Double armed reinsertion suture (DARS) of the profundus flexor tendon with immediate active mobilization of the finger. 63 cases

245 © Socidt~ d'E,dition de l'Association d'Enseignement M~dical des H@itaux de Paris, 1997

Double armed reinsertion suture (DARS) of the profundus flexor tendon with immediate active mobilization of the finger. 63 c a s e s

A. MESSINA, J.C. MESSINA

SUMMARY: Between 1982 and 1994, the authors performed 63 flexor digitorum profundus tendon reinsertions according to the <>DARS technique is a simple method which allows immediate active mobilization of the finger and appears to guarantee satisfactory functional results with no risk of tendon rupture. Ann Chir Main (Ann Hand Surg), 1997, 16, n ° 3,245-251. KEY-WORDS : Flexor tendon. - Suture.

Mobilization.

Profundus flexor tendon repair at its distal insertion and at the DIP joint still often fails because of traumatic pathological and technical causes. Many traumatic, degenerative and operative conditions may greatly contribute to worsen these problems and lead to failure of the profundus flexor tendon repair by the usual procedures :

traumatic involvement of the capsular palmar plate (section, rupture etc), -

pathological rupture or disinsertion of the profundus flexor tendon, -

disinsertion with bone avulsion of the palmar edge of P3, -

Hand Surgery Center, Clinica Fornaca, TORINO (Italie). Manuscrit re¢}u b la R~daction le 12 mai 1997. Accept6 le 8 septembre 1997.

F o r r e p r i n t s ." Dr A. M e s s i n a , V i a M o n t e R o s a r o , 10098 RIVOLI (Torino) (Italy).

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Fig. 1. - Double Armed Reinsertion Suture (DARS). A first nylon suture is criss-crossed through the tendon stump; a second nylon suture is inserted one centimeter more p r o x i m a l l y and then c r i s s - c r o s s e d in the lateral and median line of the tendon thickness. Both nylon sutures are passed through the hole of the metaphysis of P3 and tied laterally and left in situ as a lost thread. Fig. 1. - Reinsertion du tendon flechisseur profond selon la technique DARS (Double Armed Reinsertion Suture). Le premier fil de nylon 4/0 est entrelac6 darts 1'6paisseur du moignon tendineux du flechisseur. Un deuxieme fil de nylon 4/0 est entrelace, 1 cm plus proximalement que le pr6cedent, et pass6 lui aussi sur le versant lat&al et sur la ligne mediane de 1'6paisseur du tendon (v. texte). Les deux fils de nylon sont ensuite passes par un fil de Kirschner & travers un tunnel d'ancrage creuse dans les m6taphyses de P3. Les deux fils sont lies aux ills du c6t6 oppose et laiss6s in situ ~,& fil perdu,,, sur le versant lat6ral de la phalange distale. Fig. 1. - Reinserci6n del tend6n flexor profundo segQn la tecnica DARS (Double Armed Reinsertion Suture). El primerhilo de nylon 4/0 es enlazado en el espesor del mufion tendinoso del flexor. Un segundo hilo de nylon 4/0 es enlazado 1 cm en proximal al precedente y se pasa luego hacia el borde lateral y sobre la linea mediana del espesor del tendon (v. texto). Los dos hilos de nylon se pasan despu6s por un ttSnel de anclaje checho en la metafisis de P3 mediante una aguja de Kirschner. Los dos hilos son atados a los hilos de la parte opuesta y son dejados in situ - a l hilo perdido ,, sobre la vertiente lateral de la falange.

- secondary retraction of DIP palmar plate after standard tendon reinsertion, - residual scar at the flexion crease of the DIP joint with skin loss after deep burn or severe crush, -post-traumatic osteoarthritis of DIP joint. The studies by Weber E.R. [12], Gelberman et al. [2, 3], Mansk et al. [6, 7], Caplan et al. [1], Lundborg et al. [5], Ilizarov [4], Messina [8, 9, 10], confirmed that fibroblastic activity and tendon healing p e r p r i m a m are enhanced by early mobilization.

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Fig. 2. - Nylon sutures in the Double Armed Reinsertion S u t u r e are s t r o n g l y a n c h o r e d to t h e m e t a p h y s i s of P3. This allows i m m e d i a t e active mobilization of the finger without any risk of rupture of the suture or tendon disruption. Fig. 2. - Le fil de nylon de la DARS est en mesure d'ancrer fortement le moignon tendineux a. 1'6piphyse de la phalange distale sans risque de rupture ni etirement (gap) du tendon, m6me en cas de d6vascularisation de celui-ci. Fig. 2. - El hilo de nylon de la DARS puede anclar fuertemente el mufion tendinoso a la epifisis de la falange distal sin riesgo de ruptura o de estiramiento (gap) del tenddn, incluso en el caso de su devascularizacidn.

