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An evaluation of flexor tendon grafting
AN EVALUATION OF FLEXOR T E N D O N GRAFTING
By R. V. THOMPSON,F.R.C.S., F.R.A.C.S.
Assistant Plastic Surgeon, Royal Melbourne Hospital Clinical Research Project, Victor Hurley Research Trust, Royal Melbourne Hospital ONE of the unsolved problems of flexor tendon grafting is the unpredictability of the outcome of this operation. In the post-war era this procedure has been developed by highly skilled surgeons using varied techniques, and though in general the results appear satisfactory, the aura of uncertainty surrounding the end-result of the individual case must always affect the surgeon's advice to his patients. The picture is further complicated in that the serviceability of the reconstructed finger is not always proportional to the excellence of the repair. Though near-perfect results are usually serviceable, we often find that an objectively poor result proves quite valuable to the patient. Thus it would seem that a true evaluation of tendon grafting must follow two lines --firstly, an evaluation of factors affecting the objective or technical result, and secondly, an evaluation of the subjective factors which determine whether a given tendon graft will help the patient. In Melbourne, tendon grafting operations have, in the main, been developed by a group of plastic surgeons who have evolved and taught a technique which has varied little over the years. It was considered that some detached long-term follow-up study of these cases by one observer would be of particular value in elucidating some of the factors responsible for the varied outcome of these procedures. A long-term follow-up of such cases is a very difficult undertaking in a ~'ountry of long distances with a scattered and partly mobile populationnespecially among its seasonal workers and the new immigrant sections of the community. One hundred and nine conservative tendon graft operations done in the Plastic Surgery Unit of the Royal Melbourne Hospital were investigated, along with 51 conservative cases done in the private practice of one of the surgeons. It was possible to forgather only Ioo of these cases for study, and only those cases seen and studied personally by the writer have been included in this series under review, no matter how complete or final the records were. The sixty cases not included in the study were either untraceable, despite tedious search and recourse to electoral rolls, or else they lived at interstate addresses, x It is considered that the Ioo cases available for close study represent a true cross-section of results, though it must be stated that the Royal Melbourne Hospital is a hospital for adults. This belief is confirmed by the records of the cases which were not seen by the reviewer, and which indicate the same distribution of good, fair and poor results. This communication is thus devoted to the details of Ioo cases questioned, studied and recorded, using a common formula. All operations were carried out by members of the Plastic Surgery Unit of the Royal Melbourne Hospital over the past twenty years according to the technique which has been described by Rank and Wakefield (I95I). The fact that a standardised technique has been adhered to bestows special value on this study in marked contrast to many other surveys where the analysis has been dogged by frequent variations in techI Untraceable__4o ; Interstate--not sent f o r - - I 6 ; Refused follow-up--2 ; Migrated overseas--r ; Subsequent death by accident--L
22
BRITISH JOURNAL OF PLASTIC SURGERY
nique i n t r o d u c e d b y individual surgeons) so m u l t i p l y i n g the variables and m a k i n g overall conclusions o f less real value, T h e only significant variation o f p r o c e d u r e in this series is that over recent years p r i m a r y t e n d o n grafting has b e e n p e r f o r m e d m o r e frequently, b u t the actual t e c h n i q u e o f grafting has r e m a i n e d relatively constant, O f the i o o grafts followed u p ) t w e n t y five h a d p r i m a r y a n d seventy=five h a d s e c o n d a r y grafts, T h e distribution o f cases with respect to age, sex a n d digit involved is as s h o w n in Tables I) I I , and I I I and t h c periods o f foLlow-up are s h o w n in T a b l e IV, TABLE I
Secondary Grafts (75) Age
Thumb Index Middle Ring Little
0--I0
•
I 1--20
• .. ""
]
I 4
z
•
2I-30
""
7 (2)
i
.~,
4I-5 o
(i)
I
5 4 3 z (i)
z (I) I (i)
..
31-40
"~'(0
7 2 (i) 5 (i) 6 (~)
I
"I'(I)
51-6o+ (I) 2 I
4
(Figures in parentheses = Females)
TABLE II Primary Grafts (25) Age o-io
Thumb Index Middle Ring
. . ... .,. ...
Little
...
ii-2o
.
.
2i-3o
. . I 3 I
.
3 (i)
.
3I-4O
. . x .-I
.
3 (i)
.
4I-5O
. . ... I I
.
2
.
. . z ...
"'" (I)
... i
"2"(i)
TABLE I I I
(IO0 Grafts)
Digit Distribution
Thumb [ 4
Index
Middle
Ring
Little
24
I9
14
39
TABLE I V
Period of Follow-Up (Years) o--5
43
.
6-io
IX-15
16+
[
24
25
8
I
5I-6o+
.
I
AN EVALUATION OF FLEXOR TENDON GRAFTING
23
I. T H E OBJECTIVE A S S E S S M E N T A. Method o f Objective Assessment.--Since 195o when Boyes first suggested a method of recording function following a tendon graft, there has been much controversy concerning the best methods of record. The several limitations of recording only the
FIG. I Full extension of finger. Gross flexion contracture deformity.
FIG. 2 Full flexion. The finger tip touches the palmar crease but there is nointerphalangeal joint movement.
FIG. 3 The finger was serviceable to this housewife.
distance between the flexed finger tip and the distal palmar crease have been pointed out by several authors (White, I956 ; Peacock, I96I) viz.: (i) No note is taken of any fixed flexion deformity at the interphalangeal joints. Cases are seen with no active movement at either of these joints but because of considerable flexion deformity, the finger tip can be brought to, or near to, the distal palmar crease by flexion of the metacarpo-phalangeal joints alone--i.e, the finger tip reaches the palm by tenodesis effect. Such a case, though a complete technical failure, may or may not be valuable to the patient (Figs. I-3). (ii) No record is taken of finger length. As Peacock points out, a middle finger that flexes to within i in. of the distal palmar crease represents a better result than flexion of a 1/tile finger tip to within ½ in. from the distal palmar crease. The former case involves a much greater amplitude of tendon excursion. Thus we believe that it is more critical to record the full range of active movements at each interphalangeal joint and at the metacarpophalangeal joint, and to compare this
24
BRITISH JOURNAL OF PLASTIC SURGERY
with the normal range in the corresponding joint and digit of the opposite hand. It is important, too, that all joints are fully flexed during measurement of flexion, for if the interphalangeai joint ranges are recorded with the metacarpophalangeal joint incompletely flexed, a greater range of movement is often recorded, because the limited rendor. excursion can be expended at the interphalangeal joints. On the other hand, if the metacarpophalangeal joint is flexed, then less amplitude of tendon excursion is available at the interphalangeal joints before any peritendinous adhesions limit the movement range. This method of record also indicates any flexion and recurvatum deformity. In this series, the distance to which the finger tip can approach the distal palmar crease has also been measured in keeping with other surveys so as to allow comparisons (Fig. 4). The range of passive flexion is also recorded. There is one well-known trick movement patients commonly employ when the passive range of movement exceeds the active range---the repaired digit is wound into the palm by adjoining fingers, often simulating a perfect result. Though this is usually obvious in the case of the little finger, it may not always be noticed in the case of the other digits (Figs. 5-7). To simplify the analysis, results have been classified accordingly to the grouping used by White (Table V). Figures 8-13 illustrate cases which would be regarded as typical examples of an excellent result. TABLE V Grading of Results in Fingers Excellent Good Fair Poor
~2OO
> 18o > I50
< r50
~
O-IO I0-30
i½
30-4 ° >40
The figurein the first columngivesthe total range of active flexion in the three finger joints. The second columngivesthe closestdistancein inches the fingertip reaches to the distal palmar crease. The third column figure is the summation of flexion contracture in the joints of the grafted finger. TABLE VI Grading of Results in Thumb Excellent i>7o% Good 6o-70% Fair 4o-60 % Poor < 40% The range of active flexionof the interphalangealjoint of the graftedthumb is calculatedas a percentageof the range in the normal thumb of the opposite hand. The only modification of White's chart is that in the excellent group a flexion contracture up to to degrees has been accepted. This is justifiable because it was found that some degree of flexion contracture is quite common in normal fingers varying from 5 to 20 degrees. In this series there were I7 such cases where some degree of flexion contracture also existed in the corresponding digit of the uninjured hand. Even this classification, however, is not entirely adequate for in comparing fingers with the same total order of flexion, it was noted that shorter fingers reach closer to the palmar crease than do longer fingers.
AN EVALUATION OF FLEXOR TENDON GRAFTING
25
METHOD OF RECORDING
J _ J
.~
EXTENDED DIP. 30 (flexion contracture) PIP. 30 ( )
//~
~..__,.~x'~//~X~X/\ FLEX ED /I ~/ / DIP. 45 ----~,.T.~---"~ 7 / PIP. 45 MCP, 80 / / TOTAL DEGREE DIP. 45-30=15 PIP, 45-30=15 MCP. 8 0 - 0 =80 =110 FIG. 4 Method of Recording.
FIG. 5 Full extension (Case 83). FIG. 6 Full flexion. T h e finger tip fails to touch the palmar crease by at least ½ inch (Case 83). FIG. 7 By winding the finger in with the adjoining ring finger full flexion is achieved giving the appearance of an excellent result. FIG. 8 Full extension of grafted index finger (secondary graft, Case 54). FIG. 9 Full flexion. An excellent result (Case 54).
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B R I T I S H JOURNAL OF PLASTIC SURGERY
FIG. IO
Full extension--ring finger (secondary graft, Case 47). FIG. xI Full flexion. An excellent result (Case 47). Fm. i2 Full extension of little finger (primary graft, Case 57). FrG. I3 Full flexion. An excellent result (Case 57). FIG. I4 FuU extension of thumb (secondary graft, Case 58). FIG. I5 Full flexion. An excellent result (Case 58).
27
AN E V A L U A T I O N OF FLEXOR T E N D O N G R A F T I N G
To record results in the case of the thumb, White's classification has again been used as shown in Table VI and an example of an excellent result is shown in Figures 14 and 15. B. Results o f Objective A s s e s s m e n t . - - T h e various factors which are considered to influence the results are set out according to whether they pertain to the patient (general factors), or to the operative technique.
Z. G E N E R A L F A C T O R S ( T H E P A T I E N T ) Age.--In Table VII all the cases are arranged in order of age, each stroke representing an individual graft and the height of the stroke indicating whether the result was excellent, good, fair or poor. Whether a primary or secondary graft, and the preoperative state of the hand (ideal or non-ideal) is also shown. The arrows indicate division into three age-groups, 0-20 years, 21-35 years, and over 35 years. TABLE VII RESULTS
OF
I00
GRAFTS 1
PRIMARY IDEAL PRIMARY NON-IDEAL sEcoNDARY IDEAL SECONDARyNON-IDEAL
~
ilia! i:i"
i! :!iilli 1 ~ ~J
i
ii
W 67
55
50
45
40
35
!1t]
¢ 25
2O
is
iY2
(a) In the 0-20 years age-group aU secondary grafts in ideal cases (7) achieved an excellent result and of those secondary grafts performed in non-ideal cases (14) most achieved an excdlent (6) or good (7) result. For primary grafts in this group (9) there were three good and five fair results with one excellent result in an ideal case. There were no poor results in the entire group, and most of the fair results were primary grafts in non-ideal cases. These results concur with Wakefield's (1964) findings in a recent series of tendon grafts in children. (b) For the 21-35 years age-group, where a secondary graft was performed in an ideal case (I3), there were many good (3) and excellent (7) results. In the non-ideal secondary graft group (19) there were many poor results (14), one good result, the remainder fair (2) and amputated (I). For primary grafts in this age-group where the preoperative state was ideal (4) there was one excellent, two good and one poor result, and where the pre-operative state was non-ideal (4) there were, two fair and two poor results. The solitary excellent primary graft occurred in a little finger of a female hand of slender, pliable build and after a small clean-cut superficial wound with no contusional damage.
