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A relatively atraumatic method of retrieving retracted digital flexor tendons
A R E L A T I V E L Y A T R A U M A T I C M E T H O D OF R E T R I E V I N G RETRACTED DIGITAL FLEXOR TENDONS A. ADENIRAN and A. Z. BABAR
From the Department of Plastic Surgery, Salisbury District GeneralHospital, Salisbury, UK A relatively atraumatic, simple and very reliable method of retrieving the proximal end of a severed flexor tendon of a finger or thumb is described. The technique involves passing a Silastic feeding tube into the flexor tendon sheath, placing the retracted tendon within its lumen, and securing it in place with a single stitch. The feeding tube is then withdrawn until the tendon presents within the distal wound. Hypodermic needle fixation and tendon repair is then carried out in the usual manner.
Journal of Hand Surgery (British and European Volume, 1997) 22B: 1:122-124 technique which is atraumatic and achieves consistent success. Attempting blind retrieval with all manner of instruments often tends to inflict more trauma on the tendon with consequent increased risk of adhesions (Flatt, 1972; Pennington, 1977; Potenza, 1962). The suction retrieval technique described by Pennington (1977), although atraumatic, had a success rate of only about 66% of cases in the authors' hands, with failure being more
It is generally agreed that the method of handling during retrieval and suture placement contributes greatly to the eventual outcome of the repair of divided flexor tendons. Atraumatic surgical techniques tend to minimize operative damage to the tendon which is in turn liable to aggravate possible later adhesions. Various instruments and techniques for this purpose have therefore been described (Abouzahr, 1995; Ersek and Gadaria, 1985; Goshgarian, 1978; Lister, 1985; Morris and Martin, 1993; Pennington, 1977; Sourmelis and McGrouther, 1987; Stallings and Lines, 1975). We now report on another technique which to us is simpler and much less traumatic than most methods previously described. TECHNIQUE
A small transverse incision is made over the distal palmar crease at the base of the injured digit. The wound is deepened and the retracted proximal part of the tendon delivered on to the surface (Fig 1). A well lubricated Silastic feeding tube (size 10-14 depending on the size of the tendon to be retrieved) is introduced into the tendon sheath from its distal opening to emerge proximally through the palmar wound (Fig 1). The distal end of the retracted but delivered flexor tendon is then placed within the lumen of the feeding tube, which has been bevelled to facilitate insertion. The tendon is then secured in place with a single stitch of 4/0 Prolene or any other similar monofilament suture material on an atraumatic needle (Fig 2). By gently pulling the tube distally, the retracted tendon is easily delivered to the distal wound, the optimal site for repair (Fig 3). Hypodermic needle fixation of the retrieved tendon is done, and the anchoring stitch of the feeding tube is removed, the tube itself discarded (Fig 4). Tendon repair is then carried out in the usual way. DISCUSSION Of the numerous instruments and methods that have been described for manipulating retracted tendons, many fall short of attaining the ideal goal of a simple
Fig 1 122
RETRIEVAL OF RETRACTED EXTENSOR TENDONS
123
Fig 2
common in injuries of the thumb. The use of skin hooks and hypodermic needles for retracted flexor tendon retrieval was described by Morris and Martin (1993). Although they described their method as simple and quick, they did not state their success rate. The multiple puncturing of the tendon required by this method to "walk" it back into the finger wound might, in our opinion, be tedious and relatively traumatic, as originally suggested by Potenza (1962). We have found the retrieval method described by Sourmelis and McGrouther (1987) very useful for cases where the retracted tendon is still lying inside its sheath. However, when used for a tendon that has retracted much further and then lies proximal to the sheath, our experience has been that the free edge of the tendon is liable to catch on the margins of the pulleys encountered, especially the A1 pulley. This can lead to fraying of the tendon edge, and damage to its surface can also occur. We have found it necessary in such cases to open the palm proximal to the corresponding tendon sheath, and deliver the retracted portion on to the skin as described by Weeks and Wray (1973). Such cases of severe retraction have obviously suffered rupture of their vincula, thus making delivery of the tendons easy. The risks of dessication and abrasion to such tendons, as suggested by Sourmelis and McGrouther (1987), appear to be more theoretical than real, as the exposure time is very short (less than 1 minute) and the subsequent manoeuvre is practically atraumatic. Abouzahr (1995) recently described a technique that emphasized minimal handling of the tendon by using the same suture to accomplish both tendon delivery and
Fig 3
tenorrhaphy. We had previously successfully used a very similar method for minimally retracted tendons, although unlike Abouzahr we did not straighten the curved needle, thus avoiding any possibility of breakage and the need to extract fragments as foreign bodies. The method which we have described can be used for retrieving a single retracted flexor digitorum profundus or flexor digitorum superficialis tendon or, if both have retracted, they can be retrieved together. In the latter situation it is generally possible to feed both tendons into a single tube after putting them into their normal anatomical relationship. We have not had the opportunity to use our method on a severely retracted flexor pollicis longus but there seems no reason why it should not be successful. The technique we have described is simple, practically atraumatic, and has been successful in all 20 patients so far treated by this method, which is best applied in the retrieval of tendons that have separated from their vincula and retracted into the palm or wrist.
