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No man’s land revisited: the primary flexor tendon repair controversy 1
No Man’s Land Revisited: The Primary Flexor Tendon Repair Controversy William L. Newmeyer III, MD, San Francisco, CA, Paul R. Manske, MD, St. Louis, MO
New surgical procedures, novel concepts, and/or the presentation of very good results with an apparently discredited technique meet varying degrees of resistance among the establishment of any profession. In hand surgery this phenomenon was exemplified in a striking fashion with the presentation of a controversial report entitled, “Primary repair of flexor tendons in no man’s land” by Kleinert, Kutz, Ashbell, and Martinez of Louisville, KY, at the 1967 American Society for Surgery of the Hand (ASSH) annual meeting. The discussant, Joseph Boyes, expressed such skepticism that a special ASSH committee was appointed to go to Louisville and review the results to determine if they were as good as claimed. They were, and today primary flexor tendon repair is the procedure of choice for most flexor tendon lacerations. (J Hand Surg 2004;29A:1–5. Copyright © 2004 by the American Society for Surgery of the Hand.) Key words: Flexor tendon laceration, zone II, no man’s land, primary flexor tendon repair, controversy, history.
Hand surgeons have had and continue to have a remarkable fascination with zone II flexor tendon injures. Green1 reported that 8.4% of the presentations at the American Society for Surgery of the Hand (ASSH) annual meetings from the inaugural meeting in 1947 through 1993 were related to flexor tendon problems. This exceeded the next 2 most frequent topics by almost 2:1. Newmeyer2 noted that 6.8% of the scientific manuscripts published in the Journal of Hand Surgery from 1976 to early 1994 were about flexor tendon problems, ranking this topic
From San Francisco, CA; and the Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO. Received for publication June 17, 2003; accepted July 15, 2003. No benefits in any form have been received or will be received by a commercial party related directly or indirectly to the subject of this article. Reprint requests: William L. Newmeyer, MD, 84 Fifth Ave, San Francisco, CA 94118. Copyright © 2004 by the American Society for Surgery of the Hand 0363-5023/04/29A01-0001$30.00/0 doi:10.1016/S0363-5023(03)00381-2
behind only wrist/carpal problems, nerve problems, and tumors in frequency. The term no man’s land (NML) to describe flexor tendon lacerations within the digital sheath has been attributed to Bunnell. The historic derivation of NML dates to the 14th century when it was used to describe a plot of land outside the city of London used for executions. Bunnell’s encounter with the term likely was related to his experience in France during World War I where it also was used to describe the strip of devastated land between the front line trenches of the 2 opposing armies. According to Joseph Boyes (personal communication, 1982) Bunnell used the term no man’s land as early as 1934. The term did not appear in his first edition3 of Surgery of the Hand. Although not indexed, Bunnell’s first published use of the term appeared in a figure legend in both the second4 and third5 editions of his book, Surgery of the Hand; the legend read, “Primary suture of the flexor tendon between the distal crease in the palm and the middle crease in the finger (no man’s land).” It also appeared unindexed in chapter 2 of Bunnell’s The Journal of Hand Surgery
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1955 report as a civilian consultant to the Secretary of War, Surgery in World War II, Hand Surgery6; Bunnell stated, “In the zone between the distal crease in the palm and middle crease of a finger (no man’s land), the juncture of a tendon always adheres after secondary repair.” The manner in which the term was used by Bunnell leads the reader to conclude that it was used commonly in communication among hand surgeons. The term was first indexed in the fourth7 and fifth8 editions of Surgery of the Hand, authored by Boyes. The term certainly has come into wide and common usage in hand surgery. It refers to the area of the hand where the flexor digitorum superficialis and the flexor digitorum profundus change their position relative to one another while passing through a synovial sheath with minimal tolerance, approximately from the distal palmar crease to the midportion of the middle phalanx. The 2 tendons have a large amplitude, the loss of which (eg, from dense scar) will result in marked diminution of either finger flexion or extension or both. The specific investigation of the healing of lacerated tendons within the digital sheath appears early in the 20th century. Bier (cited by Hueck9) noted in 1920 the mediocre healing capacity of flexor tendons within the synovial sheath. Saloman10 in 1924 attributed this poor response to an inhibitory hormone in the synovial fluid and to the paucity of cells within the tendon that were capable of proliferation. In a 1922 report Bunnell11 stated “we must not have infection. . .nor must we have aseptic traumatic inflammation as this is almost as binding to movable parts as is the fibrosis of infection.” In a 1940 report Bunnell12 outlined not only the conditions that must be present to accomplish primary repair but the steps for doing so. These included the use of stainless steel suture material, an admonition to never repair both tendons for fear adhesions would prevent active flexion of the distal joint, and immobilization of the wrist in flexion to “leave the involved muscle unable to move forcefully enough to separate the ends of the sutured tendons.” He also notes that there would be enough motion to “stimulate growth and lessen adhesions while physiologic union is occurring.”12 It is apparent that Bunnell was aware of the importance of motion/tension on tendon healing, thus establishing the concept of early mobilization as early as 1940. In 1940 Mason13 also postulated similar conditions for primary repair. Mason recommended wide excision of the overlying sheath and to never repair both tendons. He concluded, “Primary repair is al-
