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A review of 100 flexor tendon reconstructions with prosthesis
A Review o] 100 Flexor Tendon Reconstructions with Prosthesis Richard Honner and Allan Meares
A REVIEW OF 100 FLEXOR TENDON RECONSTRUCTIONS WITH PROSTHESIS R I C H A R D H O N N E R and A L L A N MEARES, Sydney, Australia SUMMARY A series of one hundred cases where silicone rods were used to prepare a bed for flexor tendon grafting is examined, the main indication for this technique being circumstances where one stage tendon grafting was likely to have a poor result. The main complications noted were a synovitis around the silastic rods, infection, and loss of the distal attachment of the silastic rod. The overall results were satisfactory. CLINICAL MATERIAL Silicone rubber tendon prostheses of the Hunter design have been used for Flexor tendon reconstruction at the Royal Prince Alfred Hospital since 1971. A review of the first 100 cases provides the material for this paper. These operations were carried out by the authors in the period 1971-1975, in eighty-six patients, seventy of whom were male and sixteen female. The age distribution is demonstrated in figure 1. The great majority of patients were in the age group ten to forty years of age, the youngest being two years and the oldest, sixty-seven years of age. Of the eighty-six patients, three patients had three digits treated with staged silicone
30 F
100
TENDON lUCTIONS
25
2 - 6 7 Yrs. No.
of 20 Patients 15 10 5
0
10
20
30
40
50
60
Years Fig. 1. Agc distribution of cases. Richard Honner, F.R.C.S., 100 Carillon Avenue, Newtown, Sydney, 2042, Australia. 226
The Hand--VoL 9
No. 3
1977
,4 Review oJ 100 Flexor Tendon Reconstructions with Prosthesis Richard Honner and AHan Meares
TABLE 1 DIGIT D A M A G E D
Thumb Index Middle Ring Little
5 20 21 25 29
Total
100
TABLE 2 INDICATIONS
Unsuitable for Tendon Graft Multiple Tissue Reconstruction Failed Flexor Tendon Reconstruction 9 One Previous Operation 9 Two Previous Operations 9 Three Previous Operations Isolated F.D.P. Lesion Multiple Digit Reconstruction Total
22 16 20 8 I0 2 17 25 100
rubber reconstruction, and eight patients had two fingers, the remaining seventy-five patients having one digit treated with silicone tendon reconstruction. The technique was rarely used in the thumb, most other digits being approximately equal in number as call be seen in Table 1. INDICATIONS The indications for the use of the silicone tendon for reconstruction of the flexor tendon mechanism is shown in Table 2. In some patients the conditions at exploration appeared to be unsuitable for tendon grafting, and other patients required multiple tissue reconstruction such as skin flaps, nerve repairs, and skeletal reconstructive procedures. Other indications were previous failed flexor tendon surgery, multiple digit reconstruction in the one hand, and those patients who had an isolated lesion of the flexor digitorum profundus ill the finger, in the presence of an intact and working flexor digitorum superficialis. SURGICAL TECHNIQUE The surgical technique used was similar in all cases, following the description by Hunter and Salisbury in 1971. It is worth while to stress some of the principles of this technical procedure, the first requirement is the development of as much The Hand--Vol. 9
No. 3
1977
227
A Review o / 1 0 0 Flexor Tendon Reconstructions with ProSthesis Richard Honner and ,4 llan Meares
passive movement in the distal joints as possible, with careful physiotherapy techniques, and then at exploration all definitive reconstructive procedures need to be performed at the time of the insertion of the silicone rod. It is important to reconstruct pulleys at the mouth of the flexor sheath, and over the proximal and middle phalanges, and this is very satisfactorily done over the silastic tendon in situ, using remnants of the flexor tendons which are excised. A firm distal fixation beneath the stump of the profundus tendon is carried out with interrupted sutures of five zero nylon and the proximal portion of the tendon allowed to lie free, usually in the distal forearm. Passive movement of the digit should b e used to demonstrate that the proximal end of the tendon prosthesis does move freely, without any b~ckling. After the first procedure, active movement of the digit is commenced some five to seven days post-operatively, and as the wound stabilises more vigorous physiotherapy techniques can be used to restore passive motion to the digital joints. The second stage of the operation