28
BRITISH JOURNAL OF PLASTIC SURGERY
(c) In the over-35 years age-group, secondary grafts in ideal cases (6) yielded a few excellent or good results, but secondary grafts in non-ideal cases and primary grafts resulted in fair (6) and poor (8) results, and one amputation, this outnumbering the excellent (4) and good (5)results. To summarise these findings, age seems to be the factor of paramount importance for all secondary grafts. The under-2o age-group demonstrated excellent or good results, but over the age of 20 other factors had added importance. Sex.--Though in females the results were superior to those in males (Table VIII), TABLE VIII Results in Males and Females Compared Excellent* I
Good
Fair
Poor
. .
i
Females (I6%) Males (84%)
5
i
6
I
I
4
22
'
I8
I7
I
27
f
* Hereafter in this paper the following abbreviations will be used in tables. E--Excellent ; G - - G o o d ; F - - F a i r ; P--Poor.
the series is too small to draw definite conclusions. The improved results in females can largely be explained on the basis of their hand physique, for of the 16 cases all but one was classified as of pliable build, which, as will be shown, seems a major factor in determining the objective result. D i a t h e s i s . - - I n all cases it was recorded whether the patient was of fair, medium or dark complexion (on the basis of skin pigmentation, eye and hair colour). Analysis of this information was unrevealing except that post-operative induration of tissues in the operated finger was more common among subjects of fair complexion. The long-term results, however, did not appear affected. Intelligence and C o - o p e r a t i o n o f the P a t l e n t . - - S o m e assessment of the patient's general intelligence was made from reactions at the interview, from the records and from emotional responses or adaptations to persisting disabilities. Here again, however, the series would seem too small to allow definite conclusions, but the impression was gained that the more intelligent patient was more likely to achieve a good result than the unintelligent or non-co-operative. Digit Involved.--Table IX indicates the results relating to the various fingers. TABLE IX Results in Individual Digits i
E
G
F
P
Thumb Index Middle Ring I Little
2 4 3 4 14
2 6 7 3 6
'" 7 2 3 6
7 (2 ~ p s . ) T 7 (2 ps.) 13 (I amp.)
It is difficult to generalise from these figures as the breakdown numbers are so few, and many variables are not taken into account. There is, however, a clear trend that the best results are demonstrative in the index and little fingers. When it is considered
AN EVALUATION OF FLEXOR TENDON GRAFTING
29
that the poor results in the index and little fingers were unduly loaded unfavourably by non-ideal cases in the over-35 years age-group--4 and 8 respectively--the impression is that the little finger is most likely to give an excellent result under ideal circumstances, then follow the index, ring and middle fingers in declining order of frequency. There are probably several reasons why the little finger should give better results than the other fingers. The amplitude of excursion of the profundus tendon during full flexion of interphalangeal joints of index, middle, ring and little finger is 4o, 45, 32 and 29 ram. respectively. Firstly, therefore, for a given amplitude of excursion in a graft, the little finger will flex to a greater degree than the other fingers. This is explained by the fact that the angulation effect is inversely proportional to the joint radius. The ioints of the little finger have the smallest radius and hence have the greatest angulation range. Secondly, the little finger is the shortest finger, so that for a given total angulation of all joints, the pulp of the little finger will reach nearer to the palmar crease. Thirdly, the little finger has the least complicated of flexor tendon arrangements. The sublimis tendon is usually a slender structure while the profundus is a bulky and strong tendon. Thus a tendon graft in the little finger gives the closer approximation to the normal anatomical arrangement. In the other digits where the sublimis, a strong tendon, is sacrificed, it is logical to assume that this must have a more deleterious effect on the strength and range of finger flexion. This, of course, does not apply where a graft is threaded through an intact sublimis system. On the contrary, the relatively poor results in the case of the middle finger can be explained by its length and the increased amplitude of excursion normally required of its profundus tendon. Hand P h y s i q u e . - - T h e affected hands were classified into three groups," pliable ", " t h i c k " and " m e d i u m ". This classification, which is to a certain extent arbitrary, was based on considerations of the ratio of finger breadth (measured transversely across the P.I.P. joint) to finger length, finger shape (tapered or spadelike), texture of the skin (loose and pliable or thick and horny) and the range of flexion in the joints.
TABLE X Hand Build
, /
Pliable
Medium
f
Thick
]
Excellent and Good Fair and Poor
26 8 (I amp.)
2o 25 (I amp.)
5 16 (3 amps.)
Pliable fingers were usually slender and tapering, the skin loose and elastic, and the average total range of flexion at the P.I.P. joints in this series was 18o degrees. In addition, such fingers were often moderately or markedly hyperextensile. On the contrary, fingers classified as thick were often stubby, the skin tough and horny and the total range of flexion at the I.P. joints averaged 15o degrees. Manual labourers commonly have such hands. The medium class had intermediate characteristics and the average range of flexion at both I.P. joints was x6o degrees. From consideration of Table X it is apparent that excellent or good results seldom occurred in the thick class of finger but were far more frequently seen with pliable fingers.
30
BRITISH JOURNAL OF PLASTIC SURGERY
The P r e - o p e r a t i v e State o f the H a n d . - - I n Table XI two groups are compared --those in which the pre-operative state was ideal and those in which it was non-ideal. TABLE XI
Influence of Pre-o mrative State of the Hand on Results Age
Ideal (37 cases)
Non-ideal (63 cases)
E G F P E G F P
.
36+
21-35
0-20
8
8
I
I I
5
4
2 2 (I an'lp.)
4 (I amp.)
6 9 5 ...
I
4
18 (2 amps.)
I
4 4 5 7 (I amp.)
An ideal pre-operative state was one in which the following conditions applied, viz. : (a) A tidy wound not involving the posterior sheath wall and with minimal contusional damage to soft tissue (Figs. 16 and 17).
Fla. 16
Posterior sheath damage--non-ideal.
(b) Where scarring was minimal, there was good passive joint function and an absence of trophic changes in the finger. (c) Not more than one digital nerve was damaged. (d) The palmaris longus tendon was available for grafting. On the contrary, a non-ideal case was one in which one or more of these conditions did not apply, i.e. there was extensive scarring, joint dysfunction, trophic changes or
31
AN E V A L U A T I O N OF FLEXOR T E N D O N G R A F T I N G
more than one digital nerve was damaged. Such adverse factors often followed untidy injuries. In order to eliminate one of the main variables, the appropriate tables are subdivided according to the age-groups. In the o-20 age-group a good or excellent result can be anticipated in most cases, but there are more excellent results in ideal cases. Over the age of 20 group, there is a marked difference in that ideal cases usually give good or excellent results, and nonideal cases give poor or only fair results. Extensive scarring was the most frequent factor conducive to poor results. The causes of scarring in order of frequency were untidy crushing or tearing injuries, infected primary repair operations and the fossicking for tendon ends at a primary operation by inexperienced personnel. In this series injuries caused by a circular saw or buzz saw were a frequent cause of non-ideal classification (13 cases). Such injuries resulted in ragged lacerations, often involving both digital nerves and penetrating the posterior sheath wall (13 cases). The result was almost invariably poor or only fair among the over 2o age-group. Even if expert primary wound repair is carried out in such injuries, and good primary healing occurs, the problem of the scarred posterior sheath region is always present. Table XlI shows the breakdown of factors which rendered the cases non-ideal, and Table X l I I indicates the causes of injuries in the series. TABLE XlI
Frequency of Adverse Pre-o ~erative Factors (63 Non-ideal Grafts) U
C
G
T
N
J
E G F P
3 7 8 18
5 3 4 II
I 4 8 9
... 5 I 5
2 3 ... 5
I 2 3 5
Totals
36
23
22
II
I0
I0
U ~ - - U n t i d y w o u n d ; C = C i c a t r i x ; G = P a l m a r i s graft n o t available ; T = T r o p h i c c h a n g e s ; N = M o r e t h a n o n e digital n e r v e d a m a g e d ; J = J o i n t d y s f u n c t i o n .
TABLE X l I I Cause of Injury in the Series Knife Glass Saw A n g l e iron, etc. Tin Axe T o o l - b o x lid Mower
27 25 13 8 6 4 3 3
Car accident Electric drill E n g i n e block Chain Brickwork Lathe Chisel Football
2 2 2 I I I I I
2. T E C H N I C A L FACTORS
The Time Interval between Primary and Secondary Repair.--From a study of Table XIV it appears that six to twelve weeks is a satisfactory time interval between primary repair and a secondary graft. There were several cases which had yielded good results six months or more after injury. Two common problems in cases of long
32
BRITISH JOURNAL OF P L A S T I C SURGERY TABLE X l V
T i m e Interval between Primary W o u n d Repair and Secondary T e n d o n Graft o-6 weeks
6-12 weeks
8
6
E G
.°.
12-21 weeks !