ways advisable if the surgeon can secure the wound early enough and can assure himself that contaminants from human sources have not entered the wound.” (Surgeons today often forget the great fear that surgeons of that era had concerning infections and the devastating effect on results in that time before antibiotics.) In the first edition of Surgery of the Hand Bunnell presented a number of conditions that must be present for primary repair of severed tendons to even be considered.14 These include early surgery before introduced germs have become numerous, thorough debridement, covering of all vulnerable tissues, and surgery within 6 hours by one skilled in this type of surgery. Furthermore primary tendon suture in this area may be successful if the wound is debrided carefully and “sutured at a distance” from the laceration site using a stainless steel pullout wire. In suturing at a distance Bunnell placed a stainless steel holding suture proximal to the site of laceration/ repair and brought it out through the skin distally (eg, in the interdigital web) and tied it tightly and securely over a button to take all tension off the repair. The laceration itself was sutured with very fine, coapting silk sutures. The holding suture was pulled out proximally after the tendon had healed.15 Despite an acceptance of the concept of primary repair by Bunnell and Mason, 2 well-respected hand surgeons at that time, the predominant view for the first 70 years of the 20th century was that primary repair of flexor tendons in NML should be discouraged. In a 1947 report, “Immediate vs delayed repair of the digital flexor tendons,” Boyes16 noted that primary flexor tendon repair in what he then called the “critical zone” (the same anatomic area as NML) usually fails for 1 of 3 reasons: infection, excessive scarring and cicatrix from ill performed surgery, and poorly placed incisions that cause flexion contractures. He also noted “it is the opinion of many surgeons that when the results of primary repair of flexor tendons in the area are studied critically, the results are always unsatisfactory.” His preferred treatment of flexor tendon lacerations was tendon grafting. In 1950 Boyes17 gave the first of 2 monumental reports on the results of flexor tendon grafts in fingers and the thumb at the American Academy of Orthopaedic Surgeons meeting with subsequent publication in the Journal of Bone and Joint Surgery. In this first report he gave results of 138 tendon grafts in 118 patients with flexor tendon injuries in NML. In 25% of his patients the tip of the grafted digit
Newmeyer and Manske / No Man’s Land Repair Controversy
touched the distal palmar crease and in 50% it came within 12.5 mm (.5 in) of this point. Boyes’ opinion regarding poor results after primary flexor tendon repair was echoed by subsequent investigators. Hauge18 in 1955 reported on the results of tendon suture of the hand in 500 patients. Of these, 218 were flexor tendons with 98 NML primary repairs, 94 of which were unsuccessful, additionally 6 of 11 secondary NML repairs also were unsuccessful. He concluded that in general these NML injuries should be referred to a hand surgeon for a secondary treatment. His dismal results would seem to support that conclusion well . Van’t Hof and Heiple19 read a paper at the annual ASSH meeting in 1957 that subsequently was published in the Journal of Bone and Joint Surgery on flexor injuries in the fingers and thumb. Of 60 tendon repairs in 52 patients there were 16 in NML, all repaired primarily. They compared their results with those of others in published reports and concluded that “results of grafts within the flexor tunnel are distinctly better than those of primary repair.” In his discussion of the report Boyes20 opined that he hoped that the report would be “widely read and that its conclusions are carried into practice.” But he doubted that either would happen. Kelly21 in a report delivered at the 1958 ASSH annual meeting and later published in the Journal of Bone and Joint Surgery reported results of a study of 789 tendon lacerations. A total of 101 of these were in NML and had a primary repair. Despite 42 excellent results, 25 good results, and 34 poor results, his conclusion was that primary repair in this area is an unwise procedure except in unusual circumstances. Despite the predominant concept and practice that primary repair leads to functionally poor results, nevertheless a few reports began to suggest that reasonable success could be realized with primary flexor repair in NML. In 1950 Siler22 reported on a series of flexor tendon injuries sustained between 1941 to 1946 and treated by primary repair. Of 184 injuries treated, 83 could be analyzed but only 65 were followed-up long enough to evaluate the result. Thirtytwo injuries were in NML and 62% had an excellent (80% normal function) or good (50% normal function) result. It is of interest that 35 different surgeons, all presumably trained by Siler, performed the repairs. These results, although not superb, were far from producing the hopeless outcome predicted by others. They indicated that perhaps there was a place for primary repair. In 1956 Posch23 (a hand surgeon with extensive