Acknowledgements We wish to thank Mr F. A. Rossi, FRCS, Head, Department of Plastic Surgery, and the other Consultant Plastic Surgeons in the Department, for their permission to operate on their patients and report the results.
124
T H E J O U R N A L OF H A N D SURGERY VOL. 22B No. 1 F E B R U A R Y 1997
References Abouzahr M K (1995). Retrieval of the retracted flexor tendon. Plastic and Reconstructive Surgery, 96:457 460. Ersek R A, Gadaria U (1985). The flexible tendon retriever. Journal of Hand Surgery, 10A: 415. Flatt A E. The care of minor hand injuries, 3rd Edn. St Louis, C V Mosby, 1972: 172-190. Goshgarian G (1978). Retrieving the proximal end of a severed flexor tendon. Plastic and Reconstructive Surgery, 62: 108. Lister G (1985). Indications and techniques for repair of the flexor tendon sheath. H a n d Clinics, 1:85 95. Morris R J, Martin D L (1993). The use of skin hooks and hypodermic needles in tendon surgery. Journal of Hand Surgery, 18B: 33-34. Pennington D G (1977). Atraumatic retrieval of the proximal end of a severed digital flexor tendon. Plastic and Reconstructive Surgery, 60: 468-469. Potenza A D (1962). Effect of associated trauma on healing of divided tendons. Journal of Trauma, 2: 175-184. Sourmelis S G, McGrouther D A (1987). Retrieval of the retracted flexor tendon. Journal of H a n d Surgery, 12B: 109-111. Stallings J O, Lines J (1975). Relatively atraumatic tendon forceps. The Hand, 7: 74. Weeks P M, Wray R C. Management of acute hand injuries. A biological approach. Saint Louis, C V Mosby, 1973: 228-229.
Received: 15 March 1996 Accepted after revision: 22 April 1996 A. Adeniran, Department of Plastic Surgery, Salisbury District General Hospital, Salisbury SP2 8BJ, UK. © 1997 The British Society for Surgery of the Hand
Fig 4
From the Department of Plastic Surgery, Salisbury District GeneralHospital, Salisbury, UK A relatively atraumatic, simple and very reliable method of retrieving the proximal end of a severed flexor tendon of a finger or thumb is described. The technique involves passing a Silastic feeding tube into the flexor tendon sheath, placing the retracted tendon within its lumen, and securing it in place with a single stitch. The feeding tube is then withdrawn until the tendon presents within the distal wound. Hypodermic needle fixation and tendon repair is then carried out in the usual manner.
Journal of Hand Surgery (British and European Volume, 1997) 22B: 1:122-124 technique which is atraumatic and achieves consistent success. Attempting blind retrieval with all manner of instruments often tends to inflict more trauma on the tendon with consequent increased risk of adhesions (Flatt, 1972; Pennington, 1977; Potenza, 1962). The suction retrieval technique described by Pennington (1977), although atraumatic, had a success rate of only about 66% of cases in the authors' hands, with failure being more
It is generally agreed that the method of handling during retrieval and suture placement contributes greatly to the eventual outcome of the repair of divided flexor tendons. Atraumatic surgical techniques tend to minimize operative damage to the tendon which is in turn liable to aggravate possible later adhesions. Various instruments and techniques for this purpose have therefore been described (Abouzahr, 1995; Ersek and Gadaria, 1985; Goshgarian, 1978; Lister, 1985; Morris and Martin, 1993; Pennington, 1977; Sourmelis and McGrouther, 1987; Stallings and Lines, 1975). We now report on another technique which to us is simpler and much less traumatic than most methods previously described. TECHNIQUE
A small transverse incision is made over the distal palmar crease at the base of the injured digit. The wound is deepened and the retracted proximal part of the tendon delivered on to the surface (Fig 1). A well lubricated Silastic feeding tube (size 10-14 depending on the size of the tendon to be retrieved) is introduced into the tendon sheath from its distal opening to emerge proximally through the palmar wound (Fig 1). The distal end of the retracted but delivered flexor tendon is then placed within the lumen of the feeding tube, which has been bevelled to facilitate insertion. The tendon is then secured in place with a single stitch of 4/0 Prolene or any other similar monofilament suture material on an atraumatic needle (Fig 2). By gently pulling the tube distally, the retracted tendon is easily delivered to the distal wound, the optimal site for repair (Fig 3). Hypodermic needle fixation of the retrieved tendon is done, and the anchoring stitch of the feeding tube is removed, the tube itself discarded (Fig 4). Tendon repair is then carried out in the usual way. DISCUSSION Of the numerous instruments and methods that have been described for manipulating retracted tendons, many fall short of attaining the ideal goal of a simple