4 (I (i 4(3 (I
IO
4
21 weeks+
4 14
×6years)
× I year) ×x½years) x I year)
I (I × i½years)
delay before grafting were atrophy and stenosis of the sheath system with the profundus tendon retracted into the palm or an inaccessible proximal stump of the profundus tendon. Pulley M a n a g e m e n t . - - T h o s e cases in which the standard pulley arrangement could not be constructed usually had considerable weakness and limitation of flexion in the finger. These patients were generally ready to point out that if they pressed over the proximal segment of the finger, it flexed more efficiently. P r o x i m a l S t u m p Retraction and Choice o f M o t o r . m O n e of the problems of delayed secondary repair is tendon retraction, where the vinculae fail to anchor the profundus stump in the finger. This difficulty was met with increasing frequency in cases delayed over six weeks, and in four cases the tendon was retracted into an inaccessible situation over the wrist. The solution in three cases was use of the sublimis motor (above the wrist twice) and in the fourth case the ring finger sublimis was transferred. In all these cases a good or excellent result was achieved. This might indicate that the inadvisability of using a sublimis motor (as propounded by some surgeons) on theoretical considerations of its hmited tendon amplitude, might in practice be unfounded. Choice o f G r a f t . - - O n survey of Table XV and having due regard to the fact that most of the poor results using palmaris grafts occurred in non-ideal conditions or in TABLE XV Graft Used E
Palmaris with Paratenon
26
G 20
Palmaris without Paratenon Sublimis
Toe Extensor
F IO
P 22
I
I (I x L )
4 ( I XM) (z x R ) (2 x L)
3 (I × In)
(2 × R)
3 (2 x In) (I XL)
4
elderly patients, it would seem that the best prospects of an excellent result is when the palmaris with its paratenon is used. In no cases where the toe extensor was used as a graft was an excellent or good result achieved. There was no experience of the use of
AN EVALUATION OF FLEXOR TENDON GRAFTING
33
plantaris, which, according to White, is the most satisfactory replacement in the absence of palmaris. The presence of paratenon seems important. In this series one excellent result was achieved using the sublimis tendon of the little finger. This is a much thinner structure in the little finger and would be less liable to central necrosis. Finger Posture a n d Graft T e n s i o u . - - T h e posture of the finger after insertion of the graft is believed to have some bearing on the result, for where the graft was inserted in a relatively slack state, flexion contracture seemed unlikely to occur. For the same reason when poor tendon gliding ensued in these cases the finger was liable to protrude from the closed fist and create considerable disability. On the other hand, where the graft was inserted'under greater tension flexion contracture often occurred post-operatively. This was sometimes overcome by the use of a light elastic traction splint. Graft J u n c t i o n s . - - i n this series of cases the distal junction of the graft was to the profundus stump just distal to the interphalangeal joim, using a Bunnell-type stitch. However, on two occasions this junction disrupted and it is suspected that in some of the other poor results this may also have occurred at least in some degree. With any separation of this junction, flexion of the distal interphalangeal joint will be impaired. Tourniquet Time.--Prolonged periods of tourniquet application as is sometimes involved with multipIe grafts or other procedures seemed detrimental to the result. The results of multiple tendon grafts are shown in Table XVI but are insufficient in number to draw conclusions. TABLE X V I
Multiple Grafts Case No.
Age
Pre-op. State
No. of Grafts
I 2
35 33
NI I
3 2
32
NI NI NI NI NI NI
25 2I 20
18 i8
Primary or Objective Secondary Result P×3 G×I E×I F×2 P×2 Px2 Gx2 F×3 G×3
S S
S S P&S P P S
Subjective Result + + + ++ + + ++
TABLE X V I I Surgical Experience Years' Experience
E
3-5 6-io io+
6 io
G 7 5
F
I 4
I
P
5
Surgical E x p e r i e n c e . - - Fhere was conclusive evidence that the more experienced surgeons obtained superior results as shown in Table XVII. It is seen that where the
34
BRITISH JOURNAL OF PLASTIC SURGERY
surgeon had up to two years' experience, the fair and the poor results outweighed the excellent and good results, but where the experience exceeded two years, then the excellent and good results outweighed the fair and poor results. VARIATIONS IN TECHNIQUE
Preservation of S u b l i m i s . - - T h e r e were five cases in which the sublimis was undamaged and a palmaris was threaded through it to the palm. Of four secondary grafts in this way three achieved excellent results and one was fair. The one primary case gave a good result. There was no experience of resecting one slip of the sublimis in this series. Tendon Graft in a Baby aged I9 M o n t h s . - - T h i s case was reviewed at the age of 17, and an excellent result had been achieved, there being no flexion contracture and the finger flexed to within ½in. of the palmar crease. This case provides strong evidence that a graft grows in normal relation to other structures. Tendon Graft and Primary Direct R e p a i r in the Same H a n d . - - T h e r e was one interesting case in which both tendons of index and middle fingers were divided in the proximal finger segment in a girl aged 14 years. The condition for tendon grafting was non-ideal in that the lacerations were untidy and all digital nerves were divided. In the index finger the sublimis was resected and a careful primary repair of profundus performed. The middle finger had a secondary tendon graft two months later by the same surgeon. The tendon grafted finger achieved the superior result. COMPLICATIONS OF TENDON GRAFTING
Amputation.--The finger was amputated subsequent to a tendon graft on five occasions. This was usually necessitated in a working man where a failed tendon graft interfered with hand function and the patient was usually unwilling to undergo further operative procedures where a good result could not be guaranteed. One finger was amputated for painful scarring. All amputated fingers were secondary grafts, and the pre-operative state was non-ideal in three and ideal in two of them. Tenolysis.--Tenolysis was performed on five occasions with limited improvements in two cases. In general, in this series, patients who had grafts were encouraged to return to work at an early stage in their post-operative convalescence. Since most of the grafts were serviceable, few patients returned seeking further surgery. For this reason tenolysis was an uncommon procedure, though undoubtedly many of the cases might have benefited from such a procedure.
Impaired Sensation.--Occasionally there was some minor impairment of sensation in a finger in which no digital nerve damage had occurred at the time of the injury. This was never disabling. On these grounds it is concluded that the standard incisions used in this series for tendon exposure are not disabling. Recurvatum and Trigger Finger D e f c r m i t y . - - E l e v e n per cent. of cases had recurvatum (7 per cent.) and/or trigger disability (4 per cent.) at the proximal interphalangeal joint of the grafted finger and these all occurred in pliable or medium build fingers. It is thought that both these occurrences have a common aetiology, namely,
AN EVALUATION OF FLEXOR TENDON G R A F T I N G
35
lack of stabilising effect of sublimis on the proximal interphalangeal joint. Where any degree of flexion contracture occurred at the proximal interphalangeal joint the problem never arose. (It is for this reason that some surgeons advocate anchoring the slips of sublimis stump to the proximal phalanx in pliable fingers.) Quadrlga Effect.rain several instances a quadriga effect was demonstrated. This is due to a poorly gliding tendon in the grafted finger interfering with the excursion of the profundus tendon in adjoining fingers. This might also explain a not uncommon complaint of patients that fingers other than the grafted finger had a reduced power grasp though no apparent limitation of flexion.
Progressive Flexion Contracture.--There was one example in which the patient complained of progressive flexion contracture over a period of years. This was a singular occurrence. PRIMARY T E N D O N
GRAFTS
There were 25 cases of primary grafts and the results are set out in Table XVIII. The analysis suggests that other things being equal a primary graft does not give as good a result as a secondary graft. In the o-2o age-group all except one of the fair results were primary tendon grafts. The excellent results with primary grafting all TABLE XVIII Primary Grafts Age
o-zo -
21-35 36_ +___
Ideal ( I I cases)
Non-ideal (I4 cases)
2
4
I
2
I
2
2
occurred in ideal conditions, namely, a clean superficial cut, minimal contusional damage, no damage to the posterior sheath wall, no digital nerve damage and where a palmaris tendon was available for grafting. Figures I7-2o show an excellent result in which these conditions applied. However, primary tendon grafting is an attractive concept, and in our opinion the minor compromise of results with this procedure in certain cases is outweighed by certain definite advantages. Only one operation is required and this is of enormous value to the working man who avoids the loss of time between primary and secondary repair. Further, the operation of tendon grafting is technically easier to perform as a primary procedure for the exact length of tendon graft can be estimated against the length of profundus removed, there is no problem of secondary retraction of the proximal stump, the tissue planes are easier to delineate, and there is no problem of stenosis of the flexor sheath. On theoretical grounds in ideal cases the operation would at least be preferable to that of primary direct repair in the sheath. Of all the primary grafts performed, only
36
BRITISH JOURNAL OF PLASTIC SURGERY
FIG. x7 A tidy wound ideal for a primary graft (Case 94).
FIG. I8 Full extension of primary grafted little finger (Case 94).
FIG. I9 Full fiexion--metacarpophalangeal joint extended (Case 94).
FIG. 20 Full flexion--metacarpophalangeal ioint flexed. An excellent result (Case 94).
AN EVALUATION OF FLEXOR TENDON GRAFTING
37
one required tenolysis and there were no amputations. This is in contrast to Verdan~s results after primary repair, where 30 per cent. of cases required subsequent tenolysis, largely negating the advantages of primary repair. Thus we believe there is a definite place for primary grafting in ideal cases and in the young and elderly age-group, but it should be performed only with some trepidation in the skilled tradesman. This will be further discussed in Section 2 of this paper. SUMMARY OF OBJECTIVE ASSESSMENT AFTER FLEXOR TENDON GRAFTING
It was found that there were five important factors influencing the objective technical result. These were the age of the patient, the pre-operative state of the hand, the general hand physique, the tendon used as a graft and the experience of the surgeon. Age of the patient was of paramount importance. Under the age of 20 almost all secondary grafts give good or excellent results, but over the age of 20 the other four factors gain added importance in affecting the outcome. Good results can usually be expected in medium or pliable hands when the preoperative state of the hand is ideal, but are infrequent with thick fingers or with a nonideal pre-operative state of the hand. Primary grafts in general are inferior to secondary grafts except in the under-2o age-group. In the over-2o age-group where the hand physique is of pliable or medium build, where the skin wound is a clean superficial cut with minimal contusional damage and a palmaris graft used, the results almost approximate those of secondary grafts. II. T H E SUBJECTIVE A S S E S S M E N T In the past undue emphasis has been placed on the objective assessment of results after tendon graft operations ; each surgeon striving to make his series nearer perfection than the last. While this is a creditable attitude on the part of the surgeon, it is evident from the many papers written that until there is some fundamental advance in the zeproducing of tendon gliding, one can go only so far with perfection of technique. in the meantime, it might be more fruitful to investigate those factors determining the usefulness of a less than perfect resttlt, i.e. the subjective assessment.
Method of Subjective Assessment.--In this survey it was first enquired what disabilities, if any, existed in the affected finger. The emphasis was on information volunteered before any direct questioning to determine the predominant hand movements employed by the patient at his work. The relation of these particular hand functions to any disabilities complained of was then correlated. The general pattern of questioning is indicated thus : What was the occupation prior to the accident ? If different, was this related to the injury or the operation ? Was hand function modified in any way as a result of residual disability ? Was the occupation chiefly sedentary, supervisory or in manual work ? Was deficient hand function related to power grasp, thumb index pinch or fine precision function ? Where power grasp was affected it was important to establish the diameter of the tools employed. For instance, with poor flexion it might be possible to grip an axe or shovel handle quite firmly, but yet not be adequate to grasp a knife or golf stick. Did the hand tire with repetitive hand movements such as those encountered by process workers or on conveyor chains as in the case of slaughtermen ?
38
B R I T I S H J O U R N A L OF P L A S T I C SURGERY
Was the finger a nuisance or vulnerable to repeated injury from machinery because of'its protrusion or its catching on things ? Other complaints which require close questioning concerned decreased power in adjoining fingers, pain and sensory disturbances. Where associated injury of other deep structures existed, then assessment in relation to tendon dysfunction becomes much more difficult. Finally, an important question concerned economic hardship and whether or not this was related to a protracted treatment regime, especially where multiple operations were required. It was felt sometimes that a compromise in the patient's interest could have been reached earlier. In order to group the cases for analysis a system was used as shown in Table XIX. TABLE XIX Disability Rating N P a t i e n t r e g a r d e d t h e finger as n o r m a l m N o disability + M i n i m a l disability q- + M o d e r a t e disability + + + Severe disability M i n i m a l d i s a b i l i t y - - o c c a s i o n a l l y aware o f a defect ; m o d e r a t e d i s a b i l i t y - - f r e q u e n t l y aware o f a limitation ; severe d i s a b i l i t y - - f i n g e r n o t u s e d w i t h or witliout i m p a i r m e n t o f r e m a i n i n g h a n d function.
