Lee: What do you use for peripheral stitches? intentionally leave gaps between the ends when
Michael Sandow: I use a simple peripheral suture. If it suturing the tendons.
is a big tendon or is not too irregular, I use Silfver- Steve K. Lee: I have been using interlocking horizontal
skiöld method. But, for most tendons, we think mattress locking sutures. It is similar to Silfverskiöld,
simple epitendinous suture is adequate. Unless you but with interlocks. That is based on the work we
expect the peripheral stitches to bring about a lot of have done in the lab. Michael Hausman called it a
strength, simple suture is better. “Chinese finger trap.”
Daniel Mass: The complex peripheral stitches may be Daniel Mass: What I usually do is to put epitendinous
caught by pulleys. stitches to the back of the tendon first. You lock the
Michael Sandow: Absolutely. In Kessler suture, when stitch each time and make the tendon ends kissing.
we loaded the tendon, the epitendinous suture failed Then you put core suture and end with putting the
first, followed by Kessler suture; when four-strand epitendinous suture in the front of the tendon.
single-cross suture is used, the epitendious suture Daniel Mass: Most people are actually still using the
failed in the same time as the core suture, without Kessler. This is what they learned and what they have
gapping first. used.
Robert Savage: Some of the studies showed that Ade- Michael Sandow: I think the Kessler is such a rubbish
laide core with Silfverskiöld decrease the rate of method for repairing the tendon; it has very poor
rupture of the repair. Do you feel you will train your biomechanics, gapping very easily.
residents to do that repair? Jin Bo Tang: Many people and papers talk about adding
Michael Sandow: I am very happy you call it “Adelaide” Pennington locks into the Kessler. Either a grasping
repair, not the modified …, modified Savage repair. and locking Kessler is not strong. We had a study
Robert Savage: You have done a good job. several months ago and asked two surgeons to make
Michael Sandow: We did Adelaide with a simple epi- two groups of Kessler repairs, with and without
tendinous repair and had few ruptures. We had rup- Pennington lock. We couldn’t find any difference in
tures with two repairs of 4-0 nylon that registrars the strength, except 2 to 3 N differences in the gap
used to repair these tendons; the hand was out of the force.
Appendix: Symposium Discussion 2 449
Michael Sandow: You are right. A study showed what- interlocking horizontal mattress suture provides
ever you put grasping, Pennington locking Kessler or good strength. In doing this repair, each bite has to
just a simple loop around the tendon end, the suture be slightly away from the cut edge to not converge.
would deform the tendon and form a loop around Daniel Mass: I use running locks in epitendionus
the tendon, which actually does not act much suture, instead of interlocking suture. We tested it,
differently. without a core suture; it is adequately strong. Prob-
Jin Bo Tang: Is the Kleinert method of motion still ably it is not as strong, but the superficialis is flat, and
common in the United States? people don’t get the rotation right and actually
Daniel Mass: I think it is declining. More therapists use narrow the Camper’s chiasm. Just doing one slip is
the Duran method and the place-and-hold exercise. easier and adequate.
Jin Bo Tang: Do you actively move after secondary Steve K. Lee: For the superficialis tendon, I would repair
tendon graft? both slips, but quickly reduce it to one slip if there is
Daniel Mass: I do active finger motion after tendon any issue with tendon gliding. The Mayo group wrote
graft, with no-resistance, in a wrist extension splint about the benefits of repairing just one slip. It seems
or cast putting the wrist in 20° of extension and the many people are moving in that direction.
MCP joint in 60° of flexion and the IP straight. For Jin Bo Tang: Great talks and discussion. Thank you!
kids, I put a cast, and in adults, I put a splint. I left
a big hole in the cast, so the finger can move in
kids. In the unreliable patients, you can do the same
thing.
Robert Savage: Controlled “active” motion began in a
report in 1989 about the Belfast regimen. Variable
results were reported later, including those from
Manchester and Essex, with some ruptures. In a lab
study of pulleys, I noticed, and other noticed too,
that if you do not move the finger through the full
range, you are not putting the maximal load to the
tendon. The other ways of performing active motion
more easily include putting the wrist in extension: to
explain, the wrist flexed position causes the finger
extensors to become tight, and so finger flexion will
become difficult. In wrist extension, the finger exten-
sors are slack and flexion of the fingers requires much
less force. Also if the MCP joints are held in a neutral
or slightly flexed position, you will find it easy to flex
the DIP joint. Figure 3 “Work done only a few years, not decades, ahead
Steve K. Lee: Most people who do primary repair may of others actually would not make a great difference to the
still have up to 10% rupture after early active motion; overall progress in a field.”
that’s 1 out of 10. Those results are not that great. —Prof. Seiichi Ishii (back row, second from the left)
Dr. Richard Gelberman came to speak to the New commented humbly on May 26, 2010, in Tokyo, when
talking about his early work and contribution on intrinsic
York Society for Surgery of the Hand, saying “tenoly-
healing capacity of the flexor tendon in early 1970s. The