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experience and Kleinert’s mentor) reported to the Central Surgical Association in Rochester, MN, the results of 45 NML primary repairs with 39 satisfactory results. Subsequent reports of good results from primary repair or delayed primary repair in NML continued to appear. These included reports by Carter and Mersheimer,24 Lindsay and McDougall,25 and Verdan.26 In 1967 Kleinert, Kutz, Ashbell, and Martinez submitted their controversial report to the annual ASSH meeting. Kleinert was the only one of the authors who was then an ASSH member but Kutz was the scheduled presenter. Lee Milford, chairman of the program committee, told the authors before the presentation that there was some question about their results and that Kleinert would have to give the report (personal communication, November, 2002). The report was based on a 10-year experience in primary tendon repair in NML. All lacerations were clean, sharp with minimal tissue damage, no contamination, and no open fractures; however, associated closed fractures or lacerated neurovascular bundles were not a contraindication. They reported an astounding 87% good to excellent results on private service patients; this compared with 76% poor results on teaching service patients. On the private service patients there was no difference between repair of the profundus tendon only or repair of both flexor tendons.27 In the meeting abstract the number of patients was not noted, only the percent results. Boyes28 discussed the report; the recorder of the discussion noted that Boyes found “these were the most outstanding results obtained by any one in flexor tendon repair. One gathered that he questioned the percentage of good results without any failures.” The report and the subsequent discussion stimulated a great deal of controversy. The matter did not end with the conclusion of the meeting but simmered on for sometime. According to Robert McCormack (personal communication, November, 2002) it resurfaced at the “members’ only” component of the 1969 annual meeting in New York City, and a “heated discussion” took place. As Don Eyler recalls, Kleinert’s rejoinder to the doubters was “come to Louisville and see for yourselves” (personal communication, November, 2002). J. Leonard Goldner suggested a committee be appointed to evaluate the results. The committee chaired by McCormack, along with members Eyler and Paul Weeks, went to Louisville. According to McCormack, the committee members examined about 40 patients, took meticulous notes, made clinical slides
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of the results, and presented the information to the members-only part of the 1970 annual meeting the next year in Chicago. McCormack noted, “the discussion was rather mild as the successful results spoke for themselves.” Unfortunately the original 1967 Kleinert et al presentation was never published, nor were the subsequent verbatim discussions. We only have the meeting abstracts and the memories of those who were there. The first publication on primary repair of flexor tendons by the Louisville group did not appear until 197329 as a review in Orthopedic Clinics of North America. Again the published report did not give the number of patients, but only the percent results in the different categories. Additionally in the 1973 publication the investigators strongly noted the importance not only of meticulous surgery, but also of the critical role of postoperative rehabilitation, specifically the abandonment of the 3-week period of immobilization in favor of early tendon mobilization. Interestingly Boyes and Stark delivered their second monumental report on the results of 1,000 flexor tendon grafts at the Fifth Combined Meeting of the Orthopaedic Associations of the English Speaking World in Sydney, Australia, in 1970, which subsequently was published in 1971,30 2 years before the Kleinert et al publication of the results of primary flexor tendon repair. Before the Kleinert et al presentation nearly everything written or stated in support of primary flexor tendon repair was either done so “off the center stage” (ie, presented at a national meeting where few hand surgeons were present, presented by a nonAmerican or non-Canadian hand surgeon, or published in a journal not usually read by many hand surgeons) or was written in such an apologetic, humble manner that there is little wonder that surgeons were hesitant to repair flexor tendons primarily in NML. This all changed with the Kleinert et al presentation and its subsequent publication. By the late 1960s and early 1970s there were additional other factors that also encouraged a bolder course and a surgical alternative to tendon grafting. More surgeons were obtaining specialty training in hand surgery and consequently there were more people interested in and trained to perform hand surgery, specifically flexor tendon surgery. The number of members of the ASSH increased dramatically beginning in 1971; in that year 41 new members were admitted, more than the combined total of the previous 4 years. There were more training programs that produced more young surgeons who were willing to
operate on acute lacerations day or night. Finally, rehabilitation protocols were improved and hand therapists assumed a greater role in the care of tendon injuries. All of these factors contributed to making zone II flexor tendon primary repairs the standard treatment of today. Flexor tendon grafting in zone II is now for the most part more of a salvage procedure. New or different techniques always have met with resistance, particularly if, as in the case of primary flexor tendon repair, they traditionally have led to bad results. In the preantibiotic days devastating infection and attempts at primary repair by those unskilled in the nuances of hand surgery frequently led to scarring, adhesions, and immobile digits. This was the situation trained hand surgeons often encountered in the early days of hand surgery and it is little wonder there was so much opposition to NML primary repair. This flexor tendon controversy of more than 30 years ago is not unlike subsequent controversies in hand surgery; some of these include open versus endoscopic release of the carpal tunnel, microvascular replantation, hand transplantation, and others. It was notable for the exceptional level of passion and involvement on the part of the participants. Although it may be tempting for the young hand surgeons of today, inspired by this historic recollection, to pursue unconventional techniques, it is important also to remember that the road to successful ideas is littered with failed practices and concepts. We can be sure of only one thing in the advancement of hand surgery; that is, that there will continue to be future controversies as to how to improve the function and appearance of the hand. Indeed if there were none, hand surgery would be a dying specialty.