Results of Subjective Analysis.--Most good objective results from flexor tendon grafting are valuable, but not all fair and poor results were unserviceable. Table XX illustrates these findings. TABLE XX Overall Serviceability of ioo Grafts E +++ ++ ÷ N Totals
.
G .
.
.
.
.
F 2
I
Ii 3
9 (5 arnps) 3 r6 3 3I
It is seen that of the fair and poor results only I6 cases had moderate or severe disability (including 5 amputations), whereas 33 cases (two-thirds) had useful and valued fingers with only minimal disability. In 6 cases there was no subjective disability. Before further analysis, with regard to the common occupation groups, Table XXI is included to indicate the type and frequency of the various residual disabilities which patients in this series complained of. Group I. SedentaryOccupations.--This group consisted of domestics (Io), clerks (3), salesmen (3), school children (3), supervisors (z), typists (2), teacher (I), accountant (r), chemist (I) and a civil servant. From Table XXII it is seen that there were four poor or fair results and one case who complained of severe disability° This was a 49-year-old woman who had sustained
AN EVALUATION OF FLEXOR TENDON GRAFTING
39
a severely damaged digit with gross scarring of deep tissues. Following a tendon graft she persistently complained of severe pain in the scarred area and requested amputation. TABLE XXI Frequency of Various Disabilities L Power grasp impaired (a)" Weakness of grip (2z%) (b) Inability to close fist--including 4 amputations (x2 %) (c) Inability to close fist on narrow shafted tools (9%) (d) Tool slipping within grasp (5%) (e) Balance of grip disturbed--e.g, control of hammer (4%) u. Poor pinch grasp and fine manipulative movements 0 0 % ) 3. Finger catching on objects (r z % ) 4. Tiring of hand under pressure or repetitive work and fumbling (9% ~ 5. Finger getting in way and obstructing hand function (9%) 6. Pain--4ncluding one amputation (8%) 7. Liability to injury (5%) 8. Reduced flexibility offlae finger (5%) 9. Trigger effects (4%) Io. Impaired sensation--associated digital nerve damage (3%) n . Quadriga effect (x%) rz. Inability to straighten ( I % )
T~r~E XXII Sedentary Occupations (27) G
E
+++ ++
F
I
... ...
N Totals
!
P :[ (I amp.) .°°
4
i
5 iz
3
,.-
i6
7
2
,..
i
The main disabilities compained of were of minor nature, e.g. slipping of household utensils, fumbling or trigger effects. Group 2. Manual Labourers.--This group was made up of roadworkers (4), cooks and kitchen staff (4), drivers and carters (3), timber workers (3), farmers (3), railway workers (x), wharf labourers (I), meatlumpers (i) and a green-keeper. There was a considerable number of fair and poor results (I4), but, if any, the disabilities complained of were generally minimal. There were only three cases of TABLE XXIII
Manual Labourers E ++÷ ÷+
G
N
Totals
2 3 .
2
.
P
I
2
°..
x i .
F I
...... ......
+
(2I)
.
.
2
3
.
5
severe disability. There were four fair or poor objective results who did not volunteer any disability at all (Table XXlII).
4o
B R I T I S H J O U R N A L OF P L A S T I C SURGERY
This surprisingly small incidence of severe disability was explained by enquiry concerning occupation. In most of these cases the hands were used mainly for grasping wide shafts such as shovels, handles of carrying implements, axes and the like, in which a
FIG. 21 Full extension. T w o secondary grafts, ring and little f i n g e r - Residual flexion contracture (Case 45)-
FIG. 22 Full flexion--limited flexion b u t in a useful range for this t i m b e r worker, w h o had no disability
(Case 45).
complete range of flexion is not called for. Figures 2I-2 4 show examples of limited flexion but useful hands. Where disabilities did occur they were mainly weakness of power grasp, pain during heavy lifting and difficult grasping of narrow handles. TABLE X X I V
Semi-skilled Labourers (9) E +++ ++
G
F
. . . . . . . . . . . . . . . . . . . . .
+
I
N
I
Totals
2
2
2
P
I ...
... 3
2
2
Group 3. Semi-skilled Labourers.--This group included machinists (3), turbine attendants (2), process workers (I), assemblers (I), press operators (I), and a packer. The group was quite small, but among the fair and poor results (4), there was only one case with moderate disability (Table XXIV). The chief complaints were tiring of the hand with repetitive work and liability of the finger to catch on parts of machinery. One assembler had difficulty with manipulative function.
AN EVALUATION
OF F L E X O R
TENDON
GRAFTING
41
Group 4. Skilled Tradesmen.mThis group included mechanics (8), carpenters (6), butchers (6), linesmen (5), photographic technicians (3), glaziers (2), painters (2), fitters and turners (2), sheetmetal workers (I), welders (I), plumbers (I), maintenance engineers (I) and a builder.
FIG. 23
Full extension--secondary grafts middle, ring and little fingers. Some recurvation deformity (Case 84).
FIG. 24 L i m i t e d flexion but not a useful enough range for this linesman. Moderate disability (Case 84).
Among these'subjects there was a very high disability rate as shown in Table XXV. All except one of the fair and poor results (26) complained of disability with many of TABLE XXV Skilled Tradesmen (39) E + + + ++ + N
Totals
G
F
. . . . . _ ..3 --5 •-. I 4
i 2 5 ...
4
8
]
9
P 6 (4 2 9
amps)
I
18
them in the moderate and severe class. There were four amputations because the finger was such a hindrance. Even among the good results there was only one case without disability.
42
BRITISH
J O U R N A L OF P L A S T I C SURGERY
The chief complaint amongst butchers was an inadequate range of flexion to grasp a knife firmly and slipping within the grasp, but in those poor results where considerable flexion deformity existed, the disability was less because the range of flexion was in a more advantageous position of the finger (Figs. 25-27). Carpenters experienced the
Fx~. 25 Full extension. Primary grafts to middle, ring and little fingers. Considerable flexion contracture (Case 78).
FIG. 26 Full flexion. Limited flexion but a useful range for this butcher because the flexion contracture places the range of movement in a useful position (Case 78).
FIG. 27 A firm grasp on the butcher's knife was possible. No disability (Case
78).
same disabilities but to a lesser extent because the tools they used are generally of greater diameter, though picking up and holding of nails was often troublesome. The main concern among motor mechanics was reduced flexibility of the fingers and impaired thumb index pinch (Figs. 28-30) which embarrassed fine manipulation such as screwing on nuts and bolts. TABLE X X V I
Highly Skilled Tradesmen (4) E +++ ++ ÷ N
G
F
P
I I I I
Totals
Group 5. Highly Skilled Tradesmen.--There were only four in this group. A photographic engraver, a textile designer, a chicken sexer and a musician (Table XXVI). All demonstrated excellent objective results, except the musician where only a fair result was achieved in the index finger. The engraver regarded the little finger as
AN EVALUATION OF FLEXOR TENDON GRAFTING
43
normal and had no disability, the designer had no disability, the chicken sexer claimed moderate disability and the musician minimal disability (pianist).
SUMMARY OF SUBJECTIVE ASSESSMENT
Several deductions were made from this analysis. The skilled or semi-skilled worker is the most demanding of an excellent repair. It would appear then that in those cases where, after appraisal of the pre-operative factors, a poor or fair result is foreseen, special consideration should be given to the patient's occupation. It is important to know where the range of flexion would be most serviceable, whether in a relatively flexed or extended position. For the labourer who uses thick-shafted tools and implements, if a good result is not anticipated, some flexion contracture at the interphalangeal joints is likely to provide the most useful finger. For
FIGS. 28 tO 3° FIG. 23--Poor result of tendon graft in index finger. Considerable flexion contracture. FIG. 2 9 - - T h e flexion contracture allowed good thumb index pinch. Minimal disability. FIG. 3 o - - I n this case--a poor result with no flexion contracture and inefficient thumb index pinch. A severe disability.
the skilled tradesman this also applies, especially in the case of his ulnar digits where a tight grasp is essential to give firmness to the grip of narrow instruments--a knife, for example. However, since most of these people use the radial digits to a variable extent for pincer movements--picking up nails, screwing on bolts, etc., too much flexion contracture in these fingers would be a disadvantage. For sedentary workers too much flexion contracture of the radial digits is a handicap in typing and writing.
44
BRITISH JOURNAL OF PLASTIC SURGERY
This important consideration of the degree of flexion contracture can to some extent be controlled at operation by appropriate adjustment of the tension of the graft and of the position in which the finger is immobilised, i.e. its flexed or extended position in relation to that of adjoining digits.
EVALUATION OF FLEXOR T E N D O N G R A F T I N G It seems that the results of flexor tendon grafting, both objective and subjective can largely be forecast by a careful appraisal of various pre-operative factors. A. Under the age of 20 an excellcnt or good result is usual. B. In the 20-35 age-group there are three categories : (i) Firstly, those patients who have a pliable hand physique where the pre-operative state is ideal and where a palmaris graft is used. They can expect good results especially in the case of little or index fingers. (ii) Secondly, those patients who have thick and inflexible fingers in whom the pre-operative state is non-ideaL They usually achieve a poor result. (iii) The third group can be made up of various combinations of these factors and to forecast the outcome in these cases the surgeon will need to weigh the relative importance of favourable and adverse factors. Where the balance of factors suggests that poor tendon excursions will occur, then the patient's occupation must be taken into consideration if a serviceable result is to be achieved. This involves deciding in which position (relatively flexed or extended) of the finger a limited range of flexion will be most useful. Appropriate adjustments can be made at operation to ensure this. C. In the older age-group good results are less frequent but a useful finger can often result, relying on a normal range of active flexion at the metacarpophalangeal joint, if the interphalangeal joints are in a useful position. Even if no active interphalangeal movement occurs the graft may have a satisfactory tenodesing effect. Primary grafts have a place in the under-2o age-group, in labouring classes and in the older age-groups if only for reason of expediency. However, the overall results of secondary grafting are still superior to those of primary grafting and for that reason in the present sta~;eof knowledge and practice primary grafts should not be elected in skilled tradesmen where the highest standards of results are necessary.
Acknowledgement is made to members of the Plastic Surgery Unit of the Royal Melbourne Hospital (over the years I946-64) who performed the operations, especially to the surgeon in charge of this Unit, Mr B. K. Rank, who has been most helpful throughout this study and who kindly made available his private cases for interview. Acknowledgement is also made to the Victor Hurley Trust for awarding me a grant to undertake this project. REFERENCES BOYES, J. H. (I95o)..7. Bone fit Surg., 32A~ 489. PEACOCK,E. (I96I). Int. Abstr. Surg., rz3, 4~I. RANKs B. K.~ and W~EmELD, A. R. (r95I). Br. ft. plast. Surg.~ 4, 244° W/LKEFIELD,A. R. (I964). ft. :Bone J t Surg., 46A, !226. WHXTE, W. (!956). Am..7. Surg, 9x, 66~. A tgDle giving full details of each case wiU be included in the April issue of the ~ourn~o
By R. V. THOMPSON,F.R.C.S., F.R.A.C.S.