sis was necessary in 20% of (his) patients. There
photograph was taken on that day (second from the right,
is still a lot of research to be done.” We looked at back row, Prof. Poong-Teak Kim, and second from the right,
the strength of different repair and materials. Fiber- front row, Prof. Masamichi Usui). Prof. Ishii was honored as
wire has the greatest strength and the least knot “Pioneer of the Hand Surgery” in the Congress of the IFSSH in
volume (bulk). We recommend 6 knots with Fiber- October 2010 for his early work on the tendon and other
wire for repairs. Among epitendinous sutures, the contributions.
A Postscript About Progression of Thought
on Primary Tendon Repair
Jin Bo Tang, MD
I have set out to describe how my thinking pertaining reporting methods and outcomes. I sketched out zoning
to flexor tendon surgery has progressed over more than methods by observing hand specimens in the Depart-
20 years. ment of Anatomy. Later, in the early 1990s, my case
My first work on the tendon started in 1988 with a series indicated differences in results of tendon repairs
study of sheath closure using chicken models. Direct between zone 2C and other subzones. The repairs in the
closure of the sheath was found to be no better than area covered by the A2 pulley were found to produce
partial excision, and direct sheath closure at the delayed the worst outcomes.
primary stage was actually harmful to tendon gliding. It was my awareness of worse outcomes in zone 2C
This conclusion differed from a mainstream tenet at that that directed me to conducting studies focusing on the
time that sheath closure was beneficial to preventing A2 pulley and its corresponding tendon segment in
adhesions and maintaining nutrition. My ensuing work 1993–94. Clinically I compared the outcomes of repair
fostered an idea that ample space inside the sheath cavity to non-repair of the superficialis tendon in this particu-
(not closure or reconstructive surgery of the sheath per lar area, and found worse outcomes when the superfi-
se) is vitally important to healthy tendon healing and cialis was repaired. These clinical results prompted me
gliding. A key piece of evidence that led me to this con- to return to the anatomic laboratory to specifically study
sideration was that, given an equal extent of adhesions, the morphology and mechanics of tendons and pulleys.
tendons whose sheaths were enlarged with interposing There, I began to realize that purposeful incision of a
grafts exhibited better gliding than those within tightly part of the A2 pulley can be a feasible clinical option to
closed sheaths. Increasing the volume inside the sheath improve treatment results.
is thus considered imperative to both healing and This idea of active release of the A2 pulley encoun-
gliding of the tendon. I should give great credit to Pro- tered great opposition when presented to a symposium
fessor Seiichi Ishii, who earnestly mentored and sup- later. Though this study was published in The Journal of
ported my investigations in 1988 and 1989. Particular Hand Surgery (British) in 1995, even with clinical data
credit is due to this great man for creating the adhesion the idea of purposeful pulley-venting was printed only
grading criteria used in the investigation. Prof. Ishii is as an abstract in Chinese. There was considerable resis-
an early pioneer in the area of “intrinsic healing” of the tance to this “dangerous” initiative against deeply rooted
tendon. He initiated in vitro culture work to demon- traditional recommendations.
strate the capability of tenocytes to proliferate and to In late 1998, I read a report by Dr. David Elliot and
repair wounds as early as 1971, and published 3 years his colleagues of reporting results of tendon repairs in
later. In 2010, when I talked to him about this early subzones of zone 2 and venting of the A2 and A4
work, he calmly commented that work done only a few pulleys, which inspired me to send a letter to start com-
years, not decades, ahead of others actually would not munication with Dr. Elliot and to plan a 5-day visit to
make a great difference to the overall progress in a field. him in June of 1999. In Dr. Elliot’s house in the middle
He is an exemplary pioneer in science, humble in accept- of a wheat field by Chelmsford, Dr. Elliot and I spent
ing credit, yet dedicated and nurturing toward young no less than 3 entire days “randomly” discussing any
investigators. topics we could think of relating to tendon repair, taking
My second work was on subdivision of zone 2 in late notes on ideas that came up during conversations. Dr.
1989. At that time, I began independently treating hand Elliot showed me a manuscript in which he proposed
cases and regularly repaired zone 2 tendon injuries. In to subdivide zone 1. We agreed that a precise and clear
practice, I found that recording the site of injuries and determination of the site of tendon laceration is funda-
outcomes of treatment in subdivisions of zone 2 mental to any discussion of treatment. Dr. Elliot’s take
appeared not only necessary, but important in discuss- was as follows: most people who do not feel a need
ing treatment of these tendons. Literature in the 1970s to subdivide the zones probably have not had enough
and 1980s had been unclear regarding the exact site in cases to allow for observing differences in treatment
450
A Postscript About Progression of Thought on Primary Tendon Repair 451
results. We discussed the methods of repairs and the who lack background knowledge about the project but
need of stronger surgical repair; in the later years, I have strong technical skills, so they do not know what