References 1. Green DP. A brief history of the scientific program. In: American Society for Surgery of the hand. The first fifty years. New York: Churchill Livingstone, 1995:67–74. 2. Newmeyer WL III. History of The Journal of Hand Surgery: 1976 –1999. J Hand Surg 2000;25A:5–13. 3. Bunnell S. Surgery of the hand. (1st ed). Philadelphia: JB: Lippincott, 1944. 4. Bunnell S. Surgery of the hand. (2nd ed). Philadelphia 627: JB Lippincott, 1948. 5. Bunnell S. Surgery of the hand. (3rd ed). Philadelphia 712: JB Lippincott, 1956. 6. Bunnell S, ed. Surgery in world war II. Hand surgery. Washington, DC: Office of the Surgeon General, Department of the Army, 1955:50. 7. Boyes JH. Bunnell’s surgery of the hand. (4th ed). Philadelphia: JB: Lippincott, 1964. 8. Boyes JH. Bunnell’s surgery of the hand. (5th ed). Philadelphia: JB: Lippincott, 1970.
Newmeyer and Manske / No Man’s Land Repair Controversy 9. Hueck H. Ueber sehnenregeneration innherhalb echter sehnenscheiden. Arch Klin Chir 1923;127:137–164. 10. Saloman A. Klinische und experimentelle untersuchungngen ueber heilun von sehnenberletzungen ins besondere innerhalbe der sehnenscheiden. Arch Klin Chir 1924;129:397– 430. 11. Bunnell S. Repair of tendons in the fingers. Surg Gynecol Obstet 1922;35:88 –97. 12. Bunnell S. Primary repair of severed tendons. The use of stainless steel wire. Am J Surg 1940;47:502–516. 13. Mason ML. Primary and secondary tendon suture. A discussion of the significance of technique in tendon surgery. Surg Gynecol Obstet 1940;70:392– 402. 14. Bunnell S. Surgery of the hand. (1st ed). Philadelphia 460: JB Lippincott, 1944. 15. Bunnell S. Surgery of the hand. (1st ed). Philadelphia 310: JB Lippincott, 1944. 16. Boyes JH. Immediate vs delayed repair of the digital flexor tendons. Ann Western Med Surg 1947;1:145–152. 17. Boyes JH. Flexo-tendon grafts in the fingers and thumb. J Bone Joint Surg 1950;32A:489 – 499. 18. Hauge MF. The results of tendon suture of the hand. A review of 500 patients. Acta Orthop Scand 1955;24:258 – 270. 19. Van’t Hof A, Heiple KG. Flexor tendon injuries in the fingers and thumb. A comparative study. J Bone Joint Surg 1958;40A:256 –262.
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20. Boyes JH. Discussion of Van’t Hof, Heiple paper. J Bone Joint Surg 1958;40A:262, 322. 21. Kelly AP. Primary tendon repairs. A study of 789 consecutive tendon severances. J Bone Joint Surg 1959;41A:581– 598. 22. Siler VE. Primary tenorrhaphy of the flexor tendons in the hand. J Bone Joint Surg 1950;32A:218 –224. 23. Posch JL. Primary tenorrhaphies and tendon grafting procedures in hand Injuries. AMA Arch Surg 1956;73:609 – 624. 24. Carter SJ, Mersheimer WL. Deferred primary tendon repair. Results in 27 cases. Ann Surg 1966;164:913–916. 25. Lindsay WK, McDougall EP. Direct digital flexor tendon repairs. Plast Reconstr Surg 1960;26:613– 621. 26. Verdan CE. Primary repair of flexor tendons. J Bone Joint Surg 1960;42A:647– 657. 27. Kleinert HE, Kutz JE, Ashbell TS, Martinez E. Primary repair of lacerated flexor tendons in “No Man’s Land” (abstr). J Bone Joint Surg 1967;49A:577. 28. Boyes JH. Discussion of Kleinert/Kutz/Ashbell/Martinez paper (abstr). J Bone Joint Surg 1967;49A:577. 29. Kleinert HE, Kutz JE, Atasoy E, Stormo A. Primary repair of flexor tendons. Orthop Clin North Am 1973;4:865– 876. 30. Boyes JH, Stark HH. Flexor-tendon grafts in the fingers and thumb. A study of factors influencing results in 1000 cases. J Bone Joint Surg 1971;53A:1332–1342.