can be carried out when the wound is well healed, and optimum passive flexion has been obtained and this can vary from six weeks to twelve weeks after the first operation. In our series of 100 successive cases, the silicone tendon was taken to the distal forearm in the majority of patients and therefore the plantaris tendon graft was used, and when this was not available or suitable an extensor tendon from the second or third toe was used. In the second stage procedure limited exposure at each end of the tendon is performed, the distal junction is made using a four zero prolene or nylon suture passed through a drill hole in the distal phalanx and tied over a button on the finger nail. Extra interrupted sutures can be used to fix the profundus stump to the tendon graft. The distal wound is closed and an interweaving technique of the tendon graft through the mass of the profundus tendon in the distal forearm is used to select the correct tension for the tendon graft and fixed with interrupted sutures. Post-operative management of the second stage procedure requires a period of three weeks immobilisation, in which the hand is protected with flexion at the wrist and metacarpophalangeal joints with a plaster slab, and only passive movement of the digit being performed at the time of the dressing changes. After three weeks, active flexion of the digit is allowed and this progresses over the following two weeks to a full range of active and passive movement. The button is removed at the fifth or sixth week, no pullout suture is used, the suture over the button is simply cut and withdrawn. TABLE 3 RESULTS
(Thompson, 1%7)
228
Excellent Good Fair Poor
19 38 26 15
Total
98 The H a n d - - V o l . 9
No. 3
1977
A Review o] 100 Flexor Tendon Reconstructions with Prosthesis Richard Honner and Allan Meares RESULTS
An examination of the results of these 100 successive cases was performed, using the method recommended by Thompson in 1967. This method takes into account joint contractures, and the distance the finger fails to reach full extension or full flexion and on the basis of these measurements, categories of excellent, good, fair and poor are described. Using Thompson's classification the results of the silicone tendon reconstructions are shown in Table 3 nineteen were excellent, thirtyeight good, twenty-six fair and fifteen poor. (Only ninety-eight cases came to the second stage grafting.) Of the two patients who did not have the second stage procedure performed, one developed a sudden terminal malignancy, and declined further surgery and one for personal domestic reasons has postponed the second stage procedure indefinitely. An examination of these results shows that the excellent category is falsely loaded by the inclusion of those patients who had a staged silicone tendon reconstruction of the isolated lesion of the flexor digitorum profundus tendon (seventeen patients), and in these there were fourteen excellent results and three good results. If these seventeen patients were excluded from the series, there would be onIy five excellent results, thirty-five good, twenty-six fair and fifteen poor results. However, an analysis of these results, compared with other flexor tendon grafting series, such as Thompson's 1967, indicates that there are always a significant proportion of poor results in flexor tendon grafting, and in these patients where the circumstances for primary flexor grafting are less than ideal, we feel that the results of silicone tendon reconstruction are an improvement on previous techniques. TABLE 4 COMPLICATIONS (of First Stage)
Infections (Same Patient) Synovitis Ruptured Distal Attachment Severe Trauma Post-Op. Tourniquet Paralysis Total
2
8 2 2 1 15
COMPLICATIONS
Complications in the one hundred cases of reconstructions are shown in Table 4, one patient had two silicone tendons which became infected, synovitis occurred in eight patients, in two patients the distal attachment came adrift so that the tendon migrated proximally and the distal portion of the tunnel was lost. There were two patients who suffered significant trauma in the period between the first and second stage operations, and one patient had a tourniquet paralysis of all the nerves in the arms for some four weeks, due to a fauty pneumatic tourniquet, and this patient recovered full nerve function eventually. The two infections occurred in the one The Hand--Vol. 9
No. 3
1977
229
A Review of 100 Flexor Tendon Reconstructions with Prosthesis Richard Honner and Allan Meares