learned that Dr. Elliot and his colleagues started routine we are trying to prove. We intend not only to publish
use of the six-strand core repair using the looped suture our findings, but also to publish with greater confidence,
that I have favored. We agreed that a part of the pulleys with results that withstand the test of time.
can be incised and that sheath closure is not important— Our hand surgery service for disorders of hand and
still at that time I did not recognize the importance of upper extremity became a department in 2002, and has
pulley-venting to the extent that I would later—the continuously expanded to its current size of 12 staff
venting may be vital to achieve predictable treatment surgeons and 110 hospital beds. Over the past 10 years,
outcomes. We were surprised by our similar approaches my colleagues and I have steadily modified our surgical
in A2 pulley treatment without prior awareness of one techniques and rehabilitation protocols. Most of the
another. Dr. Elliot actually started to perform pulley- novel methods or technical modifications that my col-
venting in early 1995. leagues and I have applied to the clinic were derived
I established a research center for the hand in 1995 directly from our laboratory results. We also adopted a
and had a group of investigators working on tendon few clinical treatment rules directly from laboratory
projects since then. Before that, I was mostly alone on studies, e.g., optimal core suture purchase and ideal
my journey. Drs. Ren Guo Xie, Bin Wang, and Yu-tong grasping/locking sizes in a surgical repair, etc. Motion
Gu were the earliest to join in mechanical testing of protocols have been amended with new components,
tendon repair strength and in vivo studies, followed by such as passive motion prior to active motion in each
Drs. Zhi Ming Cui, Jun Tan, Yan Xu, and Zun Shan Ke. exercise session and initiation of finger motion 3 to 5
Over the past years, Drs. Yi Cao, Bei Zhu, Chuan Hao days after surgery. These modifications stemmed from
Chen, and Ya Fang Wu performed a series of excellent studies of factors affecting strength of tendon repair,
mechanical and molecular studies. On the clinical side, postoperative edema, resistance to tendon movement,
Drs. Ren Guo Xie, Bin Wang, and Jun Tan have been etc. We have been able to prove the safety of judicious
active in applying novel surgical and rehabilitation surgical venting of the pulleys through clinical follow-up
methods for years. All have been extremely dedicated; and established simplified multistrand repairs as the
to them I should give great credit. The research center standard method for zone 2 tendon repairs. Though we
has entered into full function since 1997. Over the past still face challenges of composite tissue loss/damage
15 years, we have investigated individual factors that with tendon injuries—including tendon injuries involv-
may affect tendon repair strength with in vitro mechani- ing bones or after multiple reconstructions—It is the my
cal testing; modified test models under curvilinear opinion and that of my colleagues that it is possible to
loading conditions; tested novel surgical repair methods; achieve close-to-normal recovery of function in clean-
examined the effects of pulley integrity or venting on cut tendon injuries in the finger. The outcomes of repairs
tendon gliding and adhesions with in vivo models; and of tendon injuries in the fingers are no longer unpredict-
explored molecular methods which may be used in able, which is a major advance.
enhancing tendon healing or limiting adhesions. In My colleagues and I share the belief that attention to
these investigations, the study had been set up with the intricate details of surgical repair is vital to the
detailed discussion within the group. In order to allow success of any given method. Equally important is the
myself to remain involved in some vital steps and clear and precise mastery of the surgical anatomy of the
monitor or participate the project directly, I rather strictly tendon and its pulleys. Junior surgeons may frequently
limit the number of people participating in investigation not attend to details of surgical repair techniques such
at the same time. In investigations that have led to major as ensuring sufficiently large tendon substance within a
conclusions, I repeated and verified key experimental suture’s grasps or locks and adding some tension across
steps together with colleagues. Often independent inves- the repair, and may possess no clear mental picture of
tigators have worked on projects at different times, with anatomy during surgery. Without attention to such
a portion of study contents overlapping, to verify each details, the repair may be disrupted or gap easily, and
other’s conclusions in a blinded way. To avoid bias, I do the sheath or pulleys could be treated erroneously. Sur-
not usually explain expected results to fellow investiga- geons who adopt an established method may report the
tors. I consider our conclusions reliable only when they end-results that vary enormously depending on the sur-
are obtained without a clear purpose of proving a pre- gical details. Thus attention to surgical details should be
conceived conclusion and are repeatedly proven by dif- adequately emphasized. Technical details and mastery
ferent investigators among us. Not infrequently, a study of anatomy need to be passed from experienced sur-
is published years later, after it has undergone blinded geons to junior staff members in classrooms and at the
self-verification, sometimes carried out by researchers operation table.