Fig 1 122
RETRIEVAL OF RETRACTED EXTENSOR TENDONS
123
Fig 2
common in injuries of the thumb. The use of skin hooks and hypodermic needles for retracted flexor tendon retrieval was described by Morris and Martin (1993). Although they described their method as simple and quick, they did not state their success rate. The multiple puncturing of the tendon required by this method to "walk" it back into the finger wound might, in our opinion, be tedious and relatively traumatic, as originally suggested by Potenza (1962). We have found the retrieval method described by Sourmelis and McGrouther (1987) very useful for cases where the retracted tendon is still lying inside its sheath. However, when used for a tendon that has retracted much further and then lies proximal to the sheath, our experience has been that the free edge of the tendon is liable to catch on the margins of the pulleys encountered, especially the A1 pulley. This can lead to fraying of the tendon edge, and damage to its surface can also occur. We have found it necessary in such cases to open the palm proximal to the corresponding tendon sheath, and deliver the retracted portion on to the skin as described by Weeks and Wray (1973). Such cases of severe retraction have obviously suffered rupture of their vincula, thus making delivery of the tendons easy. The risks of dessication and abrasion to such tendons, as suggested by Sourmelis and McGrouther (1987), appear to be more theoretical than real, as the exposure time is very short (less than 1 minute) and the subsequent manoeuvre is practically atraumatic. Abouzahr (1995) recently described a technique that emphasized minimal handling of the tendon by using the same suture to accomplish both tendon delivery and
Fig 3
tenorrhaphy. We had previously successfully used a very similar method for minimally retracted tendons, although unlike Abouzahr we did not straighten the curved needle, thus avoiding any possibility of breakage and the need to extract fragments as foreign bodies. The method which we have described can be used for retrieving a single retracted flexor digitorum profundus or flexor digitorum superficialis tendon or, if both have retracted, they can be retrieved together. In the latter situation it is generally possible to feed both tendons into a single tube after putting them into their normal anatomical relationship. We have not had the opportunity to use our method on a severely retracted flexor pollicis longus but there seems no reason why it should not be successful. The technique we have described is simple, practically atraumatic, and has been successful in all 20 patients so far treated by this method, which is best applied in the retrieval of tendons that have separated from their vincula and retracted into the palm or wrist.
Acknowledgements We wish to thank Mr F. A. Rossi, FRCS, Head, Department of Plastic Surgery, and the other Consultant Plastic Surgeons in the Department, for their permission to operate on their patients and report the results.
124
T H E J O U R N A L OF H A N D SURGERY VOL. 22B No. 1 F E B R U A R Y 1997
References Abouzahr M K (1995). Retrieval of the retracted flexor tendon. Plastic and Reconstructive Surgery, 96:457 460. Ersek R A, Gadaria U (1985). The flexible tendon retriever. Journal of Hand Surgery, 10A: 415. Flatt A E. The care of minor hand injuries, 3rd Edn. St Louis, C V Mosby, 1972: 172-190. Goshgarian G (1978). Retrieving the proximal end of a severed flexor tendon. Plastic and Reconstructive Surgery, 62: 108. Lister G (1985). Indications and techniques for repair of the flexor tendon sheath. H a n d Clinics, 1:85 95. Morris R J, Martin D L (1993). The use of skin hooks and hypodermic needles in tendon surgery. Journal of Hand Surgery, 18B: 33-34. Pennington D G (1977). Atraumatic retrieval of the proximal end of a severed digital flexor tendon. Plastic and Reconstructive Surgery, 60: 468-469. Potenza A D (1962). Effect of associated trauma on healing of divided tendons. Journal of Trauma, 2: 175-184. Sourmelis S G, McGrouther D A (1987). Retrieval of the retracted flexor tendon. Journal of H a n d Surgery, 12B: 109-111. Stallings J O, Lines J (1975). Relatively atraumatic tendon forceps. The Hand, 7: 74. Weeks P M, Wray R C. Management of acute hand injuries. A biological approach. Saint Louis, C V Mosby, 1973: 228-229.
Received: 15 March 1996 Accepted after revision: 22 April 1996 A. Adeniran, Department of Plastic Surgery, Salisbury District General Hospital, Salisbury SP2 8BJ, UK. © 1997 The British Society for Surgery of the Hand
Fig 4