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The use of skin hooks and hypodermic needles in tendon surgery
THE
USE
OF SKIN
HOOKS AND HYPODERMIC TENDON SURGERY
NEEDLES
IN
R. J. MORRIS and D. L. MARTIN From the Department of Plastic Surgery, Queen Mary’s University Hospital, Roehampton, London
The skin hook can be used to reduce the need for direct tendon handling and to make the task of tendon repair easier and less traumatic. Journal of Hand Surgery (British and European Volume, 1993) 18B : 33-34
Bunnell (1918) emphasized the need for atraumatic han.dling of the tendons and their surrounding structures. Potenza (1979) showed that trauma to the tendon surface is a major factor in adhesion formation, the density and severity of which reflects the degree of disruption of the stru.cture of the tendon at the time of injury and during repair. Atraumatic handling of the tendon should therefore reduce adhesions. During the exploration and repair of divided tendons it is usually necessary to apply traction to the proximal component, either because muscle tone causes retraction, or because the injury was sustained with the finger flexed. The method of handling during retrieval and suture placement therefore contribute greatly to the eventual outcome of repair. If tendons have retracted out of sight and cannot be brought into view by joint flexion, hypodermic needles may be used to retrieve them, and the tendon ends can then be manipulated using skin hooks. TECHNIQUES Tendon retrieval (Fig 1) Stage 1
A small transverse incision is made over the distal palmar crease to expose the proximal end of the flexor sheath. A transverse window is made in the synovial sheath and widened longitudinally by gentle stretching. Fig 1
Stage 2
The point of a hypodermic needle is inserted into the tendon substance (but not through it) at the most proximal edge of the opening in the sheath, and used to feed the tendon distally. The travel is limited by the extent of the window.
The use of hypodermic needles in flexor tendon retrieval. By alternately inserting and advancing needles (a) and (b) the tendon end is “walked” into the finger wound.
Tendon manipulation (Figs 2 and 3) Once the tendon has been returned to the level of injury it can be manipulated using skin hooks. These must be fine, sharp and have an arc of about 2 mm at the tip. The hook is driven into the volar surface of the tendon. It is essential that the point penetrates firmly as failure to do so results in loss of grip. Once embedded the hold is strong enough to permit the tendon to be coaxed out to a working distance, allowing a core suture of sufficient length to be inserted. The best position for insertion of the hook is where the end of the tendon just protrudes
Stage 3
A second needle is inserted proximally, the first then being removed. The second is pushed distally, again, to the !hmit of the opening. These steps are repeated until the tendon is “walked” to the wound in the finger where it can be transfixed horizontally by another needle (Lister et al, 1977). 33
THE
JOURNAL
OF HAND
SURGERY
VOL.
18B No.
1 FEBRUARY
1993
finger is extended behind the tendon to steady it. It is then possible to place the core suture in a smooth continuous action with minimal damage to the tendon. Occasionally, if the tendon end has retracted but is still visible through the wall of the sheath, a hook can be used to retrieve it. The hook is passed between the wall of the sheath and the volar surface of the tendon. Once it is past the cut end the point is turned downwards through 90” and directed into the tendon. As the hook is withdrawn the tendon is pulled out into the window and a second hook should be inserted firmly in the previously described manner. This procedure should only be used if the tendon end is visible and there should be no attempt to snare the tendon blindly. DISCUSSION Fig 2
Holding the tendon with a skin hook in the non-dominant whilst placing the core suture. The tendon is supported non-dominant middle finger.
hand by the
A variety of methods of atraumatic tendon manipulation have been described. Bunnell (1918) introduced spring steel clamps of various sizes for gripping the tendon. In 1975 Tsuge et al advocated the use of a pair of adjustable interlocking tendon clamps during repair. However, both sets of instruments are specialized and may not be readily available. Other holding techniques have been proposed including the use of fine forceps to grip the tendon by its cut end (Lister et al, 1977). This can fray the tendon. Existing methods of retrieval include the use of assorted instruments to fish blindly for proximal ends which may damage the tendon, the insertion of traction sutures through a palmar incision (Lister, 1985), and the passage of a fine catheter alongside the severed tendon which is then sutured to the side of the catheter and pulled distally with it (Sourmelis and McGrouther, 1987). Atraumatic retrieval and handling are essential to allow accurate coaptation of the tendon ends and reduce the risk of adhesion or disruption. The methods we have described are simple and quick. Acknowledgements We would like to thank Mike Duffy for his drawings Department, Queen Mary’s Hospital, Roehampton, tions.
