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Autogenous free sheath grafts in reconstruction of injured digital flexor tendon sheath at the delayed primary stage
AUTOGENOUS FREE SHEATH GRAFTS IN RECONSTRUCTION OF INJURED DIGITAL FLEXOR TENDON SHEATH AT THE DELAYED PRIMARY STAGE J. B. TANG, Q. G. ZHANG and S. ISHII From The Hand Surgery Unit, Department of Orthopedics, Ajiliated Hospital of Nantong Medical College, Jiangsu, China, and The Department of Orthopedic Surgery, Sapporo Medical College, Japan
We report our clinical experience of reconstruction of the digital flexor sheath with free autogenous sheath graft at the delayed primary stage. In 21 digits with flexor tendon lacerations, free autogenous sheath was taken from the sheath covering the first dorsal compartment to reconstruct the digital flexor sheath, where there was an obvious defect due to trauma, contusion of the syuovial surface or contracture of the digital sheath. Follow-up revealed excellent and good results in 85.7% of the cases. Ample gliding space should be kept inside the sheath tunnel to maintain tendon gliding
function. Journal of Hand Surgery
(British and European
Volume, 1993)
or contusion of the flexor sheath. Thickening and contracture were found in the sheath near the site of injury at the delayed primary stage. This was excised and the defect of the sheath was reshaped into an ellipse or a rectangle. The functionally important A2, A4 and palmar aponeurosis pulleys were preserved if possible. The tendon sheath over the first dorsal compartment in the dorsolateral aspect of the wrist is used as a donor, and this provides a large area of the synovial sheath without any effect on the function of extensor pollicis brevis and abductor pollicis longus. The size of the graft should be larger than the exact defect of the injured sheath. Care is taken not to injure the sensory branch of the radial nerve. The graft is placed in the defect with its synovial surface inside, using 7/O or 8/O nylon interrupted suture. Half the thickness of the volar subcutaneous tissue is resected before skin closure.
The significance of the synovial tendon sheath as a source of tendon nutrition has been clarified recently. The flexor tendon within its digital sheath is nourished mainly by synovial fluid, and tendon healing may be accomplished by its intrinsic capacity (Lundborg, 1976; Manske et al, 1978; Manske, 1988; Lundborg et al, 1985). Reconstruction of the injured sheath has therefore been proposed and attempted both experimentally and clinically (Eiken et al, 1975, 1978, 1980; Biro, 1980; Strauch et al, 1985; Kessler et al, 1986; Tang et al, 1989). The clinical use of autogenous free sheath graft at the delayed primary stage has not been reported before. On the basis of previous experimental studies (Tang et al, 1989 ; 1990a, and b), we have used this technique in 21 fingers with flexor tendon injuries. The technique and therapeutic results are reported and the indications are described. CLINICAL
MATERIALS POST-OPERATIVE
21 digits with flexor tendon lacerations in 17 cases were treated between May 1989 and July 1991 using autogen-
TREATMENT
The Kleinert rubber band traction device was used for 14 adult patients for about three weeks (Kleinert et al, 1973). Three childrens’ hands were rested in flexion for three weeks. Active finger flexion was then allowed, and active extension encouraged to overcome the extension deficit. Rehabilitation was continued for three months. In two digits, secondary tenolysis was performed four months after the initial surgery.
ous free sheath grafts. Ten patients were male and seven female, with ages ranging from four to 56 years, average 30.7 years. The injuries were caused by knives in eight patients, machines in six, and other causes in three. Injuries of one digital neurovascular bundle were found in five digits. There were no fractures. The fingers involved were index in nine, middle in seven, ring in two and little in three. The delayed primary repair was done between the second and the 14th days, mostly between the seventh and the 11th day after initial dkbridement and skin closure. One case was operated on after one month. OPERATIVE
18B: 31-32
RESULTS Follow-up was between five and 15 months. The flexion and extension deficit were measured at each visit and the last one was used for analysis. The functional results were evaluated by the total action movement (TAM) method postulated by ASSH. The TAM of the MP, PIP and DIP
TECHNIQUE
joints was calculated as the sum of active flexion at the three joints minus their extension lag (Kleinert and Verdan, 1983). Normal TAM is rated excellent, TAM
Under brachial plexus block, tourniquet control and magnification, the injured sheath was exposed by a volar zig-zag incision. These injuries involved some destruction 31