New surgical procedures, novel concepts, and/or the presentation of very good results with an apparently discredited technique meet varying degrees of resistance among the establishment of any profession. In hand surgery this phenomenon was exemplified in a striking fashion with the presentation of a controversial report entitled, “Primary repair of flexor tendons in no man’s land” by Kleinert, Kutz, Ashbell, and Martinez of Louisville, KY, at the 1967 American Society for Surgery of the Hand (ASSH) annual meeting. The discussant, Joseph Boyes, expressed such skepticism that a special ASSH committee was appointed to go to Louisville and review the results to determine if they were as good as claimed. They were, and today primary flexor tendon repair is the procedure of choice for most flexor tendon lacerations. (J Hand Surg 2004;29A:1–5. Copyright © 2004 by the American Society for Surgery of the Hand.) Key words: Flexor tendon laceration, zone II, no man’s land, primary flexor tendon repair, controversy, history.
Hand surgeons have had and continue to have a remarkable fascination with zone II flexor tendon injures. Green1 reported that 8.4% of the presentations at the American Society for Surgery of the Hand (ASSH) annual meetings from the inaugural meeting in 1947 through 1993 were related to flexor tendon problems. This exceeded the next 2 most frequent topics by almost 2:1. Newmeyer2 noted that 6.8% of the scientific manuscripts published in the Journal of Hand Surgery from 1976 to early 1994 were about flexor tendon problems, ranking this topic
From San Francisco, CA; and the Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO. Received for publication June 17, 2003; accepted July 15, 2003. No benefits in any form have been received or will be received by a commercial party related directly or indirectly to the subject of this article. Reprint requests: William L. Newmeyer, MD, 84 Fifth Ave, San Francisco, CA 94118. Copyright © 2004 by the American Society for Surgery of the Hand 0363-5023/04/29A01-0001$30.00/0 doi:10.1016/S0363-5023(03)00381-2
behind only wrist/carpal problems, nerve problems, and tumors in frequency. The term no man’s land (NML) to describe flexor tendon lacerations within the digital sheath has been attributed to Bunnell. The historic derivation of NML dates to the 14th century when it was used to describe a plot of land outside the city of London used for executions. Bunnell’s encounter with the term likely was related to his experience in France during World War I where it also was used to describe the strip of devastated land between the front line trenches of the 2 opposing armies. According to Joseph Boyes (personal communication, 1982) Bunnell used the term no man’s land as early as 1934. The term did not appear in his first edition3 of Surgery of the Hand. Although not indexed, Bunnell’s first published use of the term appeared in a figure legend in both the second4 and third5 editions of his book, Surgery of the Hand; the legend read, “Primary suture of the flexor tendon between the distal crease in the palm and the middle crease in the finger (no man’s land).” It also appeared unindexed in chapter 2 of Bunnell’s The Journal of Hand Surgery
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1955 report as a civilian consultant to the Secretary of War, Surgery in World War II, Hand Surgery6; Bunnell stated, “In the zone between the distal crease in the palm and middle crease of a finger (no man’s land), the juncture of a tendon always adheres after secondary repair.” The manner in which the term was used by Bunnell leads the reader to conclude that it was used commonly in communication among hand surgeons. The term was first indexed in the fourth7 and fifth8 editions of Surgery of the Hand, authored by Boyes. The term certainly has come into wide and common usage in hand surgery. It refers to the area of the hand where the flexor digitorum superficialis and the flexor digitorum profundus change their position relative to one another while passing through a synovial sheath with minimal tolerance, approximately from the distal palmar crease to the midportion of the middle phalanx. The 2 tendons have a large amplitude, the loss of which (eg, from dense scar) will result in marked diminution of either finger flexion or extension or both. The specific investigation of the healing of lacerated tendons within the digital sheath appears early in the 20th century. Bier (cited by Hueck9) noted in 1920 the mediocre healing capacity of flexor tendons within the synovial sheath. Saloman10 in 1924 attributed this poor response to an inhibitory hormone in the synovial fluid and to the paucity of cells within the tendon that were capable of proliferation. In a 1922 report Bunnell11 stated “we must not have infection. . .nor must we have aseptic traumatic inflammation as this is almost as binding to movable parts as is the fibrosis of infection.” In a 1940 report Bunnell12 outlined not only the conditions that must be present to accomplish primary repair but the steps for doing so. These included the use of stainless steel suture material, an admonition to never repair both tendons for fear adhesions would prevent active flexion of the distal joint, and immobilization of the wrist in flexion to “leave the involved muscle unable to move forcefully enough to separate the ends of the sutured tendons.” He also notes that there would be enough motion to “stimulate growth and lessen adhesions while physiologic union is occurring.”12 It is apparent that Bunnell was aware of the importance of motion/tension on tendon healing, thus establishing the concept of early mobilization as early as 1940. In 1940 Mason13 also postulated similar conditions for primary repair. Mason recommended wide excision of the overlying sheath and to never repair both tendons. He concluded, “Primary repair is al-