and the Medical Illustration for photographic reproduc-
References Fig 3
The use of a hook in retrieving a tendon which has retracted within the sheath but is still visible in the wound.
from the sheath. The sheath itself then provides the counter pressure and support required to insert the hook. It may be possible to position the tendon at the mouth of the sheath by adjusting the degree of flexion of the finger. Alternatively the tendon can be supported by a finger or against surrounding tissues as the hook is inserted. Once in place care must be taken to regulate the tension on the hook to keep its point engaged. During the repair the hook is held in the non-dominant hand, between the thumb and index finger. The middle
BUNNELL, S. (1918). Repair of tendons in the fingers and description of two new instruments. Surgery Gynecology and Obstetrics, 26: 103-l 10. LISTER, G. D., KLEINERT, H. E., KUTZ, J. E. and ATASOY, E. (1977). Primary flexor tendon repair followed by immediate controlled mobilization. Journalof Hand Surgery, 2: 6: 441451. LISTER, G. (1985). Indications and techniques for repair of the flexor tendon sheath. Hand Clinics, 1: 1:85-95. POTENZA, A. D. The healing process in wounds of the dlgrtal flexor tendons and tendon grafts: An experimental study. In: Verdan C (Ed.): Tendon Surgeryoffhe Hand. Edinburgh, Churchill Livingstone, 1979: 40-54. SOURMELIS, S. G. and McGROUTHER, D. A. (1987). Retrieval of the retracted flexor tendon. Journal of Hand Surgery, 12-B: 1: 109-l 11. TSUGE, K., IKUTA, Y. and MATSUISHI, Y. (1975) Intra-tendinous tendon suture in the hand : A new technique. The Hand, 7 : 3 : 25&255. Accepted: 8 May 1991 MI D. L. Martin, FRCS, Queen Mary’s University Hospital, Roehampton SW15 SPN. 0 1993 The British Society for Surgery of the Hand
Lane, London
USE
OF SKIN
HOOKS AND HYPODERMIC TENDON SURGERY
NEEDLES
IN
R. J. MORRIS and D. L. MARTIN From the Department of Plastic Surgery, Queen Mary’s University Hospital, Roehampton, London
The skin hook can be used to reduce the need for direct tendon handling and to make the task of tendon repair easier and less traumatic. Journal of Hand Surgery (British and European Volume, 1993) 18B : 33-34
Bunnell (1918) emphasized the need for atraumatic han.dling of the tendons and their surrounding structures. Potenza (1979) showed that trauma to the tendon surface is a major factor in adhesion formation, the density and severity of which reflects the degree of disruption of the stru.cture of the tendon at the time of injury and during repair. Atraumatic handling of the tendon should therefore reduce adhesions. During the exploration and repair of divided tendons it is usually necessary to apply traction to the proximal component, either because muscle tone causes retraction, or because the injury was sustained with the finger flexed. The method of handling during retrieval and suture placement therefore contribute greatly to the eventual outcome of repair. If tendons have retracted out of sight and cannot be brought into view by joint flexion, hypodermic needles may be used to retrieve them, and the tendon ends can then be manipulated using skin hooks. TECHNIQUES Tendon retrieval (Fig 1) Stage 1
A small transverse incision is made over the distal palmar crease to expose the proximal end of the flexor sheath. A transverse window is made in the synovial sheath and widened longitudinally by gentle stretching. Fig 1
Stage 2
The point of a hypodermic needle is inserted into the tendon substance (but not through it) at the most proximal edge of the opening in the sheath, and used to feed the tendon distally. The travel is limited by the extent of the window.
The use of hypodermic needles in flexor tendon retrieval. By alternately inserting and advancing needles (a) and (b) the tendon end is “walked” into the finger wound.