Since 1982 we started using the DARS (doubled armed reinsertion suture), performed by means of a lost thread double suture, to allow immediate active mobilization of the finger [9, 10], in order to obtain earlier consolidation o f the distal insertion of the profundus flexor tendon to overcome the potential problems of adhesions (after finger immobilization) and to avoid the concomitant risk of tendon disruption in early mobilization.

OPERATIVE TECHNIQUE AND POST OPERATIVE CARE The double lost thread reinsertion suture (DARS) has b e e n p e r f o r m e d for p r i m a r y and d e l a y e d primary (within 1 to 2 weeks) profundus flexor tendon reinsertion (fig. 1, 2). The operation is performed under regional anesthesia.

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Exposure of the injured tendon is achieved by means of mid-lateral direct exposure and lateral enlargement of the pulley by a synovial flap at the appropriate pulley level (A4, A5) [11]. The technique involves a double Bunnell suture with nylon 4/0 situated on the lateral and median line of the tendon thickness (fig. 3). This preserves the blood supply of the posterior portion of the tendon (vincula tendinum) and allows anterior synovial nutrition in the avascular portion. A classical insertional epiphyseal hole on the palmar surface of P3 is performed and the tendon stump is partially introduced into this hole (each lacerated structure of the DIP joint is repaired before tendon reinsertion). The nylon suture is anchored to the proximal metaphysis of P3 through a transverse hole, then tied and left in situ like a <>. The second and more proximal suture thread is inserted one centimeter proximally to the first Bunnell suture in the same lateral and median line of the tendon thickness and anchored to P3 in the same way as the previous suture. The double suture protects the tendon junction from muscular strain during active contraction and during hand-therapy, so the finger may be bent actively and immediately without contrast. The patient returns home soon after the operation and is allowed to use his hand (he may drive, put on his clothes, eat etc.). After the operation, the wound is only covered by 2 or 3 small triangular shaped dressings which do not interfere with active flexion of the finger. If necessary, hand-therapy may be started immediately by the physiotherapist. Occupational therapy and active flexion of the finger against traction or any resistance must be avoided for 3 weeks. If the finger becomes edematous, hand-therapy must be stopped for 1 or 2 days ; cold compresses etc., may be prescribed to reduce edema; antibiotic treatment is recommended for 6-8 days postoperatively. If a collateral nerve or the whole neurovascular pedicle is repaired, a small plaster back slab is recommended to prevent complete extension of the finger, but active flexion may nevertheless be commenced immediatly.

The commonest traumatic mechanism of injury of profundus flexor tendon of the fingers was a cutting lesion (knife, glass, sheet iron, etc.) in 26 cases. A traumatic subcutaneous rupture occurred in 4 cases after a severe tear of the distal phalanx with concomitant disruption of joint capsule and palmar plate ; 3 cases had a bone disinsertion with fracture of the epiphyseal edge after a fall, sporting activities such as catching a baseball on the tip of a finger or stubbing the finger with P3 extended. A subcutaneous pathological rupture or disinsertion occurred on 7 profundus flexor tendons in a contest of non specific tenosynovitis, arthritis deformans, rheumatoid tenosynovitis; in these cases we found degeneration of the tendon stump or invasion of the tendon by rheumatoid pannus (fig. 4, 5). The injury and repairs concerned the following digits : thumb 13 ; index 9 ; long 6; ring 5 ; small 7. No intolerance to lost thread material, reactive tenosynovitis, or post operative inflammation reaction was observed in the treated cases. RESULTS Follow-up examinations were performed 1 to 12 years after the operation. II Personal assessment of the results of flexor tendon repair in the digital canal

Excellent The finger regained full active and passive motion. The patient is satisfied. Good possibility of full active metacarpophalangeal mobility; complete passive mobility of the involved joint; - the finger shows a variable degree of functional limitation in flexion and extension of an interphalangeal joint: a) possibility of active distal interphalangeal mobility of at least 5 to 10 degrees; b) possibility of active proximal interphalangeal mobility of at least 30 to 45 degrees; c) finger pulp can actively touch the palm; d) patient is satisfied at work and play. -

-

CLINICAL MATERIAL Between 1982 and 1994, we performed DARS with lost thread on 63 patients; forty operated tendons were reviewed at the end of 1995. The patients consisted of 35 males and 5 females ranging in age from 7 to 75 years.

Poor Joint stiffness or tendon shortening are present; or adhesions prevent any joint movement; or absence of active joint mobility; or the finger pulp can not touch the palm; or the patient is not satisfied.