ways advisable if the surgeon can secure the wound early enough and can assure himself that contaminants from human sources have not entered the wound.” (Surgeons today often forget the great fear that surgeons of that era had concerning infections and the devastating effect on results in that time before antibiotics.) In the first edition of Surgery of the Hand Bunnell presented a number of conditions that must be present for primary repair of severed tendons to even be considered.14 These include early surgery before introduced germs have become numerous, thorough debridement, covering of all vulnerable tissues, and surgery within 6 hours by one skilled in this type of surgery. Furthermore primary tendon suture in this area may be successful if the wound is debrided carefully and “sutured at a distance” from the laceration site using a stainless steel pullout wire. In suturing at a distance Bunnell placed a stainless steel holding suture proximal to the site of laceration/ repair and brought it out through the skin distally (eg, in the interdigital web) and tied it tightly and securely over a button to take all tension off the repair. The laceration itself was sutured with very fine, coapting silk sutures. The holding suture was pulled out proximally after the tendon had healed.15 Despite an acceptance of the concept of primary repair by Bunnell and Mason, 2 well-respected hand surgeons at that time, the predominant view for the first 70 years of the 20th century was that primary repair of flexor tendons in NML should be discouraged. In a 1947 report, “Immediate vs delayed repair of the digital flexor tendons,” Boyes16 noted that primary flexor tendon repair in what he then called the “critical zone” (the same anatomic area as NML) usually fails for 1 of 3 reasons: infection, excessive scarring and cicatrix from ill performed surgery, and poorly placed incisions that cause flexion contractures. He also noted “it is the opinion of many surgeons that when the results of primary repair of flexor tendons in the area are studied critically, the results are always unsatisfactory.” His preferred treatment of flexor tendon lacerations was tendon grafting. In 1950 Boyes17 gave the first of 2 monumental reports on the results of flexor tendon grafts in fingers and the thumb at the American Academy of Orthopaedic Surgeons meeting with subsequent publication in the Journal of Bone and Joint Surgery. In this first report he gave results of 138 tendon grafts in 118 patients with flexor tendon injuries in NML. In 25% of his patients the tip of the grafted digit
Newmeyer and Manske / No Man’s Land Repair Controversy
touched the distal palmar crease and in 50% it came within 12.5 mm (.5 in) of this point. Boyes’ opinion regarding poor results after primary flexor tendon repair was echoed by subsequent investigators. Hauge18 in 1955 reported on the results of tendon suture of the hand in 500 patients. Of these, 218 were flexor tendons with 98 NML primary repairs, 94 of which were unsuccessful, additionally 6 of 11 secondary NML repairs also were unsuccessful. He concluded that in general these NML injuries should be referred to a hand surgeon for a secondary treatment. His dismal results would seem to support that conclusion well . Van’t Hof and Heiple19 read a paper at the annual ASSH meeting in 1957 that subsequently was published in the Journal of Bone and Joint Surgery on flexor injuries in the fingers and thumb. Of 60 tendon repairs in 52 patients there were 16 in NML, all repaired primarily. They compared their results with those of others in published reports and concluded that “results of grafts within the flexor tunnel are distinctly better than those of primary repair.” In his discussion of the report Boyes20 opined that he hoped that the report would be “widely read and that its conclusions are carried into practice.” But he doubted that either would happen. Kelly21 in a report delivered at the 1958 ASSH annual meeting and later published in the Journal of Bone and Joint Surgery reported results of a study of 789 tendon lacerations. A total of 101 of these were in NML and had a primary repair. Despite 42 excellent results, 25 good results, and 34 poor results, his conclusion was that primary repair in this area is an unwise procedure except in unusual circumstances. Despite the predominant concept and practice that primary repair leads to functionally poor results, nevertheless a few reports began to suggest that reasonable success could be realized with primary flexor repair in NML. In 1950 Siler22 reported on a series of flexor tendon injuries sustained between 1941 to 1946 and treated by primary repair. Of 184 injuries treated, 83 could be analyzed but only 65 were followed-up long enough to evaluate the result. Thirtytwo injuries were in NML and 62% had an excellent (80% normal function) or good (50% normal function) result. It is of interest that 35 different surgeons, all presumably trained by Siler, performed the repairs. These results, although not superb, were far from producing the hopeless outcome predicted by others. They indicated that perhaps there was a place for primary repair. In 1956 Posch23 (a hand surgeon with extensive
3
experience and Kleinert’s mentor) reported to the Central Surgical Association in Rochester, MN, the results of 45 NML primary repairs with 39 satisfactory results. Subsequent reports of good results from primary repair or delayed primary repair in NML continued to appear. These included reports by Carter and Mersheimer,24 Lindsay and McDougall,25 and Verdan.26 In 1967 Kleinert, Kutz, Ashbell, and Martinez submitted their controversial report to the annual ASSH meeting. Kleinert was the only one of the authors who was then an ASSH member but Kutz was the scheduled presenter. Lee Milford, chairman of the program committee, told the authors before the presentation that there was some question about their results and that Kleinert would have to give the report (personal communication, November, 2002). The report was based on a 10-year experience in primary tendon repair in NML. All lacerations were clean, sharp with minimal tissue