Assistant Plastic Surgeon, Royal Melbourne Hospital Clinical Research Project, Victor Hurley Research Trust, Royal Melbourne Hospital ONE of the unsolved problems of flexor tendon grafting is the unpredictability of the outcome of this operation. In the post-war era this procedure has been developed by highly skilled surgeons using varied techniques, and though in general the results appear satisfactory, the aura of uncertainty surrounding the end-result of the individual case must always affect the surgeon's advice to his patients. The picture is further complicated in that the serviceability of the reconstructed finger is not always proportional to the excellence of the repair. Though near-perfect results are usually serviceable, we often find that an objectively poor result proves quite valuable to the patient. Thus it would seem that a true evaluation of tendon grafting must follow two lines --firstly, an evaluation of factors affecting the objective or technical result, and secondly, an evaluation of the subjective factors which determine whether a given tendon graft will help the patient. In Melbourne, tendon grafting operations have, in the main, been developed by a group of plastic surgeons who have evolved and taught a technique which has varied little over the years. It was considered that some detached long-term follow-up study of these cases by one observer would be of particular value in elucidating some of the factors responsible for the varied outcome of these procedures. A long-term follow-up of such cases is a very difficult undertaking in a ~'ountry of long distances with a scattered and partly mobile populationnespecially among its seasonal workers and the new immigrant sections of the community. One hundred and nine conservative tendon graft operations done in the Plastic Surgery Unit of the Royal Melbourne Hospital were investigated, along with 51 conservative cases done in the private practice of one of the surgeons. It was possible to forgather only Ioo of these cases for study, and only those cases seen and studied personally by the writer have been included in this series under review, no matter how complete or final the records were. The sixty cases not included in the study were either untraceable, despite tedious search and recourse to electoral rolls, or else they lived at interstate addresses, x It is considered that the Ioo cases available for close study represent a true cross-section of results, though it must be stated that the Royal Melbourne Hospital is a hospital for adults. This belief is confirmed by the records of the cases which were not seen by the reviewer, and which indicate the same distribution of good, fair and poor results. This communication is thus devoted to the details of Ioo cases questioned, studied and recorded, using a common formula. All operations were carried out by members of the Plastic Surgery Unit of the Royal Melbourne Hospital over the past twenty years according to the technique which has been described by Rank and Wakefield (I95I). The fact that a standardised technique has been adhered to bestows special value on this study in marked contrast to many other surveys where the analysis has been dogged by frequent variations in techI Untraceable__4o ; Interstate--not sent f o r - - I 6 ; Refused follow-up--2 ; Migrated overseas--r ; Subsequent death by accident--L
22
BRITISH JOURNAL OF PLASTIC SURGERY
nique i n t r o d u c e d b y individual surgeons) so m u l t i p l y i n g the variables and m a k i n g overall conclusions o f less real value, T h e only significant variation o f p r o c e d u r e in this series is that over recent years p r i m a r y t e n d o n grafting has b e e n p e r f o r m e d m o r e frequently, b u t the actual t e c h n i q u e o f grafting has r e m a i n e d relatively constant, O f the i o o grafts followed u p ) t w e n t y five h a d p r i m a r y a n d seventy=five h a d s e c o n d a r y grafts, T h e distribution o f cases with respect to age, sex a n d digit involved is as s h o w n in Tables I) I I , and I I I and t h c periods o f foLlow-up are s h o w n in T a b l e IV, TABLE I
Secondary Grafts (75) Age
Thumb Index Middle Ring Little
0--I0
•
I 1--20
• .. ""
]
I 4
z
•
2I-30
""
7 (2)
i
.~,
4I-5 o
(i)
I
5 4 3 z (i)
z (I) I (i)
..
31-40
"~'(0
7 2 (i) 5 (i) 6 (~)
I
"I'(I)
51-6o+ (I) 2 I
4
(Figures in parentheses = Females)
TABLE II Primary Grafts (25) Age o-io
Thumb Index Middle Ring
. . ... .,. ...
Little
...
ii-2o
.
.
2i-3o
. . I 3 I
.
3 (i)
.
3I-4O
. . x .-I
.
3 (i)
.
4I-5O
. . ... I I
.
2
.
. . z ...
"'" (I)
... i
"2"(i)
TABLE I I I
(IO0 Grafts)
Digit Distribution
Thumb [ 4
Index
Middle
Ring
Little
24
I9
14
39
TABLE I V
Period of Follow-Up (Years) o--5
43
.
6-io
IX-15
16+
[
24
25
8
I
5I-6o+
.
I
AN EVALUATION OF FLEXOR TENDON GRAFTING
23
I. T H E OBJECTIVE A S S E S S M E N T A. Method o f Objective Assessment.--Since 195o when Boyes first suggested a method of recording function following a tendon graft, there has been much controversy concerning the best methods of record. The several limitations of recording only the
FIG. I Full extension of finger. Gross flexion contracture deformity.
FIG. 2 Full flexion. The finger tip touches the palmar crease but there is nointerphalangeal joint movement.
FIG. 3 The finger was serviceable to this housewife.
distance between the flexed finger tip and the distal palmar crease have been pointed out by several authors (White, I956 ; Peacock, I96I) viz.: (i) No note is taken of any fixed flexion deformity at the interphalangeal joints. Cases are seen with no active movement at either of these joints but because of considerable flexion deformity, the finger tip can be brought to, or near to, the distal palmar crease by flexion of the metacarpo-phalangeal joints alone--i.e, the finger tip reaches the palm by tenodesis effect. Such a case, though a complete technical failure, may or may not be valuable to the patient (Figs. I-3). (ii) No record is taken of finger length. As Peacock points out, a middle finger that flexes to within i in. of the distal palmar crease represents a better result than flexion of a 1/tile finger tip to within ½ in. from the distal palmar crease. The former case involves a much greater amplitude of tendon excursion. Thus we believe that it is more critical to record the full range of active movements at each interphalangeal joint and at the metacarpophalangeal joint, and to compare this
24
BRITISH JOURNAL OF PLASTIC SURGERY
with the normal range in the corresponding joint and digit of the opposite hand. It is important, too, that all joints are fully flexed during measurement of flexion, for if the interphalangeai joint ranges are recorded with the metacarpophalangeal joint incompletely flexed, a greater range of movement is often recorded, because the limited rendor. excursion can be expended at the interphalangeal joints. On the other hand, if the metacarpophalangeal joint is flexed, then less amplitude of tendon excursion is available at the interphalangeal joints before any peritendinous adhesions limit the movement range. This method of record also indicates any flexion and recurvatum deformity. In this series, the distance to which the finger tip can approach the distal palmar crease has also been measured in keeping with other surveys so as to allow comparisons (Fig. 4). The range of passive flexion is also recorded. There is one well-known trick movement patients commonly employ when the passive range of movement exceeds the active range---the repaired digit is wound into the palm by adjoining fingers, often simulating a perfect result. Though this is usually obvious in the case of the little finger, it may not always be noticed in the case of the other digits (Figs. 5-7). To simplify the analysis, results have been classified accordingly to the grouping used by White (Table V). Figures 8-13 illustrate cases which would be regarded as typical examples of an excellent result. TABLE V Grading of Results in Fingers Excellent Good Fair Poor
~2OO
> 18o > I50
< r50
~
O-IO I0-30
30-4 ° >40
The figurein the first columngivesthe total range of active flexion in the three finger joints. The second columngivesthe closestdistancein inches the fingertip reaches to the distal palmar crease. The third column figure is the summation of flexion contracture in the joints of the grafted finger. TABLE VI Grading of Results in Thumb Excellent i>7o% Good 6o-70% Fair 4o-60 % Poor < 40% The range of active flexionof the interphalangealjoint of the graftedthumb is calculatedas a percentageof the range in the normal thumb of the opposite hand. The only modification of White's chart is that in the excellent group a flexion contracture up to to degrees has been accepted. This is justifiable because it was found that some degree of flexion contracture is quite common in normal fingers varying from 5 to 20 degrees. In this series there were I7 such cases where some degree of flexion contracture also existed in the corresponding digit of the uninjured hand. Even this classification, however, is not entirely adequate for in comparing fingers with the same total order of flexion, it was noted that shorter fingers reach closer to the palmar crease than do longer fingers.
AN EVALUATION OF FLEXOR TENDON GRAFTING
25
METHOD OF RECORDING
J _ J
.~
EXTENDED DIP. 30 (flexion contracture) PIP. 30 ( )
//~
~..__,.~x'~//~X~X/\ FLEX ED /I ~/ / DIP. 45 ----~,.T.~---"~ 7 / PIP. 45 MCP, 80 / / TOTAL DEGREE DIP. 45-30=15 PIP, 45-30=15 MCP. 8 0 - 0 =80 =110 FIG. 4 Method of Recording.
FIG. 5 Full extension (Case 83). FIG. 6 Full flexion. T h e finger tip fails to touch the palmar crease by at least ½ inch (Case 83). FIG. 7 By winding the finger in with the adjoining ring finger full flexion is achieved giving the appearance of an excellent result. FIG. 8 Full extension of grafted index finger (secondary graft, Case 54). FIG. 9 Full flexion. An excellent result (Case 54).
26
B R I T I S H JOURNAL OF PLASTIC SURGERY
FIG. IO
Full extension--ring finger (secondary graft, Case 47). FIG. xI Full flexion. An excellent result (Case 47). Fm. i2 Full extension of little finger (primary graft, Case 57). FrG. I3 Full flexion. An excellent result (Case 57). FIG. I4 FuU extension of thumb (secondary graft, Case 58). FIG. I5 Full flexion. An excellent result (Case 58).
27
AN E V A L U A T I O N OF FLEXOR T E N D O N G R A F T I N G
To record results in the case of the thumb, White's classification has again been used as shown in Table VI and an example of an excellent result is shown in Figures 14 and 15. B. Results o f Objective A s s e s s m e n t . - - T h e various factors which are considered to influence the results are set out according to whether they pertain to the patient (general factors), or to the operative technique.
Z. G E N E R A L F A C T O R S ( T H E P A T I E N T ) Age.--In Table VII all the cases are arranged in order of age, each stroke representing an individual graft and the height of the stroke indicating whether the result was excellent, good, fair or poor. Whether a primary or secondary graft, and the preoperative state of the hand (ideal or non-ideal) is also shown. The arrows indicate division into three age-groups, 0-20 years, 21-35 years, and over 35 years. TABLE VII RESULTS
OF
I00
GRAFTS 1
PRIMARY IDEAL PRIMARY NON-IDEAL sEcoNDARY IDEAL SECONDARyNON-IDEAL
~
ilia! i:i"
i! :!iilli 1 ~ ~J
i
ii
W 67
55
50
45
40
35
!1t]
¢ 25
2O
is
iY2
(a) In the 0-20 years age-group aU secondary grafts in ideal cases (7) achieved an excellent result and of those secondary grafts performed in non-ideal cases (14) most achieved an excdlent (6) or good (7) result. For primary grafts in this group (9) there were three good and five fair results with one excellent result in an ideal case. There were no poor results in the entire group, and most of the fair results were primary grafts in non-ideal cases. These results concur with Wakefield's (1964) findings in a recent series of tendon grafts in children. (b) For the 21-35 years age-group, where a secondary graft was performed in an ideal case (I3), there were many good (3) and excellent (7) results. In the non-ideal secondary graft group (19) there were many poor results (14), one good result, the remainder fair (2) and amputated (I). For primary grafts in this age-group where the preoperative state was ideal (4) there was one excellent, two good and one poor result, and where the pre-operative state was non-ideal (4) there were, two fair and two poor results. The solitary excellent primary graft occurred in a little finger of a female hand of slender, pliable build and after a small clean-cut superficial wound with no contusional damage.