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A : Nutrient tendon pathways. Rvnovial nutrition trinsic nutrition lterfascicular) Extrinsic nutrition (vincula tendinum)

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Fig. 3. - Biologic and dynamic features of DARS technique. The f i g u r e - o f - e i g h t shape of the tendon, by means of lateral and median line position of the DARS suture, reduces its gliding surface by two-thirds. This particular situation also protects the suture knots and, in recent injuries, it preserves the dorsal blood supply and anterior synovial nutrition of the tendon. Fig. 3. - Principes biologiques et dynamiques de la DARS. Dans les lesions recentes, les deux ills de nylon entrelaces dans I'epaisseur du moignon tendineux, en position lat6rale et mediane, n'entravent pas, la vascularisation dorsale (vincula tendinum) et la nutrition synoviale de la partie a n t & i e u r e du tendon (avasculaire). La position mediane et laterale des ills de nylon transforme la forme ellipsoTdale du tendon en une forme en 8, r6duisant ainsi des deux tiers la surface de frottement ant~rieure du tendon et prot6geant le noeud et le materiel de suture du frottement contre les poulies. Ce montage permet donc la mobilisation active immediate du doigt et la consolidation physiologique et precoce du tendon; elle rend possible un retour rapide au travail.

B: DARS in recent injuries •y and delayed primary repair eeks post-injury) Synovial nutrition of anterior half of the tendon; the knot of DARS is protected during tendon silding

DARS suture is situated on the lateral and median line in order to preserve a good vascularity of posterior half of tendon

C: DARS in early secondary repair . . . . . . aeks, post-injury) andon nutrition is assured by synovial pitenon nutrition (pump effect - Weber 1986) Extrinsic vascularity is definitif compromised (Lundberg 1980) Fig. 3. - Principios biologicos y dinamicos de la DARS. En las lesiones recientes, los dos hilos de nylon enlazados en el mufion del tendon, en posicion lateral y mediana, no influyen sobre la vascularizacion dorsal (vincula tendinum) y la nutricidn sinovial de la parte anterior del tendon (sin vascularizaci6n). La posicidn mediana y lateral de los hilos de nylon transforma la forma eliptica del tend6n en forma de 8, reduciendo en tres tercios la supercifie de rose anterior del tenddn y protegiendo el nudo y el material de sutura de las poleas. Este montaje permite la movilizaci6n activa inmediata del dedo y la consolidacion fisiologica y precoz del tendon ; ademfis favorice un retorno rapido al trabajo.

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Fig. 4. - Subcutaneous flexor tendon rupture with palmar capsule disruption of the thumb. Reinsertion of the tendon stump by DARS is ensured by two nylon sutures passed through a metaphyseal hole of P3, tied laterally and left in situ as a lost thread. This ensures a strong suture with no risk of disruption during active mobilization of the finger. Fig. 4. - Rupture traumatique sous-cutanee du tendon long fl6chisseur du pouce. Reinsertion du moignon tendineux par la t e c h n i q u e DARS ~. la base de la p h a l a n g e distale. L'ancrage est assure par deux fils de nylon 4/0 pass6s b. travers un trou transversal m6taphysaire de P3. Les fils sont sutures avec leurs correspondants du c6t6 oppose et laiss6s in s i t u a ~,fil perdu ,,. Ce montage decharge la jonction ost6o-tendineuse en neutralisant la force musculaire qui s'exerce pendant la mobilisation active du doigt. Fig. 4. - Ruptura traumfitica del flexor largo del pulgar. Reinserci6n del mufion tendinoso con la tecnica DARS en la base de la falange distal. El enclaje esta asegurado por los dos hilos de nylon 4/0, pasados a traves de un agujero transversal en la metfifisis de P3. Los hilos se suturan con sus correspondientes del lado opuesto y dejados in situ a ,, hilo perdido,,. Este montaje descarga la articulaci6n osteotendinosa, neutralizando la fuerza muscolar que se ejerce en la movilizacion activa del dedo.

- According to our personal method, we scored our results as follows : excellent : 20 % (8 cases) ; good: 70% (28 cases); poor: 10% (10 cases). - Evaluation o f the results according to TAM (total active motion) was : excellent : 20 % ; good : 6 0 % ; fair: 10%; poor: 10%. DISCUSSION The development of surgical techniques has led to the increasing availability of different methods to ensure earlier repair of flexor tendon lacerations. In treated cases, immediate, active mobilization of the finger demonstrates strong insertion of the profundus flexor tendon by means of DARS which avoids the risk of rupture of the anchorage on P3.