damage, no contamination, and no open fractures; however, associated closed fractures or lacerated neurovascular bundles were not a contraindication. They reported an astounding 87% good to excellent results on private service patients; this compared with 76% poor results on teaching service patients. On the private service patients there was no difference between repair of the profundus tendon only or repair of both flexor tendons.27 In the meeting abstract the number of patients was not noted, only the percent results. Boyes28 discussed the report; the recorder of the discussion noted that Boyes found “these were the most outstanding results obtained by any one in flexor tendon repair. One gathered that he questioned the percentage of good results without any failures.” The report and the subsequent discussion stimulated a great deal of controversy. The matter did not end with the conclusion of the meeting but simmered on for sometime. According to Robert McCormack (personal communication, November, 2002) it resurfaced at the “members’ only” component of the 1969 annual meeting in New York City, and a “heated discussion” took place. As Don Eyler recalls, Kleinert’s rejoinder to the doubters was “come to Louisville and see for yourselves” (personal communication, November, 2002). J. Leonard Goldner suggested a committee be appointed to evaluate the results. The committee chaired by McCormack, along with members Eyler and Paul Weeks, went to Louisville. According to McCormack, the committee members examined about 40 patients, took meticulous notes, made clinical slides
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The Journal of Hand Surgery / Vol. 29A No. 1 January 2004
of the results, and presented the information to the members-only part of the 1970 annual meeting the next year in Chicago. McCormack noted, “the discussion was rather mild as the successful results spoke for themselves.” Unfortunately the original 1967 Kleinert et al presentation was never published, nor were the subsequent verbatim discussions. We only have the meeting abstracts and the memories of those who were there. The first publication on primary repair of flexor tendons by the Louisville group did not appear until 197329 as a review in Orthopedic Clinics of North America. Again the published report did not give the number of patients, but only the percent results in the different categories. Additionally in the 1973 publication the investigators strongly noted the importance not only of meticulous surgery, but also of the critical role of postoperative rehabilitation, specifically the abandonment of the 3-week period of immobilization in favor of early tendon mobilization. Interestingly Boyes and Stark delivered their second monumental report on the results of 1,000 flexor tendon grafts at the Fifth Combined Meeting of the Orthopaedic Associations of the English Speaking World in Sydney, Australia, in 1970, which subsequently was published in 1971,30 2 years before the Kleinert et al publication of the results of primary flexor tendon repair. Before the Kleinert et al presentation nearly everything written or stated in support of primary flexor tendon repair was either done so “off the center stage” (ie, presented at a national meeting where few hand surgeons were present, presented by a nonAmerican or non-Canadian hand surgeon, or published in a journal not usually read by many hand surgeons) or was written in such an apologetic, humble manner that there is little wonder that surgeons were hesitant to repair flexor tendons primarily in NML. This all changed with the Kleinert et al presentation and its subsequent publication. By the late 1960s and early 1970s there were additional other factors that also encouraged a bolder course and a surgical alternative to tendon grafting. More surgeons were obtaining specialty training in hand surgery and consequently there were more people interested in and trained to perform hand surgery, specifically flexor tendon surgery. The number of members of the ASSH increased dramatically beginning in 1971; in that year 41 new members were admitted, more than the combined total of the previous 4 years. There were more training programs that produced more young surgeons who were willing to
operate on acute lacerations day or night. Finally, rehabilitation protocols were improved and hand therapists assumed a greater role in the care of tendon injuries. All of these factors contributed to making zone II flexor tendon primary repairs the standard treatment of today. Flexor tendon grafting in zone II is now for the most part more of a salvage procedure. New or different techniques always have met with resistance, particularly if, as in the case of primary flexor tendon repair, they traditionally have led to bad results. In the preantibiotic days devastating infection and attempts at primary repair by those unskilled in the nuances of hand surgery frequently led to scarring, adhesions, and immobile digits. This was the situation trained hand surgeons often encountered in the early days of hand surgery and it is little wonder there was so much opposition to NML primary repair. This flexor tendon controversy of more than 30 years ago is not unlike subsequent controversies in hand surgery; some of these include open versus endoscopic release of the carpal tunnel, microvascular replantation, hand transplantation, and others. It was notable for the exceptional level of passion and involvement on the part of the participants. Although it may be tempting for the young hand surgeons of today, inspired by this historic recollection, to pursue unconventional techniques, it is important also to remember that the road to successful ideas is littered with failed practices and concepts. We can be sure of only one thing in the advancement of hand surgery; that is, that there will continue to be future controversies as to how to improve the function and appearance of the hand. Indeed if there were none, hand surgery would be a dying specialty.