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(ClinicalKey 2012.) Tang, Jin Bo - Tendon Surgery of The Hand (2012) - Opt

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What are tendons and their function?

What are tendons and their function?

What are some common tendon injuries in the hand?

What are some common tendon injuries in the hand?

TENDON SURGERY

Jean Claude Guimberteau, MD

David Elliot, MA, FRCS, BM, BCh

TENDON SURGERY OF THE HAND ISBN: 978-1-4377-2230-7

Copyright © 2012 by Saunders, an imprint of Elsevier Inc.

Library of Congress Cataloging-in-Publication Data

Senior Content Strategist: Don Scholz

Last digit is the print number: 9 8 7 6 5 4 3 2 1

This book is dedicated to my wife, Bari, for her continuous emotional

I would like to thank two illustrious colleagues, Harold Kleinert and

I wish to thank my family—James Sr., Lily, Anthony, Barbara, and

Roberto Adani, MD Philip E. Blazar, MD

Alphonsus K.S. Chong, MBBS, MRCS(Ed), Robert R.L. Gray, MD

Massimo Corain, MD Ioannis Kostas-Agnantis, MD

Brandon E. Earp, MD Armin Kraus, MD

Andrew E. Farber, DO Fraser J. Leversedge, MD

Michel Mansat, MD Mark A. Rider, MBChB, FRCS, FRACS

Shian Chao Tay, PhD Esther Vögelin, MD, PhD

Ghislaine Traber-Hoffmann, MD Ren Guo Xie, MD

Gwendolyn Van Strien, LPT, MSc

OUTLINE reinforced by the pisiform-hamate ligament. On the

different populations all over the world.9 In humans,

loading the FCR tendon rotated the scaphoid in flexion

Structure of the Digital Flexor Sheath

the profundus tendon is less in adults than in fetuses.

Figure 1-4 Top, Loose vertical fibers join adjacent layers

Flexor digitorum Vinculum longum Vinculum brevis

Flexor digitorum Vinculum Vinculum

interossei can be absent. The dorsal interossei are some-

On the dorsum of the hand, the extensor tendons are

Figure 1-10 The flexor pollicis longus (FPL) pulley system

of the FPB as one of the palmar interossei.2,39 The oppo-

OUTLINE TENDON NUTRITION

This chapter will review current knowledge on tendon Vascular Sources

transforming growth factor (TGF)β as well as mechani-

EFFECT OF PHYSICAL FACTORS

Patch containing cells,

OUTLINE fingers, frictional force must be encountered. An et al1

Tendons can be classified as intrasynovial and extrasy-

tendon at the medial malleolus are other examples of

Figure 3-3 Left, Intrasynovial tendon region, Surrounding

Intrasynovial Extrasynovial Hybrid

FDP tendon Before testing After 1000-cycle After 1000-cycle

surface. The extracellular matrix of the epitenon layer Core protein

and decreases abrasion during tendon motion (Figure

disruption of this mechanism has been suggested as a

Biomechanics of Tendon Motion

relaxation added, the amplitude of the profundus tendon excur-

Figure 3-11 The moment arm is the

599% for high-friction repair technique, which then

OUTLINE The end-to-end repair commonly consists of two

Box 4-1 Groups Contributing to Major Information of Tendon Repair Biomechanics

Gelberman–St Louis Group: In vitro and in vivo models: canine tendons

Mass-Chicago Group: In vitro model and in vivo models: human tendons

Trumble-Seattle Group: In vitro model: human tendons

TENDON SURGERY OF THE HAND ISBN: 978-1-4377-2230-7

OUTLINE fingers, frictional force must be encountered. An et al1