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Fig. 5. - This finger has preserved its active motion which is possible immediately after DARS. The patient is very happy to use his finger without plaster or any finger limitation during tendon healing.

Fig. 5. - Contr61e clinique de la flexion active du pouce chez le m6me patient. Le doigt a toujours garde sa mobilite active apr6s la r6insertion tendineuse du long flechisseur. L'intervention, effectu6e en anesth6sie tronculaire, ne n6cessite pas d'hospitalisation. Le patient est satisfait de pouvoir utiliser imm6diatement son doigt sans plfitre ni aucune limitation fonctionnelle pendant la gu6rison biologique du tendon. Fig. 5. - Revisi6n clinica de la flexi6n activa del pulgar en el mismo paciente. El dedo conserva su movilidad activa despues de la reinserci6n tendinosa del flexor largo. La intervenci6n, hecha bajo anestesia local, no exige hospitalizaci6n. El paciente se siente satisfecho de poder utilizar inmediatamente el dedo, sin yeso y sin ninguna otra limitaci6n funcional durante la cicatrizaci6n biol6gica del tendon.

Nevertheless, in some cases, two to three weeks after bone anchorage, X-rays revealed a larger transverse hole due to the presence of nylon threads and to the traction stress of flexor muscle strain. However, subsequent post operative review confirmed that bone insertion of the tendon stump was strong and definitive so that traction stress no longer affected the bone hole. In fact, no cases of disruption under stress or spontaneously were observed in any of the patients treated by Double Armed Reinsertion Suture, even when loss of blood supply of the distal stump was observed in the case of pathological or traumatic ruptures. This is certain by due to the strong distal reinsertion suture of the tendon, in which immediate mobilization improves the new blood supply and consolidation [ 10].

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In young patients under the age o f 15 years, anchorage of the nylon threads is performed at the apex of P3. Via a skin incision performed 2-3 mm. under the nail, we pass the two nylon threads into the subcutaneous tissue of the phalangeal apex; they are then passed and tied on the lateral surface of P3 according to the standard technique described above. We are also convinced that the biological problem of tendon junction healing in devascularized stumps is also improved by lateral enlargement and closure of the synovial sheath which is able to preserve the blood supply of the synovial tendon stump [ 11 ]. Fair and poor results can be attributed to severe injuries of the capsule, ligaments, palmar plate and articular fractures concomitant to the tendon disinsertion, as well as subsequent shortening o f the profundus flexor tendon in cases with associated distal stump degeneration due to traumatic or pathological loss. It has been demonstrated that tendon strangling in the middle of its thickness by the nylon threads does not alter the blood supply o f the residual vincula

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tendinum of the dorsal half of the tendon and does not interfere with the synovial blood supply of the anterior half of the tendon. In any case, the median position of the suture changes the ellipsoidal shape of the tendon with its large friction surface into a figure-of-eight shape, resulting in a two-thirds reduction of the gliding surface of the tendon and a protection land in its lateral and median line for the knots and the suture threads (fig. 3). No suture intolerance has been observed during active mobilization of the flexor tendon.

CONCLUSION The <> (DARS) with lost threads is a simple technique which protects the tendon suture from muscular strain and allows early active mobilization after profundus flexor tendon injury. No risk of tendon disruption and very satisfactory functional results may be expected with this technique.

REFERENCES 1. C A P L A N H. S., H U N T E R J.M., M E R K L I N R.J. - Intrinsic vascularisation of flexor tendons. Symposium on tendon surgery in the hand. Am. Acad. Orthop. Surg., 1957, Saint-Louis, Mosby Comp., 48-58. 2. GELBERMAN R.H., MENON J., GONSALVES M. AKENSON W.H. - The effect of mobilization on the vascuiarisation of healing flexor tendons in dogs. Clin. Orthop., 1980, 153, 283-289. 3. GELBERMAN R.H., VAN DER BERG J.S., LUNDBORG G.N., AKESON W.H. Flexor tendon healing and restoration of the gliding surface. £ Bone Joint Surg., 1983, 65A, 70-80. 4. ILIZAROV G.A. - Introduzione alla conoscenza delle metodiche di Ilizarov in Ortopedia e Traumatologia, Milano, Ediz. Medi Surgical Video, 1983. 5. L U N D B O R G G., HOLM S., M Y R H A G E R. - The role of the synovial fluid and tendon sheath for flexor tendon nutrition. Seand. ,L Plast. Reconstr., 1980, 14, 99-107. 6. M A N S K E P.R., G E L B E R M A N R., V A N D E R BERG J. S., LESKER P. - Intrinsic flexor tendon repair. ,/2 Bone Joint Surg., 1984, 66/1, 385-396.