patient, where poor surgical technique allowed the distal suturing of the rods to fail, the rods protruded eventually through the skin and a pyogenic infection developed along the whole length of the rod from the fingertip into the forearm. This disaster did not respond to immobilisation and antibiotics, and required removal of the rods and further reconstructive surgery at a later date. The complication of synovitis is of interest, it is characterised by a warm swollen red finger, without any systemic evidence of a pyogenic infection, and exploration reveals a brownish sterile fluid, with an inflamed, swollen synovial lining of the sheath, formed around the silastic tendon. The synovitis is often confined to the finger, and fluctuation can be demonstrated along this extent, and occasionally will extend into the palm or forearm. The exact cause of the synovitis is not known, it may be an irritation due to a very tight pulley or constricting scar tissue causing local buckling of the tendon, or it may be a reaction to some of the material used in the manufacture of the silicone tendon, or perhaps, a minor foreign body contamination at the time of the insertion of the rod. In four patients this synovitis settled easily with a period of immobilisation on a plaster splint, in the early cases we added antibiotic therapy to this immobilisation but this now appears unnecessary where the clinical diagnosis is straightforward. There were four patients where the synovitis did not respond to immobilisation, aspiration was used as a diagnostic procedure in one of these cases but not repeated, and our approach to the problem of the resistant synovitis was to go ahead with the second stage grafting and at the time of the procedure to try to improve the passive range of flexion by manipulation after removal of the rod and drainage of the swollen sheath, and in these four cases the flexor tendon grafting went ahead without any major incident, although the results in these four cases were only one good, and three fair results. The main factor in the relatively poor results in these patients appears to be the loss of passive movement due to the gross swelling in the digit accompanied by the period of immobilisation used in an attempt to resolve the synovitis. It may be that repeated aspiration would solve this problem, but we were concerned about the possibility of secondarily infecting the synovial fluid, and did not use this form of treatment. The patients who suffered severe trauma to the finger between the first and second operations demonstrated to us that the digit which lacks active flexion, and contains a large foreign body, is at considerably increased risk in normal activities. One patient suffered a compound fracture to the proximal phalanx of the digit with the silicone tendon, with extrusion of the prosthesis, and in this particular case was treated aggressively, with internal fixation of the fracture, careful cleansing of the wound and the sheath, insertion of a new prosthetic tendon and repair of the sheath and skin wound. With antibiotic cover infection did not occur, a good passive range of movement in the digit was re-established, and eventually an excellent result was achieved with later tendon grafting. CONCLUSION
Where circumstances are suitable, the standard flexor tendon grafting procedure offers a good chance of recovery of active flexion in the digit, but there are occasional poor results. In circumstances where conditions for flexor tendon grafting are less than optimal, the inc'dence of poor results is likely to increase significantly, 230
The Hand--Vol. 9
No. 3
1977
A Review of 100 Flexor Tendon Reconstructions with Prosthesis Richard Honner and Allan Meares
(Thompson 1967) and it has been our approach to use a staged reconstruction technique for flexor tendons, using the silicone rubber tendon of the Hunter design to prepare a bed for the later definitive grafting procedure. There are significant complications of this two stage procedure, but the results indicate that this is a reliable technique which achieves reasonable results in digits where the one stage grafting procedure is very likely to give a high incidence of poor results. REFERENCES
HUNTER, J. M. and SALISBURY, R. E. (1971) Flexor-Tendon Reconstruction in Severely Damaged Hands. A Two Stage Procedure using a Silicone Dacron Reinforced Gliding Prosthesis Prior to Tendon Grafting. Journal of Bone and Joint Surgery, 53A: 829-858. THOMPSON, R. V. (1967) An Evaluation of Flexor Tendon Grafting. British Journal of Plastic Surgery, 20: 21-44.