28
BRITISH JOURNAL OF PLASTIC SURGERY
(c) In the over-35 years age-group, secondary grafts in ideal cases (6) yielded a few excellent or good results, but secondary grafts in non-ideal cases and primary grafts resulted in fair (6) and poor (8) results, and one amputation, this outnumbering the excellent (4) and good (5)results. To summarise these findings, age seems to be the factor of paramount importance for all secondary grafts. The under-2o age-group demonstrated excellent or good results, but over the age of 20 other factors had added importance. Sex.--Though in females the results were superior to those in males (Table VIII), TABLE VIII Results in Males and Females Compared Excellent* I
Good
Fair
Poor
. .
i
Females (I6%) Males (84%)
5
i
6
I
I
4
22
'
I8
I7
I
27
f
* Hereafter in this paper the following abbreviations will be used in tables. E--Excellent ; G - - G o o d ; F - - F a i r ; P--Poor.
the series is too small to draw definite conclusions. The improved results in females can largely be explained on the basis of their hand physique, for of the 16 cases all but one was classified as of pliable build, which, as will be shown, seems a major factor in determining the objective result. D i a t h e s i s . - - I n all cases it was recorded whether the patient was of fair, medium or dark complexion (on the basis of skin pigmentation, eye and hair colour). Analysis of this information was unrevealing except that post-operative induration of tissues in the operated finger was more common among subjects of fair complexion. The long-term results, however, did not appear affected. Intelligence and C o - o p e r a t i o n o f the P a t l e n t . - - S o m e assessment of the patient's general intelligence was made from reactions at the interview, from the records and from emotional responses or adaptations to persisting disabilities. Here again, however, the series would seem too small to allow definite conclusions, but the impression was gained that the more intelligent patient was more likely to achieve a good result than the unintelligent or non-co-operative. Digit Involved.--Table IX indicates the results relating to the various fingers. TABLE IX Results in Individual Digits i
E
G
F
P
Thumb Index Middle Ring I Little
2 4 3 4 14
2 6 7 3 6
'" 7 2 3 6
7 (2 ~ p s . ) T 7 (2 ps.) 13 (I amp.)
It is difficult to generalise from these figures as the breakdown numbers are so few, and many variables are not taken into account. There is, however, a clear trend that the best results are demonstrative in the index and little fingers. When it is considered
AN EVALUATION OF FLEXOR TENDON GRAFTING
29
that the poor results in the index and little fingers were unduly loaded unfavourably by non-ideal cases in the over-35 years age-group--4 and 8 respectively--the impression is that the little finger is most likely to give an excellent result under ideal circumstances, then follow the index, ring and middle fingers in declining order of frequency. There are probably several reasons why the little finger should give better results than the other fingers. The amplitude of excursion of the profundus tendon during full flexion of interphalangeal joints of index, middle, ring and little finger is 4o, 45, 32 and 29 ram. respectively. Firstly, therefore, for a given amplitude of excursion in a graft, the little finger will flex to a greater degree than the other fingers. This is explained by the fact that the angulation effect is inversely proportional to the joint radius. The ioints of the little finger have the smallest radius and hence have the greatest angulation range. Secondly, the little finger is the shortest finger, so that for a given total angulation of all joints, the pulp of the little finger will reach nearer to the palmar crease. Thirdly, the little finger has the least complicated of flexor tendon arrangements. The sublimis tendon is usually a slender structure while the profundus is a bulky and strong tendon. Thus a tendon graft in the little finger gives the closer approximation to the normal anatomical arrangement. In the other digits where the sublimis, a strong tendon, is sacrificed, it is logical to assume that this must have a more deleterious effect on the strength and range of finger flexion. This, of course, does not apply where a graft is threaded through an intact sublimis system. On the contrary, the relatively poor results in the case of the middle finger can be explained by its length and the increased amplitude of excursion normally required of its profundus tendon. Hand P h y s i q u e . - - T h e affected hands were classified into three groups," pliable ", " t h i c k " and " m e d i u m ". This classification, which is to a certain extent arbitrary, was based on considerations of the ratio of finger breadth (measured transversely across the P.I.P. joint) to finger length, finger shape (tapered or spadelike), texture of the skin (loose and pliable or thick and horny) and the range of flexion in the joints.
TABLE X Hand Build
, /
Pliable
Medium
f
Thick
]
Excellent and Good Fair and Poor
26 8 (I amp.)
2o 25 (I amp.)
5 16 (3 amps.)
Pliable fingers were usually slender and tapering, the skin loose and elastic, and the average total range of flexion at the P.I.P. joints in this series was 18o degrees. In addition, such fingers were often moderately or markedly hyperextensile. On the contrary, fingers classified as thick were often stubby, the skin tough and horny and the total range of flexion at the I.P. joints averaged 15o degrees. Manual labourers commonly have such hands. The medium class had intermediate characteristics and the average range of flexion at both I.P. joints was x6o degrees. From consideration of Table X it is apparent that excellent or good results seldom occurred in the thick class of finger but were far more frequently seen with pliable fingers.
30
BRITISH JOURNAL OF PLASTIC SURGERY
The P r e - o p e r a t i v e State o f the H a n d . - - I n Table XI two groups are compared --those in which the pre-operative state was ideal and those in which it was non-ideal. TABLE XI
Influence of Pre-o mrative State of the Hand on Results Age
Ideal (37 cases)
Non-ideal (63 cases)
E G F P E G F P
.
36+
21-35
0-20
8
8
I
I I
5
4
2 2 (I an'lp.)
4 (I amp.)
6 9 5 ...
I
4
18 (2 amps.)
I
4 4 5 7 (I amp.)
An ideal pre-operative state was one in which the following conditions applied, viz. : (a) A tidy wound not involving the posterior sheath wall and with minimal contusional damage to soft tissue (Figs. 16 and 17).
Fla. 16
Posterior sheath damage--non-ideal.
(b) Where scarring was minimal, there was good passive joint function and an absence of trophic changes in the finger. (c) Not more than one digital nerve was damaged. (d) The palmaris longus tendon was available for grafting. On the contrary, a non-ideal case was one in which one or more of these conditions did not apply, i.e. there was extensive scarring, joint dysfunction, trophic changes or
31
AN E V A L U A T I O N OF FLEXOR T E N D O N G R A F T I N G
more than one digital nerve was damaged. Such adverse factors often followed untidy injuries. In order to eliminate one of the main variables, the appropriate tables are subdivided according to the age-groups. In the o-20 age-group a good or excellent result can be anticipated in most cases, but there are more excellent results in ideal cases. Over the age of 20 group, there is a marked difference in that ideal cases usually give good or excellent results, and nonideal cases give poor or only fair results. Extensive scarring was the most frequent factor conducive to poor results. The causes of scarring in order of frequency were untidy crushing or tearing injuries, infected primary repair operations and the fossicking for tendon ends at a primary operation by inexperienced personnel. In this series injuries caused by a circular saw or buzz saw were a frequent cause of non-ideal classification (13 cases). Such injuries resulted in ragged lacerations, often involving both digital nerves and penetrating the posterior sheath wall (13 cases). The result was almost invariably poor or only fair among the over 2o age-group. Even if expert primary wound repair is carried out in such injuries, and good primary healing occurs, the problem of the scarred posterior sheath region is always present. Table XlI shows the breakdown of factors which rendered the cases non-ideal, and Table X l I I indicates the causes of injuries in the series. TABLE XlI
Frequency of Adverse Pre-o ~erative Factors (63 Non-ideal Grafts) U
C
G
T
N
J
E G F P
3 7 8 18
5 3 4 II
I 4 8 9
... 5 I 5
2 3 ... 5
I 2 3 5
Totals
36
23
22
II
I0
I0
U ~ - - U n t i d y w o u n d ; C = C i c a t r i x ; G = P a l m a r i s graft n o t available ; T = T r o p h i c c h a n g e s ; N = M o r e t h a n o n e digital n e r v e d a m a g e d ; J = J o i n t d y s f u n c t i o n .
TABLE X l I I Cause of Injury in the Series Knife Glass Saw A n g l e iron, etc. Tin Axe T o o l - b o x lid Mower
27 25 13 8 6 4 3 3
Car accident Electric drill E n g i n e block Chain Brickwork Lathe Chisel Football
2 2 2 I I I I I
2. T E C H N I C A L FACTORS
The Time Interval between Primary and Secondary Repair.--From a study of Table XIV it appears that six to twelve weeks is a satisfactory time interval between primary repair and a secondary graft. There were several cases which had yielded good results six months or more after injury. Two common problems in cases of long
32
BRITISH JOURNAL OF P L A S T I C SURGERY TABLE X l V
T i m e Interval between Primary W o u n d Repair and Secondary T e n d o n Graft o-6 weeks
6-12 weeks
8
6
E G
.°.
12-21 weeks !