7. MANSKE P.R., LESKER P.A. - Flexor tendon nutrition. Hand Clin., i985, 1, 13-24. 8. MESSINA A. - La <> nuovo metodo di riparazione dei tendini flessori delle dita con mobilizzazione attiva immediata. Riv. Chit. Mano, 1988, 25, 87-95. 10. MESSINA A. The double armed suture : tendon repair with immediate mobilization of the fingers. £ Hand Surg., i992, 17A, 137-142. 11. MESSINA A., MESSINA J.C. The direct midlateral approach with lateral enlargement of the pulley system for repair of flexor tendons in fingers. J. Hand Surg., 1996, 21B, 463-468. 12. WEBER E.R. -Nutritional pathways for flexor tendons in the digital theca. In : HUNTER, SCHNEIDER, McKIN (Eds) : Tendon Surgery in theHand, Toronto, The C.V. Mosby C., 1987, 91-99.

A. M E S S I N A , J.C. M E S S I N A . - D o u b l e r6insertion d ' u n tendon fl6chisseur profond (DARS) avec mobilisation active i m m 6 d i a t e du doigt. 63 cas. (En Anglais). A n n C h i r M a i n (Ann H a n d S u r g ) , 1997, 16, n ° 3 , 2 4 5 - 2 5 1 .

A. M E S S I N A , J.C. M E S S I N A . - D o b l e r e i n s e r c i d n de u n tenddn flexor profundo (DARS) con movilizacidn activa i n m e d i a t a del dedo. A n n C h i t M a i n (Ann H a n d S u r g ) , 1997, 16, n ° 3 , 2 4 5 - 2 5 1 .

RI~SUMt~: Entre 1982 et 1994, les auteurs ont pratiqu6 63 r6insertions du tendon fldchisseur profond des doigts selon la mdthode DARS (double armed reinsertion suture) fi <>. I1 s'agit de deux sutures de Bunnell appuy6es sur les parties lat6rales et antdrieures de la tranche de section tendineuse. Les fils de nylon sont pass6s au travers d'un trou transversal fait fi la base de la phalange distale. En post-

RESI~IMEN: Entre 1982 y 1994 los autores practicaron 63 reinserciones de un tenddn flexor profundo de los dedos seg/m el m6todo DARS (Double armed reinsertion suture) al <>. Se trata de dos suturas de Bunnell apoyadas sobre las partes laterales y anteriores del borde de seccidn tendinosa. Los hilos de nylon se pasan a trav6s de un agujero transversal hecho a la base de la falange distal. En post operatorio

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o p 6 r a t o i r e une f l e x i o n active sans r 6 s i s t a n c e est d e m a n d 6 e . U n e limite en e x t e n s i o n n ' e s t utilisde q u ' e n cas de l~sion associ~e d ' u n p~dicule vasculonerveux. Quarante tendons ont 6t6 revus pour cette 6tude (patients figds de 7 fi 75 ans, 35 h o m m e s pour 5 femmes). La 16sion int6ressait 13 fois le pouce et 27 fois les doigts longs. Selon les crit6res de l'auteur, les r6sultats ont 6t6 not6s excellents 20 % (8 cas) ; bons 7 0 % (28 cas); mauvais 10% (10 cas). La technique D A R S /t <> est une rn6thode simple qui p e r m e t une mobilisation active imm6diate du doigt et semble garantir des r6sultats fonctionnels satisfaisants, sans risque de rupture tendineuse.

se r e q u i e r e u n a f l e x i 6 n a c t i v a sin r e s i s t e n c i a . Solamente se limita la extensi6n en caso del lesi6n asociada del pediculo vasculo nervioso. Se reexaminaron 40 tendones en este estudio (edad de 7 a 75 afios, 35 hombres y 5 mujeres). La lesidn se localizaba 13 v e c e s en el pulgar y 27 veces en los dedos largos. Segfin los criterios del autor, los resultados se calificaron c o m o excelentes en 20 % (8 casos) ; buenos en 70 % (28 c a s o s ) y malos en 10 % (10 casos). La t6cnica D A R S al <> es un m6todo simple que permite una movilizacidn activa inmediata del dedo y parece garantizar un resultado funcional satisfactorio sin riesgo de ruptura del tenddn.

MOTS-CLI~S : Tendons fl6chisseurs. - Suture. - Mobilisation.

PALABRAS-CLAVE: Tend6n flexor. - Sumra. - Movilizaci6n.

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MESSINA A., MESSINA J.C. Ann Chir Main (Ann Hand Surg), 1997, 16, n ° 3,245-251.