32
greater than 75% of the normal side good, TAM greater than 50% fair, TAM less than 50% poor and TAM worse than before surgery is graded worse. Among 21 fingers in 17 cases, seven fingers were rated excellent (33.3x)), 11 good(52.4x)andthreefair (14.3%). No tendon rupture occurred. DISCUSSION Experimental studies (Tang et al, 1989, 1990b) have shown that the free grafted tendon sheath can survive well, and that it provides a smooth gliding surface for the repaired tendon, preventing the ingrowth of adhesions. After four weeks, the grafted sheath possesses similar properties to normal sheath, confirming Eiken’s preliminary experimental work using chickens (1975 and 1980). At delayed primary repair, the direct suture of the injured sheath may impair tendon gliding, and replacement with fresh autogenous graft produces better functional outcomes than direct suture (Tang et al, 1990a). The technique of tendon sheath grafting is indicated when there is an obvious defect due to severe trauma to the sheath, in which case direct suture of the sheath is impossible. When there are obvious contusions on the synovial surface or contracture of the sheath, replacement with an autograft is also justified. In the above circumstances, the graft should be larger than the real size of the defect. When both superficial and deep flexor tendons have been repaired, swelling of the tendons may constrict the gliding space, and interposition of a patch of elliptical autogenous sheath between the cut ends of the injured sheath may provide enlarged space for the tendons to glide in. The graft should be handled atraumatically and magnification is advisable. Excision of volar subcutaneous tissue is important to avoid narrowing due to compression of the sutured skin. Furthermore, resection of a portion of subcutaneous tissue converts space originally occupied by subcutaneous tissue into inner sheath gliding space. As a result of this and the fact that the graft is larger than the real size of defect, the gliding
THE
JOURNAL
OF HAND
SURGERY
VOL.
18B No. 1 FEBRUARY
1993
function may be improved even under the same amount of adhesions. References BIRO, V. V. (1980). Experimentelle sehnenscheidenbildung aus einer vene. Handchirurgie. 12: 193-195. EIKEN, O., LUNDBORG, G. and RANK, F. (1975). The role of the digital synovial sheath in tendon grafting: An experimental and clinical study on autologous tendon grafting in the digit. Scandinavian Journal of Plastic and Reconstructive Surgery, 9: 3: 182-189. EIKEN, O., HAGBERG, L. and RANK,, F. (1978). The healing process of transplanted digital tendon sheath synovium: Experimental autoradiographicstudiesinchickens.Scandinavian JoumalofPlasticandReconstructive Surgery, 12: 3: 225-229. EIKEN, O., HOLMBERG, .I., EKEROT, L. and SALGEBACK, S. (1980). Restoration of the digital tendon sheath: A new concept of tendon grafting. Scandinavian Journal of Plastic and Reconstructive Surgery, 14: 1: 89-97. KESSLER, F. B., EPSTEIN, M. J., LANNIK, D., MAHER, D. and PAPPU, S. (1986). Fascia patch graft for a digital flexor sheath defect over primary tendon repair in the chicken. Journal of Hand Surgery, 11A: 2: 241-245. KLEINERT, H. E., KUTZ, J. E., ASTASOY, E. and STORMO, A. (1973). Primary repair of flexor tendons. Orthopedic Clinics of North America, 4: 865-876. KLEINERT, J. E. and VERDAN, C. (1983). Report ofthe committeeon tendon injures. Journal of Hand Surgery. 8 : 5 : 794798. LUNDBORG, G. (1976). Experimental flexor tendon healing without adhesion formation-a new concept of tendon nutrition and intrinsic healing mechanisms: A preliminary report. The Hand, 8: 3: 2355238. LUNDBORG, G., RANK, F. and HEINAU, B. (1985). Intrinsictendon healing: A new experimental model. Scandinavian Joumalof Plastic and Reconstructivesurgery. 19: 2: 113-117. MANSKE, P. R., BRIDWELL, K. and LESKER, P. A. (1978). Nutrient pathways to flexor tendons of chickens using tritiated proline. Journal of Hand Surgery, 3: 4: 352-357. MANSKE, P. R. (1988). Flexor tendon healing. Journal of Hand Surgery, 13B: 3 : 237-245. STRAUCH, B., DE MOURA, W., FERDER, M., HALL, C., SAGI, A. and GREENSTEIN, B. (1985). The fate of tendon healing after restoration of the integrity of the tendon sheath with autogenous vein grafts. Journal of Hand Surgery, 10A: 6: 190-795. TANG, J. B., ISHII, S., USUI, M., AOKI, M. and MASUDA, K. (1989). An experimental study of free tendon sheath graft for flexor tendon injuries. Journal of the Japanese Society for Surgery of The Hand. 6: 3 : 485-489. TANG, J. B., ISHII, S. and USUI, M. (199Oa). Surgical management of the tendon sheath at different repair stages. Chinese Medical Journal, 103: 4: 295-303. TANG, J. B., ISHII, S. and USUI, M. (1990b). Surviving processes of free grafted tendon sheath. Chinese Journal of Surgery, 28 : 8 : 473475.