Tendon manipulation (Figs 2 and 3) Once the tendon has been returned to the level of injury it can be manipulated using skin hooks. These must be fine, sharp and have an arc of about 2 mm at the tip. The hook is driven into the volar surface of the tendon. It is essential that the point penetrates firmly as failure to do so results in loss of grip. Once embedded the hold is strong enough to permit the tendon to be coaxed out to a working distance, allowing a core suture of sufficient length to be inserted. The best position for insertion of the hook is where the end of the tendon just protrudes
Stage 3
A second needle is inserted proximally, the first then being removed. The second is pushed distally, again, to the !hmit of the opening. These steps are repeated until the tendon is “walked” to the wound in the finger where it can be transfixed horizontally by another needle (Lister et al, 1977). 33
THE
JOURNAL
OF HAND
SURGERY
VOL.
18B No.
1 FEBRUARY
1993
finger is extended behind the tendon to steady it. It is then possible to place the core suture in a smooth continuous action with minimal damage to the tendon. Occasionally, if the tendon end has retracted but is still visible through the wall of the sheath, a hook can be used to retrieve it. The hook is passed between the wall of the sheath and the volar surface of the tendon. Once it is past the cut end the point is turned downwards through 90” and directed into the tendon. As the hook is withdrawn the tendon is pulled out into the window and a second hook should be inserted firmly in the previously described manner. This procedure should only be used if the tendon end is visible and there should be no attempt to snare the tendon blindly. DISCUSSION Fig 2
Holding the tendon with a skin hook in the non-dominant whilst placing the core suture. The tendon is supported non-dominant middle finger.
hand by the
A variety of methods of atraumatic tendon manipulation have been described. Bunnell (1918) introduced spring steel clamps of various sizes for gripping the tendon. In 1975 Tsuge et al advocated the use of a pair of adjustable interlocking tendon clamps during repair. However, both sets of instruments are specialized and may not be readily available. Other holding techniques have been proposed including the use of fine forceps to grip the tendon by its cut end (Lister et al, 1977). This can fray the tendon. Existing methods of retrieval include the use of assorted instruments to fish blindly for proximal ends which may damage the tendon, the insertion of traction sutures through a palmar incision (Lister, 1985), and the passage of a fine catheter alongside the severed tendon which is then sutured to the side of the catheter and pulled distally with it (Sourmelis and McGrouther, 1987). Atraumatic retrieval and handling are essential to allow accurate coaptation of the tendon ends and reduce the risk of adhesion or disruption. The methods we have described are simple and quick. Acknowledgements We would like to thank Mike Duffy for his drawings Department, Queen Mary’s Hospital, Roehampton, tions.
and the Medical Illustration for photographic reproduc-
References Fig 3
The use of a hook in retrieving a tendon which has retracted within the sheath but is still visible in the wound.
from the sheath. The sheath itself then provides the counter pressure and support required to insert the hook. It may be possible to position the tendon at the mouth of the sheath by adjusting the degree of flexion of the finger. Alternatively the tendon can be supported by a finger or against surrounding tissues as the hook is inserted. Once in place care must be taken to regulate the tension on the hook to keep its point engaged. During the repair the hook is held in the non-dominant hand, between the thumb and index finger. The middle
BUNNELL, S. (1918). Repair of tendons in the fingers and description of two new instruments. Surgery Gynecology and Obstetrics, 26: 103-l 10. LISTER, G. D., KLEINERT, H. E., KUTZ, J. E. and ATASOY, E. (1977). Primary flexor tendon repair followed by immediate controlled mobilization. Journalof Hand Surgery, 2: 6: 441451. LISTER, G. (1985). Indications and techniques for repair of the flexor tendon sheath. Hand Clinics, 1: 1:85-95. POTENZA, A. D. The healing process in wounds of the dlgrtal flexor tendons and tendon grafts: An experimental study. In: Verdan C (Ed.): Tendon Surgeryoffhe Hand. Edinburgh, Churchill Livingstone, 1979: 40-54. SOURMELIS, S. G. and McGROUTHER, D. A. (1987). Retrieval of the retracted flexor tendon. Journal of Hand Surgery, 12-B: 1: 109-l 11. TSUGE, K., IKUTA, Y. and MATSUISHI, Y. (1975) Intra-tendinous tendon suture in the hand : A new technique. The Hand, 7 : 3 : 25&255. Accepted: 8 May 1991 MI D. L. Martin, FRCS, Queen Mary’s University Hospital, Roehampton SW15 SPN. 0 1993 The British Society for Surgery of the Hand
Lane, London