4 (I (i 4(3 (I
IO
4
21 weeks+
4 14
×6years)
× I year) ×x½years) x I year)
I (I × i½years)
delay before grafting were atrophy and stenosis of the sheath system with the profundus tendon retracted into the palm or an inaccessible proximal stump of the profundus tendon. Pulley M a n a g e m e n t . - - T h o s e cases in which the standard pulley arrangement could not be constructed usually had considerable weakness and limitation of flexion in the finger. These patients were generally ready to point out that if they pressed over the proximal segment of the finger, it flexed more efficiently. P r o x i m a l S t u m p Retraction and Choice o f M o t o r . m O n e of the problems of delayed secondary repair is tendon retraction, where the vinculae fail to anchor the profundus stump in the finger. This difficulty was met with increasing frequency in cases delayed over six weeks, and in four cases the tendon was retracted into an inaccessible situation over the wrist. The solution in three cases was use of the sublimis motor (above the wrist twice) and in the fourth case the ring finger sublimis was transferred. In all these cases a good or excellent result was achieved. This might indicate that the inadvisability of using a sublimis motor (as propounded by some surgeons) on theoretical considerations of its hmited tendon amplitude, might in practice be unfounded. Choice o f G r a f t . - - O n survey of Table XV and having due regard to the fact that most of the poor results using palmaris grafts occurred in non-ideal conditions or in TABLE XV Graft Used E
Palmaris with Paratenon
26
G 20
Palmaris without Paratenon Sublimis
Toe Extensor
F IO
P 22
I
I (I x L )
4 ( I XM) (z x R ) (2 x L)
3 (I × In)
(2 × R)
3 (2 x In) (I XL)
4
elderly patients, it would seem that the best prospects of an excellent result is when the palmaris with its paratenon is used. In no cases where the toe extensor was used as a graft was an excellent or good result achieved. There was no experience of the use of
AN EVALUATION OF FLEXOR TENDON GRAFTING
33
plantaris, which, according to White, is the most satisfactory replacement in the absence of palmaris. The presence of paratenon seems important. In this series one excellent result was achieved using the sublimis tendon of the little finger. This is a much thinner structure in the little finger and would be less liable to central necrosis. Finger Posture a n d Graft T e n s i o u . - - T h e posture of the finger after insertion of the graft is believed to have some bearing on the result, for where the graft was inserted in a relatively slack state, flexion contracture seemed unlikely to occur. For the same reason when poor tendon gliding ensued in these cases the finger was liable to protrude from the closed fist and create considerable disability. On the other hand, where the graft was inserted'under greater tension flexion contracture often occurred post-operatively. This was sometimes overcome by the use of a light elastic traction splint. Graft J u n c t i o n s . - - i n this series of cases the distal junction of the graft was to the profundus stump just distal to the interphalangeal joim, using a Bunnell-type stitch. However, on two occasions this junction disrupted and it is suspected that in some of the other poor results this may also have occurred at least in some degree. With any separation of this junction, flexion of the distal interphalangeal joint will be impaired. Tourniquet Time.--Prolonged periods of tourniquet application as is sometimes involved with multipIe grafts or other procedures seemed detrimental to the result. The results of multiple tendon grafts are shown in Table XVI but are insufficient in number to draw conclusions. TABLE X V I
Multiple Grafts Case No.
Age
Pre-op. State
No. of Grafts
I 2
35 33
NI I
3 2
32
NI NI NI NI NI NI
25 2I 20
18 i8
Primary or Objective Secondary Result P×3 G×I E×I F×2 P×2 Px2 Gx2 F×3 G×3
S S
S S P&S P P S
Subjective Result + + + ++ + + ++
TABLE X V I I Surgical Experience Years' Experience
E
3-5 6-io io+
6 io
G 7 5
F
I 4
I
P
5
Surgical E x p e r i e n c e . - - Fhere was conclusive evidence that the more experienced surgeons obtained superior results as shown in Table XVII. It is seen that where the
34
BRITISH JOURNAL OF PLASTIC SURGERY
surgeon had up to two years' experience, the fair and the poor results outweighed the excellent and good results, but where the experience exceeded two years, then the excellent and good results outweighed the fair and poor results. VARIATIONS IN TECHNIQUE
Preservation of S u b l i m i s . - - T h e r e were five cases in which the sublimis was undamaged and a palmaris was threaded through it to the palm. Of four secondary grafts in this way three achieved excellent results and one was fair. The one primary case gave a good result. There was no experience of resecting one slip of the sublimis in this series. Tendon Graft in a Baby aged I9 M o n t h s . - - T h i s case was reviewed at the age of 17, and an excellent result had been achieved, there being no flexion contracture and the finger flexed to within ½in. of the palmar crease. This case provides strong evidence that a graft grows in normal relation to other structures. Tendon Graft and Primary Direct R e p a i r in the Same H a n d . - - T h e r e was one interesting case in which both tendons of index and middle fingers were divided in the proximal finger segment in a girl aged 14 years. The condition for tendon grafting was non-ideal in that the lacerations were untidy and all digital nerves were divided. In the index finger the sublimis was resected and a careful primary repair of profundus performed. The middle finger had a secondary tendon graft two months later by the same surgeon. The tendon grafted finger achieved the superior result. COMPLICATIONS OF TENDON GRAFTING
Amputation.--The finger was amputated subsequent to a tendon graft on five occasions. This was usually necessitated in a working man where a failed tendon graft interfered with hand function and the patient was usually unwilling to undergo further operative procedures where a good result could not be guaranteed. One finger was amputated for painful scarring. All amputated fingers were secondary grafts, and the pre-operative state was non-ideal in three and ideal in two of them. Tenolysis.--Tenolysis was performed on five occasions with limited improvements in two cases. In general, in this series, patients who had grafts were encouraged to return to work at an early stage in their post-operative convalescence. Since most of the grafts were serviceable, few patients returned seeking further surgery. For this reason tenolysis was an uncommon procedure, though undoubtedly many of the cases might have benefited from such a procedure.
Impaired Sensation.--Occasionally there was some minor impairment of sensation in a finger in which no digital nerve damage had occurred at the time of the injury. This was never disabling. On these grounds it is concluded that the standard incisions used in this series for tendon exposure are not disabling. Recurvatum and Trigger Finger D e f c r m i t y . - - E l e v e n per cent. of cases had recurvatum (7 per cent.) and/or trigger disability (4 per cent.) at the proximal interphalangeal joint of the grafted finger and these all occurred in pliable or medium build fingers. It is thought that both these occurrences have a common aetiology, namely,
AN EVALUATION OF FLEXOR TENDON G R A F T I N G
35
lack of stabilising effect of sublimis on the proximal interphalangeal joint. Where any degree of flexion contracture occurred at the proximal interphalangeal joint the problem never arose. (It is for this reason that some surgeons advocate anchoring the slips of sublimis stump to the proximal phalanx in pliable fingers.) Quadrlga Effect.rain several instances a quadriga effect was demonstrated. This is due to a poorly gliding tendon in the grafted finger interfering with the excursion of the profundus tendon in adjoining fingers. This might also explain a not uncommon complaint of patients that fingers other than the grafted finger had a reduced power grasp though no apparent limitation of flexion.
Progressive Flexion Contracture.--There was one example in which the patient complained of progressive flexion contracture over a period of years. This was a singular occurrence. PRIMARY T E N D O N
GRAFTS
There were 25 cases of primary grafts and the results are set out in Table XVIII. The analysis suggests that other things being equal a primary graft does not give as good a result as a secondary graft. In the o-2o age-group all except one of the fair results were primary tendon grafts. The excellent results with primary grafting all TABLE XVIII Primary Grafts Age
o-zo -
21-35 36_ +___
Ideal ( I I cases)
Non-ideal (I4 cases)
2
4
I
2
I
2
2
occurred in ideal conditions, namely, a clean superficial cut, minimal contusional damage, no damage to the posterior sheath wall, no digital nerve damage and where a palmaris tendon was available for grafting. Figures I7-2o show an excellent result in which these conditions applied. However, primary tendon grafting is an attractive concept, and in our opinion the minor compromise of results with this procedure in certain cases is outweighed by certain definite advantages. Only one operation is required and this is of enormous value to the working man who avoids the loss of time between primary and secondary repair. Further, the operation of tendon grafting is technically easier to perform as a primary procedure for the exact length of tendon graft can be estimated against the length of profundus removed, there is no problem of secondary retraction of the proximal stump, the tissue planes are easier to delineate, and there is no problem of stenosis of the flexor sheath. On theoretical grounds in ideal cases the operation would at least be preferable to that of primary direct repair in the sheath. Of all the primary grafts performed, only
36
BRITISH JOURNAL OF PLASTIC SURGERY
FIG. x7 A tidy wound ideal for a primary graft (Case 94).
FIG. I8 Full extension of primary grafted little finger (Case 94).
FIG. I9 Full fiexion--metacarpophalangeal joint extended (Case 94).
FIG. 20 Full flexion--metacarpophalangeal ioint flexed. An excellent result (Case 94).
AN EVALUATION OF FLEXOR TENDON GRAFTING
37
one required tenolysis and there were no amputations. This is in contrast to Verdan~s results after primary repair, where 30 per cent. of cases required subsequent tenolysis, largely negating the advantages of primary repair. Thus we believe there is a definite place for primary grafting in ideal cases and in the young and elderly age-group, but it should be performed only with some trepidation in the skilled tradesman. This will be further discussed in Section 2 of this paper. SUMMARY OF OBJECTIVE ASSESSMENT AFTER FLEXOR TENDON GRAFTING
It was found that there were five important factors influencing the objective technical result. These were the age of the patient, the pre-operative state of the hand, the general hand physique, the tendon used as a graft and the experience of the surgeon. Age of the patient was of paramount importance. Under the age of 20 almost all secondary grafts give good or excellent results, but over the age of 20 the other four factors gain added importance in affecting the outcome. Good results can usually be expected in medium or pliable hands when the preoperative state of the hand is ideal, but are infrequent with thick fingers or with a nonideal pre-operative state of the hand. Primary grafts in general are inferior to secondary grafts except in the under-2o age-group. In the over-2o age-group where the hand physique is of pliable or medium build, where the skin wound is a clean superficial cut with minimal contusional damage and a palmaris graft used, the results almost approximate those of secondary grafts. II. T H E SUBJECTIVE A S S E S S M E N T In the past undue emphasis has been placed on the objective assessment of results after tendon graft operations ; each surgeon striving to make his series nearer perfection than the last. While this is a creditable attitude on the part of the surgeon, it is evident from the many papers written that until there is some fundamental advance in the zeproducing of tendon gliding, one can go only so far with perfection of technique. in the meantime, it might be more fruitful to investigate those factors determining the usefulness of a less than perfect resttlt, i.e. the subjective assessment.
Method of Subjective Assessment.--In this survey it was first enquired what disabilities, if any, existed in the affected finger. The emphasis was on information volunteered before any direct questioning to determine the predominant hand movements employed by the patient at his work. The relation of these particular hand functions to any disabilities complained of was then correlated. The general pattern of questioning is indicated thus : What was the occupation prior to the accident ? If different, was this related to the injury or the operation ? Was hand function modified in any way as a result of residual disability ? Was the occupation chiefly sedentary, supervisory or in manual work ? Was deficient hand function related to power grasp, thumb index pinch or fine precision function ? Where power grasp was affected it was important to establish the diameter of the tools employed. For instance, with poor flexion it might be possible to grip an axe or shovel handle quite firmly, but yet not be adequate to grasp a knife or golf stick. Did the hand tire with repetitive hand movements such as those encountered by process workers or on conveyor chains as in the case of slaughtermen ?
38
B R I T I S H J O U R N A L OF P L A S T I C SURGERY
Was the finger a nuisance or vulnerable to repeated injury from machinery because of'its protrusion or its catching on things ? Other complaints which require close questioning concerned decreased power in adjoining fingers, pain and sensory disturbances. Where associated injury of other deep structures existed, then assessment in relation to tendon dysfunction becomes much more difficult. Finally, an important question concerned economic hardship and whether or not this was related to a protracted treatment regime, especially where multiple operations were required. It was felt sometimes that a compromise in the patient's interest could have been reached earlier. In order to group the cases for analysis a system was used as shown in Table XIX. TABLE XIX Disability Rating N P a t i e n t r e g a r d e d t h e finger as n o r m a l m N o disability + M i n i m a l disability q- + M o d e r a t e disability + + + Severe disability M i n i m a l d i s a b i l i t y - - o c c a s i o n a l l y aware o f a defect ; m o d e r a t e d i s a b i l i t y - - f r e q u e n t l y aware o f a limitation ; severe d i s a b i l i t y - - f i n g e r n o t u s e d w i t h or witliout i m p a i r m e n t o f r e m a i n i n g h a n d function.