The H a n d - - V o L 9
No. 3
1977
231
A REVIEW OF 100 FLEXOR TENDON RECONSTRUCTIONS WITH PROSTHESIS R I C H A R D H O N N E R and A L L A N MEARES, Sydney, Australia SUMMARY A series of one hundred cases where silicone rods were used to prepare a bed for flexor tendon grafting is examined, the main indication for this technique being circumstances where one stage tendon grafting was likely to have a poor result. The main complications noted were a synovitis around the silastic rods, infection, and loss of the distal attachment of the silastic rod. The overall results were satisfactory. CLINICAL MATERIAL Silicone rubber tendon prostheses of the Hunter design have been used for Flexor tendon reconstruction at the Royal Prince Alfred Hospital since 1971. A review of the first 100 cases provides the material for this paper. These operations were carried out by the authors in the period 1971-1975, in eighty-six patients, seventy of whom were male and sixteen female. The age distribution is demonstrated in figure 1. The great majority of patients were in the age group ten to forty years of age, the youngest being two years and the oldest, sixty-seven years of age. Of the eighty-six patients, three patients had three digits treated with staged silicone
30 F
100
TENDON lUCTIONS
25
2 - 6 7 Yrs. No.
of 20 Patients 15 10 5
0
10
20
30
40
50
60
Years Fig. 1. Agc distribution of cases. Richard Honner, F.R.C.S., 100 Carillon Avenue, Newtown, Sydney, 2042, Australia. 226
The Hand--VoL 9
No. 3
1977
,4 Review oJ 100 Flexor Tendon Reconstructions with Prosthesis Richard Honner and AHan Meares
TABLE 1 DIGIT D A M A G E D
Thumb Index Middle Ring Little
5 20 21 25 29
Total
100
TABLE 2 INDICATIONS
Unsuitable for Tendon Graft Multiple Tissue Reconstruction Failed Flexor Tendon Reconstruction 9 One Previous Operation 9 Two Previous Operations 9 Three Previous Operations Isolated F.D.P. Lesion Multiple Digit Reconstruction Total
22 16 20 8 I0 2 17 25 100
rubber reconstruction, and eight patients had two fingers, the remaining seventy-five patients having one digit treated with silicone tendon reconstruction. The technique was rarely used in the thumb, most other digits being approximately equal in number as call be seen in Table 1. INDICATIONS The indications for the use of the silicone tendon for reconstruction of the flexor tendon mechanism is shown in Table 2. In some patients the conditions at exploration appeared to be unsuitable for tendon grafting, and other patients required multiple tissue reconstruction such as skin flaps, nerve repairs, and skeletal reconstructive procedures. Other indications were previous failed flexor tendon surgery, multiple digit reconstruction in the one hand, and those patients who had an isolated lesion of the flexor digitorum profundus ill the finger, in the presence of an intact and working flexor digitorum superficialis. SURGICAL TECHNIQUE The surgical technique used was similar in all cases, following the description by Hunter and Salisbury in 1971. It is worth while to stress some of the principles of this technical procedure, the first requirement is the development of as much The Hand--Vol. 9
No. 3
1977
227
A Review o / 1 0 0 Flexor Tendon Reconstructions with ProSthesis Richard Honner and ,4 llan Meares
passive movement in the distal joints as possible, with careful physiotherapy techniques, and then at exploration all definitive reconstructive procedures need to be performed at the time of the insertion of the silicone rod. It is important to reconstruct pulleys at the mouth of the flexor sheath, and over the proximal and middle phalanges, and this is very satisfactorily done over the silastic tendon in situ, using remnants of the flexor tendons which are excised. A firm distal fixation beneath the stump of the profundus tendon is carried out with interrupted sutures of five zero nylon and the proximal portion of the tendon allowed to lie free, usually in the distal forearm. Passive movement of the digit should b e used to demonstrate that the proximal end of the tendon prosthesis does move freely, without any b~ckling. After the first procedure, active movement of the digit is commenced some five to seven days post-operatively, and as the wound stabilises more vigorous physiotherapy techniques can be used to restore passive motion to the digital joints. The second stage of the operation can be carried out when the wound is well healed, and optimum passive flexion has been obtained and this can vary from six weeks