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Atraumatic flexor tendon retrieval
MODERN
OPERATIVE
TECHNICS
Atraumatic Flexor Tendon Retrieval E. D. W. W.
The timing (that is, primary repair versus secondary repair) and method (repair versus graft) of reconstruction of divided flexor tendons in the hand is still a somewhat controversial subject. If primary repair is carried out, a minor but vexing problem is the recovery of the proximal tendon stump, which very often retracts into the palm when not held by the vincula. Approximately five years ago two of us (ESK and WPG) devised a useful and so far foolproof system for atraumatic and rapid recovery of this proximal tendon stump. Since it was first used, it has been a routine part of our surgical armamentarium and has been helpful in approximately fifty tendon repair cases. It is the purpose of this paper to outline the technic in the hope that others may find it helpful.
S. R. L. P.
KILGORE, Jr, MD, San Francisco, California ADAMS, MD, San Francisco, California NEWMEYER, MD, San Francisco, California GRAHAM, MD, Hershey, Pennsylvania
This allows a totally atraumatic passage to the palm wound where the tip of the catheter is withdrawn. The proximal tendon stump(s) is (are) withdrawn onto a sopping wet sponge imbued with normal saline solution and the tip(s) held with a 4-O atraumatic nylon suture. If two tendons have been divided, the sublimis is freed from the profundus, pulled down, divided, and allowed to retract proximally. The end of the profundus is tied end to end to the plastic catheter with the 4-O nylon suture. (Figure 1.) Catheter and suture are reintroduced into the palmar portion of the sheath and withdrawn into the finger while the sheath is distended with normal saline solution. If only the profundus
Technic
Once it is determined that the proximal profundus stump cannot be atraumatically presented and grasped at the site of tendon injury, a counter incision is made in the palm of the hand over the involved tendon sheath. This usually parallels the distal palmar crease and need be little more than one inch long. The sheath is then exposed and opened longitudinally without traumatizing the tendons within it. An appropriately sized sterile plastic catheter, such as an Intracathe or a small feeding tube (number 15 for adults, number 19 or smaller for children, cut to a convenient length) is then attached to a 20 cc syringe filled with normal saline solution. The tip of this catheter is then introduced through the distal wound into the tendon sheath and advanced proximally while distending the sheath with spurts of saline solution. From the Hand Service, Deuartment of General Surgery, University Of California School of Medicine, San Francisco, California. Reurint reauests mav be addressed to Dr Newmever. 450 Sutter Streei, Suite 2222, San kr’sncisco, California 94108. .
430
Figure 1. The catheter has been passed retrograde through the sheath and out the palmar counter incision. It is shown here sutured to the tendon and ready for reintroduction into the sheath and passage into the finger wound. The mldportion of the catheter can be seen exiting from the finger wound. It is very important to distend the sheath with normal saline solution while the tendon is passed.
The American
Journal of Surgery
Atraumatic Flexor Tendon
has been divided, the process is similar. The catheter will pass with equal ease with one or both tendons divided because of the distention of the sheath with saline solution under mild pressure. A little care must be exercised to avoid twisting the threaded tendon stump. The tendon repair proceeds in the normal fashion using 4-O nylon sutures mounted on fine cutting needles.* These are placed in a crisscrossing or
* Ethicon has developed for our service a superb 8 inch long, double armed tendon suture with P-8 needles.
Votume 122, September
1971
Retrieval
horizontal mattress fashion. Marginal interrupted 6-O nylon sutures (Ethicon single armed sutures with mounted P-l needles) are sometimes used as well. The tendon sheath is not touched with the needles. The palmar and distal wounds are closed and the hand is appropriately dressed and splinted. Summary
A method is presented for atraumatic tendonthreading along a flexor tendon sheath. This method has repeatedly proved itself, without fail, over the past five years.
431
OPERATIVE
TECHNICS
Atraumatic Flexor Tendon Retrieval E. D. W. W.
The timing (that is, primary repair versus secondary repair) and method (repair versus graft) of reconstruction of divided flexor tendons in the hand is still a somewhat controversial subject. If primary repair is carried out, a minor but vexing problem is the recovery of the proximal tendon stump, which very often retracts into the palm when not held by the vincula. Approximately five years ago two of us (ESK and WPG) devised a useful and so far foolproof system for atraumatic and rapid recovery of this proximal tendon stump. Since it was first used, it has been a routine part of our surgical armamentarium and has been helpful in approximately fifty tendon repair cases. It is the purpose of this paper to outline the technic in the hope that others may find it helpful.
S. R. L. P.
KILGORE, Jr, MD, San Francisco, California ADAMS, MD, San Francisco, California NEWMEYER, MD, San Francisco, California GRAHAM, MD, Hershey, Pennsylvania
This allows a totally atraumatic passage to the palm wound where the tip of the catheter is withdrawn. The proximal tendon stump(s) is (are) withdrawn onto a sopping wet sponge imbued with normal saline solution and the tip(s) held with a 4-O atraumatic nylon suture. If two tendons have been divided, the sublimis is freed from the profundus, pulled down, divided, and allowed to retract proximally. The end of the profundus is tied end to end to the plastic catheter with the 4-O nylon suture. (Figure 1.) Catheter and suture are reintroduced into the palmar portion of the sheath and withdrawn into the finger while the sheath is distended with normal saline solution. If only the profundus
Technic
Once it is determined that the proximal profundus stump cannot be atraumatically presented and grasped at the site of tendon injury, a counter incision is made in the palm of the hand over the involved tendon sheath. This usually parallels the distal palmar crease and need be little more than one inch long. The sheath is then exposed and opened longitudinally without traumatizing the tendons within it. An appropriately sized sterile plastic catheter, such as an Intracathe or a small feeding tube (number 15 for adults, number 19 or smaller for children, cut to a convenient length) is then attached to a 20 cc syringe filled with normal saline solution. The tip of this catheter is then introduced through the distal wound into the tendon sheath and advanced proximally while distending the sheath with spurts of saline solution. From the Hand Service, Deuartment of General Surgery, University Of California School of Medicine, San Francisco, California. Reurint reauests mav be addressed to Dr Newmever. 450 Sutter Streei, Suite 2222, San kr’sncisco, California 94108. .
430
Figure 1. The catheter has been passed retrograde through the sheath and out the palmar counter incision. It is shown here sutured to the tendon and ready for reintroduction into the sheath and passage into the finger wound. The mldportion of the catheter can be seen exiting from the finger wound. It is very important to distend the sheath with normal saline solution while the tendon is passed.
The American
Journal of Surgery
Atraumatic Flexor Tendon
has been divided, the process is similar. The catheter will pass with equal ease with one or both tendons divided because of the distention of the sheath with saline solution under mild pressure. A little care must be exercised to avoid twisting the threaded tendon stump. The tendon repair proceeds in the normal fashion using 4-O nylon sutures mounted on fine cutting needles.* These are placed in a crisscrossing or
* Ethicon has developed for our service a superb 8 inch long, double armed tendon suture with P-8 needles.
Votume 122, September
1971
Retrieval
horizontal mattress fashion. Marginal interrupted 6-O nylon sutures (Ethicon single armed sutures with mounted P-l needles) are sometimes used as well. The tendon sheath is not touched with the needles. The palmar and distal wounds are closed and the hand is appropriately dressed and splinted. Summary
A method is presented for atraumatic tendonthreading along a flexor tendon sheath. This method has repeatedly proved itself, without fail, over the past five years.
431