References 1. Green DP. A brief history of the scientific program. In: American Society for Surgery of the hand. The first fifty years. New York: Churchill Livingstone, 1995:67–74. 2. Newmeyer WL III. History of The Journal of Hand Surgery: 1976 –1999. J Hand Surg 2000;25A:5–13. 3. Bunnell S. Surgery of the hand. (1st ed). Philadelphia: JB: Lippincott, 1944. 4. Bunnell S. Surgery of the hand. (2nd ed). Philadelphia 627: JB Lippincott, 1948. 5. Bunnell S. Surgery of the hand. (3rd ed). Philadelphia 712: JB Lippincott, 1956. 6. Bunnell S, ed. Surgery in world war II. Hand surgery. Washington, DC: Office of the Surgeon General, Department of the Army, 1955:50. 7. Boyes JH. Bunnell’s surgery of the hand. (4th ed). Philadelphia: JB: Lippincott, 1964. 8. Boyes JH. Bunnell’s surgery of the hand. (5th ed). Philadelphia: JB: Lippincott, 1970.
Newmeyer and Manske / No Man’s Land Repair Controversy 9. Hueck H. Ueber sehnenregeneration innherhalb echter sehnenscheiden. Arch Klin Chir 1923;127:137–164. 10. Saloman A. Klinische und experimentelle untersuchungngen ueber heilun von sehnenberletzungen ins besondere innerhalbe der sehnenscheiden. Arch Klin Chir 1924;129:397– 430. 11. Bunnell S. Repair of tendons in the fingers. Surg Gynecol Obstet 1922;35:88 –97. 12. Bunnell S. Primary repair of severed tendons. The use of stainless steel wire. Am J Surg 1940;47:502–516. 13. Mason ML. Primary and secondary tendon suture. A discussion of the significance of technique in tendon surgery. Surg Gynecol Obstet 1940;70:392– 402. 14. Bunnell S. Surgery of the hand. (1st ed). Philadelphia 460: JB Lippincott, 1944. 15. Bunnell S. Surgery of the hand. (1st ed). Philadelphia 310: JB Lippincott, 1944. 16. Boyes JH. Immediate vs delayed repair of the digital flexor tendons. Ann Western Med Surg 1947;1:145–152. 17. Boyes JH. Flexo-tendon grafts in the fingers and thumb. J Bone Joint Surg 1950;32A:489 – 499. 18. Hauge MF. The results of tendon suture of the hand. A review of 500 patients. Acta Orthop Scand 1955;24:258 – 270. 19. Van’t Hof A, Heiple KG. Flexor tendon injuries in the fingers and thumb. A comparative study. J Bone Joint Surg 1958;40A:256 –262.
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20. Boyes JH. Discussion of Van’t Hof, Heiple paper. J Bone Joint Surg 1958;40A:262, 322. 21. Kelly AP. Primary tendon repairs. A study of 789 consecutive tendon severances. J Bone Joint Surg 1959;41A:581– 598. 22. Siler VE. Primary tenorrhaphy of the flexor tendons in the hand. J Bone Joint Surg 1950;32A:218 –224. 23. Posch JL. Primary tenorrhaphies and tendon grafting procedures in hand Injuries. AMA Arch Surg 1956;73:609 – 624. 24. Carter SJ, Mersheimer WL. Deferred primary tendon repair. Results in 27 cases. Ann Surg 1966;164:913–916. 25. Lindsay WK, McDougall EP. Direct digital flexor tendon repairs. Plast Reconstr Surg 1960;26:613– 621. 26. Verdan CE. Primary repair of flexor tendons. J Bone Joint Surg 1960;42A:647– 657. 27. Kleinert HE, Kutz JE, Ashbell TS, Martinez E. Primary repair of lacerated flexor tendons in “No Man’s Land” (abstr). J Bone Joint Surg 1967;49A:577. 28. Boyes JH. Discussion of Kleinert/Kutz/Ashbell/Martinez paper (abstr). J Bone Joint Surg 1967;49A:577. 29. Kleinert HE, Kutz JE, Atasoy E, Stormo A. Primary repair of flexor tendons. Orthop Clin North Am 1973;4:865– 876. 30. Boyes JH, Stark HH. Flexor-tendon grafts in the fingers and thumb. A study of factors influencing results in 1000 cases. J Bone Joint Surg 1971;53A:1332–1342.