to twelve weeks after the first operation. In our series of 100 successive cases, the silicone tendon was taken to the distal forearm in the majority of patients and therefore the plantaris tendon graft was used, and when this was not available or suitable an extensor tendon from the second or third toe was used. In the second stage procedure limited exposure at each end of the tendon is performed, the distal junction is made using a four zero prolene or nylon suture passed through a drill hole in the distal phalanx and tied over a button on the finger nail. Extra interrupted sutures can be used to fix the profundus stump to the tendon graft. The distal wound is closed and an interweaving technique of the tendon graft through the mass of the profundus tendon in the distal forearm is used to select the correct tension for the tendon graft and fixed with interrupted sutures. Post-operative management of the second stage procedure requires a period of three weeks immobilisation, in which the hand is protected with flexion at the wrist and metacarpophalangeal joints with a plaster slab, and only passive movement of the digit being performed at the time of the dressing changes. After three weeks, active flexion of the digit is allowed and this progresses over the following two weeks to a full range of active and passive movement. The button is removed at the fifth or sixth week, no pullout suture is used, the suture over the button is simply cut and withdrawn. TABLE 3 RESULTS
(Thompson, 1%7)
228
Excellent Good Fair Poor
19 38 26 15
Total
98 The H a n d - - V o l . 9
No. 3
1977
A Review o] 100 Flexor Tendon Reconstructions with Prosthesis Richard Honner and Allan Meares RESULTS
An examination of the results of these 100 successive cases was performed, using the method recommended by Thompson in 1967. This method takes into account joint contractures, and the distance the finger fails to reach full extension or full flexion and on the basis of these measurements, categories of excellent, good, fair and poor are described. Using Thompson's classification the results of the silicone tendon reconstructions are shown in Table 3 nineteen were excellent, thirtyeight good, twenty-six fair and fifteen poor. (Only ninety-eight cases came to the second stage grafting.) Of the two patients who did not have the second stage procedure performed, one developed a sudden terminal malignancy, and declined further surgery and one for personal domestic reasons has postponed the second stage procedure indefinitely. An examination of these results shows that the excellent category is falsely loaded by the inclusion of those patients who had a staged silicone tendon reconstruction of the isolated lesion of the flexor digitorum profundus tendon (seventeen patients), and in these there were fourteen excellent results and three good results. If these seventeen patients were excluded from the series, there would be onIy five excellent results, thirty-five good, twenty-six fair and fifteen poor results. However, an analysis of these results, compared with other flexor tendon grafting series, such as Thompson's 1967, indicates that there are always a significant proportion of poor results in flexor tendon grafting, and in these patients where the circumstances for primary flexor grafting are less than ideal, we feel that the results of silicone tendon reconstruction are an improvement on previous techniques. TABLE 4 COMPLICATIONS (of First Stage)
Infections (Same Patient) Synovitis Ruptured Distal Attachment Severe Trauma Post-Op. Tourniquet Paralysis Total
2
8 2 2 1 15
COMPLICATIONS
Complications in the one hundred cases of reconstructions are shown in Table 4, one patient had two silicone tendons which became infected, synovitis occurred in eight patients, in two patients the distal attachment came adrift so that the tendon migrated proximally and the distal portion of the tunnel was lost. There were two patients who suffered significant trauma in the period between the first and second stage operations, and one patient had a tourniquet paralysis of all the nerves in the arms for some four weeks, due to a fauty pneumatic tourniquet, and this patient recovered full nerve function eventually. The two infections occurred in the one The Hand--Vol. 9
No. 3
1977
229
A Review of 100 Flexor Tendon Reconstructions with Prosthesis Richard Honner and Allan Meares