Accepted: 21 February 1992 Jin-ba Tang, MD, Department of Orthopedic Surgery, Sapporo Medical 16 Chuoku, Sapporo, 060 Japan. 0 1993 The British Society for Surgery of the Hand
College,
South 1 West
We report our clinical experience of reconstruction of the digital flexor sheath with free autogenous sheath graft at the delayed primary stage. In 21 digits with flexor tendon lacerations, free autogenous sheath was taken from the sheath covering the first dorsal compartment to reconstruct the digital flexor sheath, where there was an obvious defect due to trauma, contusion of the syuovial surface or contracture of the digital sheath. Follow-up revealed excellent and good results in 85.7% of the cases. Ample gliding space should be kept inside the sheath tunnel to maintain tendon gliding
function. Journal of Hand Surgery
(British and European
Volume, 1993)
or contusion of the flexor sheath. Thickening and contracture were found in the sheath near the site of injury at the delayed primary stage. This was excised and the defect of the sheath was reshaped into an ellipse or a rectangle. The functionally important A2, A4 and palmar aponeurosis pulleys were preserved if possible. The tendon sheath over the first dorsal compartment in the dorsolateral aspect of the wrist is used as a donor, and this provides a large area of the synovial sheath without any effect on the function of extensor pollicis brevis and abductor pollicis longus. The size of the graft should be larger than the exact defect of the injured sheath. Care is taken not to injure the sensory branch of the radial nerve. The graft is placed in the defect with its synovial surface inside, using 7/O or 8/O nylon interrupted suture. Half the thickness of the volar subcutaneous tissue is resected before skin closure.
The significance of the synovial tendon sheath as a source of tendon nutrition has been clarified recently. The flexor tendon within its digital sheath is nourished mainly by synovial fluid, and tendon healing may be accomplished by its intrinsic capacity (Lundborg, 1976; Manske et al, 1978; Manske, 1988; Lundborg et al, 1985). Reconstruction of the injured sheath has therefore been proposed and attempted both experimentally and clinically (Eiken et al, 1975, 1978, 1980; Biro, 1980; Strauch et al, 1985; Kessler et al, 1986; Tang et al, 1989). The clinical use of autogenous free sheath graft at the delayed primary stage has not been reported before. On the basis of previous experimental studies (Tang et al, 1989 ; 1990a, and b), we have used this technique in 21 fingers with flexor tendon injuries. The technique and therapeutic results are reported and the indications are described. CLINICAL
MATERIALS POST-OPERATIVE
21 digits with flexor tendon lacerations in 17 cases were treated between May 1989 and July 1991 using autogen-
TREATMENT
The Kleinert rubber band traction device was used for 14 adult patients for about three weeks (Kleinert et al, 1973). Three childrens’ hands were rested in flexion for three weeks. Active finger flexion was then allowed, and active extension encouraged to overcome the extension deficit. Rehabilitation was continued for three months. In two digits, secondary tenolysis was performed four months after the initial surgery.
ous free sheath grafts. Ten patients were male and seven female, with ages ranging from four to 56 years, average 30.7 years. The injuries were caused by knives in eight patients, machines in six, and other causes in three. Injuries of one digital neurovascular bundle were found in five digits. There were no fractures. The fingers involved were index in nine, middle in seven, ring in two and little in three. The delayed primary repair was done between the second and the 14th days, mostly between the seventh and the 11th day after initial dkbridement and skin closure. One case was operated on after one month. OPERATIVE
18B: 31-32
RESULTS Follow-up was between five and 15 months. The flexion and extension deficit were measured at each visit and the last one was used for analysis. The functional results were evaluated by the total action movement (TAM) method postulated by ASSH. The TAM of the MP, PIP and DIP
TECHNIQUE
joints was calculated as the sum of active flexion at the three joints minus their extension lag (Kleinert and Verdan, 1983). Normal TAM is rated excellent, TAM
Under brachial plexus block, tourniquet control and magnification, the injured sheath was exposed by a volar zig-zag incision. These injuries involved some destruction 31
32
greater than 75% of the normal side good, TAM greater than 50% fair, TAM less than 50% poor and TAM worse than before surgery is graded worse. Among 21 fingers in 17 cases, seven fingers were rated excellent (33.3x)), 11 good(52.4x)andthreefair (14.3%). No tendon rupture occurred. DISCUSSION Experimental studies (Tang et al, 1989, 1990b) have shown that the free grafted tendon sheath can survive well, and that it provides a smooth gliding surface for the repaired tendon, preventing the ingrowth of adhesions. After four weeks, the grafted sheath possesses similar properties to normal sheath, confirming Eiken’s preliminary experimental work using chickens (1975 and 1980). At delayed primary repair, the direct suture of the injured sheath may impair tendon gliding, and replacement with fresh autogenous graft produces better functional outcomes than direct suture (Tang et al, 1990a). The technique of tendon sheath grafting is indicated when there is an obvious defect due to severe trauma to the sheath, in which case direct suture of the sheath is impossible. When there are obvious contusions on the synovial surface or contracture of the sheath, replacement with an autograft is also justified. In the above circumstances, the graft should be larger than the real size of the defect. When both superficial and deep flexor tendons have been repaired, swelling of the tendons may constrict the gliding space, and interposition of a patch of elliptical autogenous sheath between the cut ends of the injured sheath may provide enlarged space for the tendons to glide in. The graft should be handled atraumatically and magnification is advisable. Excision of volar subcutaneous tissue is important to avoid narrowing due to compression of the sutured skin. Furthermore, resection of a portion of subcutaneous tissue converts space originally occupied by subcutaneous tissue into inner sheath gliding space. As a result of this and the fact that the graft is larger than the real size of defect, the gliding
THE
JOURNAL
OF HAND
SURGERY
VOL.