Results of Subjective Analysis.--Most good objective results from flexor tendon grafting are valuable, but not all fair and poor results were unserviceable. Table XX illustrates these findings. TABLE XX Overall Serviceability of ioo Grafts E +++ ++ ÷ N Totals
.
G .
.
.
.
.
F 2
I
Ii 3
9 (5 arnps) 3 r6 3 3I
It is seen that of the fair and poor results only I6 cases had moderate or severe disability (including 5 amputations), whereas 33 cases (two-thirds) had useful and valued fingers with only minimal disability. In 6 cases there was no subjective disability. Before further analysis, with regard to the common occupation groups, Table XXI is included to indicate the type and frequency of the various residual disabilities which patients in this series complained of. Group I. SedentaryOccupations.--This group consisted of domestics (Io), clerks (3), salesmen (3), school children (3), supervisors (z), typists (2), teacher (I), accountant (r), chemist (I) and a civil servant. From Table XXII it is seen that there were four poor or fair results and one case who complained of severe disability° This was a 49-year-old woman who had sustained
AN EVALUATION OF FLEXOR TENDON GRAFTING
39
a severely damaged digit with gross scarring of deep tissues. Following a tendon graft she persistently complained of severe pain in the scarred area and requested amputation. TABLE XXI Frequency of Various Disabilities L Power grasp impaired (a)" Weakness of grip (2z%) (b) Inability to close fist--including 4 amputations (x2 %) (c) Inability to close fist on narrow shafted tools (9%) (d) Tool slipping within grasp (5%) (e) Balance of grip disturbed--e.g, control of hammer (4%) u. Poor pinch grasp and fine manipulative movements 0 0 % ) 3. Finger catching on objects (r z % ) 4. Tiring of hand under pressure or repetitive work and fumbling (9% ~ 5. Finger getting in way and obstructing hand function (9%) 6. Pain--4ncluding one amputation (8%) 7. Liability to injury (5%) 8. Reduced flexibility offlae finger (5%) 9. Trigger effects (4%) Io. Impaired sensation--associated digital nerve damage (3%) n . Quadriga effect (x%) rz. Inability to straighten ( I % )
T~r~E XXII Sedentary Occupations (27) G
E
+++ ++
F
I
... ...
N Totals
!
P :[ (I amp.) .°°
4
i
5 iz
3
,.-
i6
7
2
,..
i
The main disabilities compained of were of minor nature, e.g. slipping of household utensils, fumbling or trigger effects. Group 2. Manual Labourers.--This group was made up of roadworkers (4), cooks and kitchen staff (4), drivers and carters (3), timber workers (3), farmers (3), railway workers (x), wharf labourers (I), meatlumpers (i) and a green-keeper. There was a considerable number of fair and poor results (I4), but, if any, the disabilities complained of were generally minimal. There were only three cases of TABLE XXIII
Manual Labourers E ++÷ ÷+
G
N
Totals
2 3 .
2
.
P
I
2
°..
x i .
F I
...... ......
+
(2I)
.
.
2
3
.
5
severe disability. There were four fair or poor objective results who did not volunteer any disability at all (Table XXlII).
4o
B R I T I S H J O U R N A L OF P L A S T I C SURGERY
This surprisingly small incidence of severe disability was explained by enquiry concerning occupation. In most of these cases the hands were used mainly for grasping wide shafts such as shovels, handles of carrying implements, axes and the like, in which a
FIG. 21 Full extension. T w o secondary grafts, ring and little f i n g e r - Residual flexion contracture (Case 45)-
FIG. 22 Full flexion--limited flexion b u t in a useful range for this t i m b e r worker, w h o had no disability
(Case 45).
complete range of flexion is not called for. Figures 2I-2 4 show examples of limited flexion but useful hands. Where disabilities did occur they were mainly weakness of power grasp, pain during heavy lifting and difficult grasping of narrow handles. TABLE X X I V
Semi-skilled Labourers (9) E +++ ++
G
F
. . . . . . . . . . . . . . . . . . . . .
+
I
N
I
Totals
2
2
2
P
I ...
... 3
2
2
Group 3. Semi-skilled Labourers.--This group included machinists (3), turbine attendants (2), process workers (I), assemblers (I), press operators (I), and a packer. The group was quite small, but among the fair and poor results (4), there was only one case with moderate disability (Table XXIV). The chief complaints were tiring of the hand with repetitive work and liability of the finger to catch on parts of machinery. One assembler had difficulty with manipulative function.
AN EVALUATION
OF F L E X O R
TENDON
GRAFTING
41
Group 4. Skilled Tradesmen.mThis group included mechanics (8), carpenters (6), butchers (6), linesmen (5), photographic technicians (3), glaziers (2), painters (2), fitters and turners (2), sheetmetal workers (I), welders (I), plumbers (I), maintenance engineers (I) and a builder.
FIG. 23
Full extension--secondary grafts middle, ring and little fingers. Some recurvation deformity (Case 84).
FIG. 24 L i m i t e d flexion but not a useful enough range for this linesman. Moderate disability (Case 84).
Among these'subjects there was a very high disability rate as shown in Table XXV. All except one of the fair and poor results (26) complained of disability with many of TABLE XXV Skilled Tradesmen (39) E + + + ++ + N
Totals
G
F
. . . . . _ ..3 --5 •-. I 4
i 2 5 ...
4
8
]
9
P 6 (4 2 9
amps)
I
18
them in the moderate and severe class. There were four amputations because the finger was such a hindrance. Even among the good results there was only one case without disability.
42
BRITISH
J O U R N A L OF P L A S T I C SURGERY
The chief complaint amongst butchers was an inadequate range of flexion to grasp a knife firmly and slipping within the grasp, but in those poor results where considerable flexion deformity existed, the disability was less because the range of flexion was in a more advantageous position of the finger (Figs. 25-27). Carpenters experienced the
Fx~. 25 Full extension. Primary grafts to middle, ring and little fingers. Considerable flexion contracture (Case 78).
FIG. 26 Full flexion. Limited flexion but a useful range for this butcher because the flexion contracture places the range of movement in a useful position (Case 78).
FIG. 27 A firm grasp on the butcher's knife was possible. No disability (Case
78).
same disabilities but to a lesser extent because the tools they used are generally of greater diameter, though picking up and holding of nails was often troublesome. The main concern among motor mechanics was reduced flexibility of the fingers and impaired thumb index pinch (Figs. 28-30) which embarrassed fine manipulation such as screwing on nuts and bolts. TABLE X X V I
Highly Skilled Tradesmen (4) E +++ ++ ÷ N
G
F
P
I I I I
Totals
Group 5. Highly Skilled Tradesmen.--There were only four in this group. A photographic engraver, a textile designer, a chicken sexer and a musician (Table XXVI). All demonstrated excellent objective results, except the musician where only a fair result was achieved in the index finger. The engraver regarded the little finger as
AN EVALUATION OF FLEXOR TENDON GRAFTING
43
normal and had no disability, the designer had no disability, the chicken sexer claimed moderate disability and the musician minimal disability (pianist).
SUMMARY OF SUBJECTIVE ASSESSMENT
Several deductions were made from this analysis. The skilled or semi-skilled worker is the most demanding of an excellent repair. It would appear then that in those cases where, after appraisal of the pre-operative factors, a poor or fair result is foreseen, special consideration should be given to the patient's occupation. It is important to know where the range of flexion would be most serviceable, whether in a relatively flexed or extended position. For the labourer who uses thick-shafted tools and implements, if a good result is not anticipated, some flexion contracture at the interphalangeal joints is likely to provide the most useful finger. For
FIGS. 28 tO 3° FIG. 23--Poor result of tendon graft in index finger. Considerable flexion contracture. FIG. 2 9 - - T h e flexion contracture allowed good thumb index pinch. Minimal disability. FIG. 3 o - - I n this case--a poor result with no flexion contracture and inefficient thumb index pinch. A severe disability.
the skilled tradesman this also applies, especially in the case of his ulnar digits where a tight grasp is essential to give firmness to the grip of narrow instruments--a knife, for example. However, since most of these people use the radial digits to a variable extent for pincer movements--picking up nails, screwing on bolts, etc., too much flexion contracture in these fingers would be a disadvantage. For sedentary workers too much flexion contracture of the radial digits is a handicap in typing and writing.
44
BRITISH JOURNAL OF PLASTIC SURGERY
This important consideration of the degree of flexion contracture can to some extent be controlled at operation by appropriate adjustment of the tension of the graft and of the position in which the finger is immobilised, i.e. its flexed or extended position in relation to that of adjoining digits.
EVALUATION OF FLEXOR T E N D O N G R A F T I N G It seems that the results of flexor tendon grafting, both objective and subjective can largely be forecast by a careful appraisal of various pre-operative factors. A. Under the age of 20 an excellcnt or good result is usual. B. In the 20-35 age-group there are three categories : (i) Firstly, those patients who have a pliable hand physique where the pre-operative state is ideal and where a palmaris graft is used. They can expect good results especially in the case of little or index fingers. (ii) Secondly, those patients who have thick and inflexible fingers in whom the pre-operative state is non-ideaL They usually achieve a poor result. (iii) The third group can be made up of various combinations of these factors and to forecast the outcome in these cases the surgeon will need to weigh the relative importance of favourable and adverse factors. Where the balance of factors suggests that poor tendon excursions will occur, then the patient's occupation must be taken into consideration if a serviceable result is to be achieved. This involves deciding in which position (relatively flexed or extended) of the finger a limited range of flexion will be most useful. Appropriate adjustments can be made at operation to ensure this. C. In the older age-group good results are less frequent but a useful finger can often result, relying on a normal range of active flexion at the metacarpophalangeal joint, if the interphalangeal joints are in a useful position. Even if no active interphalangeal movement occurs the graft may have a satisfactory tenodesing effect. Primary grafts have a place in the under-2o age-group, in labouring classes and in the older age-groups if only for reason of expediency. However, the overall results of secondary grafting are still superior to those of primary grafting and for that reason in the present sta~;eof knowledge and practice primary grafts should not be elected in skilled tradesmen where the highest standards of results are necessary.
Acknowledgement is made to members of the Plastic Surgery Unit of the Royal Melbourne Hospital (over the years I946-64) who performed the operations, especially to the surgeon in charge of this Unit, Mr B. K. Rank, who has been most helpful throughout this study and who kindly made available his private cases for interview. Acknowledgement is also made to the Victor Hurley Trust for awarding me a grant to undertake this project. REFERENCES BOYES, J. H. (I95o)..7. Bone fit Surg., 32A~ 489. PEACOCK,E. (I96I). Int. Abstr. Surg., rz3, 4~I. RANKs B. K.~ and W~EmELD, A. R. (r95I). Br. ft. plast. Surg.~ 4, 244° W/LKEFIELD,A. R. (I964). ft. :Bone J t Surg., 46A, !226. WHXTE, W. (!956). Am..7. Surg, 9x, 66~. A tgDle giving full details of each case wiU be included in the April issue of the ~ourn~o