patient, where poor surgical technique allowed the distal suturing of the rods to fail, the rods protruded eventually through the skin and a pyogenic infection developed along the whole length of the rod from the fingertip into the forearm. This disaster did not respond to immobilisation and antibiotics, and required removal of the rods and further reconstructive surgery at a later date. The complication of synovitis is of interest, it is characterised by a warm swollen red finger, without any systemic evidence of a pyogenic infection, and exploration reveals a brownish sterile fluid, with an inflamed, swollen synovial lining of the sheath, formed around the silastic tendon. The synovitis is often confined to the finger, and fluctuation can be demonstrated along this extent, and occasionally will extend into the palm or forearm. The exact cause of the synovitis is not known, it may be an irritation due to a very tight pulley or constricting scar tissue causing local buckling of the tendon, or it may be a reaction to some of the material used in the manufacture of the silicone tendon, or perhaps, a minor foreign body contamination at the time of the insertion of the rod. In four patients this synovitis settled easily with a period of immobilisation on a plaster splint, in the early cases we added antibiotic therapy to this immobilisation but this now appears unnecessary where the clinical diagnosis is straightforward. There were four patients where the synovitis did not respond to immobilisation, aspiration was used as a diagnostic procedure in one of these cases but not repeated, and our approach to the problem of the resistant synovitis was to go ahead with the second stage grafting and at the time of the procedure to try to improve the passive range of flexion by manipulation after removal of the rod and drainage of the swollen sheath, and in these four cases the flexor tendon grafting went ahead without any major incident, although the results in these four cases were only one good, and three fair results. The main factor in the relatively poor results in these patients appears to be the loss of passive movement due to the gross swelling in the digit accompanied by the period of immobilisation used in an attempt to resolve the synovitis. It may be that repeated aspiration would solve this problem, but we were concerned about the possibility of secondarily infecting the synovial fluid, and did not use this form of treatment. The patients who suffered severe trauma to the finger between the first and second operations demonstrated to us that the digit which lacks active flexion, and contains a large foreign body, is at considerably increased risk in normal activities. One patient suffered a compound fracture to the proximal phalanx of the digit with the silicone tendon, with extrusion of the prosthesis, and in this particular case was treated aggressively, with internal fixation of the fracture, careful cleansing of the wound and the sheath, insertion of a new prosthetic tendon and repair of the sheath and skin wound. With antibiotic cover infection did not occur, a good passive range of movement in the digit was re-established, and eventually an excellent result was achieved with later tendon grafting. CONCLUSION
Where circumstances are suitable, the standard flexor tendon grafting procedure offers a good chance of recovery of active flexion in the digit, but there are occasional poor results. In circumstances where conditions for flexor tendon grafting are less than optimal, the inc'dence of poor results is likely to increase significantly, 230
The Hand--Vol. 9
No. 3
1977
A Review of 100 Flexor Tendon Reconstructions with Prosthesis Richard Honner and Allan Meares
(Thompson 1967) and it has been our approach to use a staged reconstruction technique for flexor tendons, using the silicone rubber tendon of the Hunter design to prepare a bed for the later definitive grafting procedure. There are significant complications of this two stage procedure, but the results indicate that this is a reliable technique which achieves reasonable results in digits where the one stage grafting procedure is very likely to give a high incidence of poor results. REFERENCES
HUNTER, J. M. and SALISBURY, R. E. (1971) Flexor-Tendon Reconstruction in Severely Damaged Hands. A Two Stage Procedure using a Silicone Dacron Reinforced Gliding Prosthesis Prior to Tendon Grafting. Journal of Bone and Joint Surgery, 53A: 829-858. THOMPSON, R. V. (1967) An Evaluation of Flexor Tendon Grafting. British Journal of Plastic Surgery, 20: 21-44.
The H a n d - - V o L 9
No. 3
1977
231