18B No. 1 FEBRUARY
1993
function may be improved even under the same amount of adhesions. References BIRO, V. V. (1980). Experimentelle sehnenscheidenbildung aus einer vene. Handchirurgie. 12: 193-195. EIKEN, O., LUNDBORG, G. and RANK, F. (1975). The role of the digital synovial sheath in tendon grafting: An experimental and clinical study on autologous tendon grafting in the digit. Scandinavian Journal of Plastic and Reconstructive Surgery, 9: 3: 182-189. EIKEN, O., HAGBERG, L. and RANK,, F. (1978). The healing process of transplanted digital tendon sheath synovium: Experimental autoradiographicstudiesinchickens.Scandinavian JoumalofPlasticandReconstructive Surgery, 12: 3: 225-229. EIKEN, O., HOLMBERG, .I., EKEROT, L. and SALGEBACK, S. (1980). Restoration of the digital tendon sheath: A new concept of tendon grafting. Scandinavian Journal of Plastic and Reconstructive Surgery, 14: 1: 89-97. KESSLER, F. B., EPSTEIN, M. J., LANNIK, D., MAHER, D. and PAPPU, S. (1986). Fascia patch graft for a digital flexor sheath defect over primary tendon repair in the chicken. Journal of Hand Surgery, 11A: 2: 241-245. KLEINERT, H. E., KUTZ, J. E., ASTASOY, E. and STORMO, A. (1973). Primary repair of flexor tendons. Orthopedic Clinics of North America, 4: 865-876. KLEINERT, J. E. and VERDAN, C. (1983). Report ofthe committeeon tendon injures. Journal of Hand Surgery. 8 : 5 : 794798. LUNDBORG, G. (1976). Experimental flexor tendon healing without adhesion formation-a new concept of tendon nutrition and intrinsic healing mechanisms: A preliminary report. The Hand, 8: 3: 2355238. LUNDBORG, G., RANK, F. and HEINAU, B. (1985). Intrinsictendon healing: A new experimental model. Scandinavian Joumalof Plastic and Reconstructivesurgery. 19: 2: 113-117. MANSKE, P. R., BRIDWELL, K. and LESKER, P. A. (1978). Nutrient pathways to flexor tendons of chickens using tritiated proline. Journal of Hand Surgery, 3: 4: 352-357. MANSKE, P. R. (1988). Flexor tendon healing. Journal of Hand Surgery, 13B: 3 : 237-245. STRAUCH, B., DE MOURA, W., FERDER, M., HALL, C., SAGI, A. and GREENSTEIN, B. (1985). The fate of tendon healing after restoration of the integrity of the tendon sheath with autogenous vein grafts. Journal of Hand Surgery, 10A: 6: 190-795. TANG, J. B., ISHII, S., USUI, M., AOKI, M. and MASUDA, K. (1989). An experimental study of free tendon sheath graft for flexor tendon injuries. Journal of the Japanese Society for Surgery of The Hand. 6: 3 : 485-489. TANG, J. B., ISHII, S. and USUI, M. (199Oa). Surgical management of the tendon sheath at different repair stages. Chinese Medical Journal, 103: 4: 295-303. TANG, J. B., ISHII, S. and USUI, M. (1990b). Surviving processes of free grafted tendon sheath. Chinese Journal of Surgery, 28 : 8 : 473475.
Accepted: 21 February 1992 Jin-ba Tang, MD, Department of Orthopedic Surgery, Sapporo Medical 16 Chuoku, Sapporo, 060 Japan. 0 1993 The British Society for Surgery of the Hand
College,
South 1 West