Delayed flexor tendon repair in the digital sheath with end-to-end suture and fascial graft

Delayed flexor tendon repair in the digital sheath with end-to-end suture and fascial graft

Delayed Flexor Tendon Repair--K. Suzuki DELAYED FLEXOR TENDON REPAIR IN THE DIGITAL SHEATH WITH END'TO-END SUTURE A N D FASCIAL G R A F T K A T S U M...

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Delayed Flexor Tendon Repair--K. Suzuki

DELAYED FLEXOR TENDON REPAIR IN THE DIGITAL SHEATH WITH END'TO-END SUTURE A N D FASCIAL G R A F T K A T S U M I SUZUKI, Kawasaki, Japan SUMMARY The results of treatment of nine divided tendons in scarred fingers by secondary suture and reconstruction of a new sheath by faucial graft is reported and discussed. INTRODUCTION Generally, in this clinic, a divided flexor tendon in the digital sheath of the hand has been repaired by conventional free tendon grafting as reported by Bunnell. In order to get better results, many different procedures have been tried, such as wrapping the repaired tendon with a "millipore microweb membrane" (Sato 1962), making a new sheath by using silicone rod (Sato, 1962; Gaisford, 1969; Hunter 1969 and 1971), and grafting composite tissue (Peacock 1960, Chacha 1974). Since 1972, in a limited number of cases where the fingers were graded as "scar" by Boyes' classification (Boyes 1971) following incorrect initial treatment and less than one centimetre resection of the tendon was necessary, the freshened ends of divided tendons were sutured by a buried 3-0 nylon stitch and the sutured tendon was wrapped in a grafted sheet of forearm fascia. As a rule, the tendon of flexor digitorum superflcialis was resected. TECHNIQUE In the finger, a volar zigzag incision is made. If the digital sheath is intact, a minimum is resected to allow a free complete range of gliding of the sutured tendon. When both ends of the divided tendon of the flexor digitorum profundus can be approached easily, the freshened ends are repaired by buried 3-0 nylon suture. Then a curved incision is made on the volar surface of the forearm. After the subcutaneous fatty tissue has been cleared, a suitable rectangular area of superficial fascia is resected for use as a graft. Then, the sutured tendon is wrapped loosely with the fascial sheet as shown in Fig. 1. In one case, the divided tendon of the flexor digitorum superficialis was also sutured in the same way. In order to prevent adhesion between the two flexor tendons, a grafted fascial sheet was wrapped around both tendons and loosely fixed by suture to the digital sheath as shown in Fig. 2. After dressing, the finger is maintained in a plaster cast for four weeks, with moderate flexion at the wrist, and slight flexion at the metacarpophalangeal and the interphalangeal joints. RESULTS In eight patients, tendons have been repaired by this method since 1972. A summary of the cases is listed in Table 1. K. Suzuki, M.D., Kanto Rosai Hospital, Nakaharaku, Kawasaki City, Kanagawa, Japan. The Hand--Vol, 8

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Fig. 1. Diagram of the technique. Fig. 2. Arrangement of the grafted fascial sheet around both tendons. TABLE 1 Case

Age & Sex

Finger Cause of Injury

Period from Period lniury of Followup

Site o[ Site oJ Loss Loss of Deject of Bow Stri. of Extension Pulley Flexion (White) (Boyes)

PIPJ 5.2Cm 32° PIPJ 0 0 None 0 0 None 5.6Cm 71 ° MPJ 5.0Cm 52° & PIPJ 6. 3 M. R.L. Glass 98 days 23m. None None 0.4Cm. 0 7. 6 M. L.L. Glass 1716 days 13m. None None 1.8Cm. 5° 8. 2 M. L.M. Glass 95 days 3m. None None 3.0Cm. 0 Notes: Case 3, FDS also sutured. Cases 4, 5, and 7 were Multiple Finger Injuries. 1. 2. 3. 4. 5.

39 21 4 39 25

M. M. M. F. M.

L.I. R.I. L.R. L.M. R.M.

Iron block Iron door Glass Rotat. saw Iron door

21 81 17 71 21

days days days days days

17m. 9m. 9m. 9m. 8m.

Mid.Phal. Mid.Phal. Metacarp. Metacarp. None

Seven patients were male and one female. Tendon ruptures of multiple fingers were found in three patients. In these patients, only one finger was repaired by this method. The age varied from two to thirty-nine years. Results in children were better than adults. All cases had "scar" from incorrect initial treatment in the other clinics. The period of follow-up ranged from three to twenty-three months (average eleven months). Results were evaluated by assessing bow stringing, loss of flexion (distance of pulp from distal palmar crease) and loss of extension (sum of angular defect of proximal and distal interphalangeal joints in active extension) as shown in Table 1 (Suzuki, 1971). Good recovery was attained in four patients. The best results were gained in children. Three patients with tendon division in multiple fingers showed the worst results. The child (Case 3) with divided tendons of both flexor digitorum profundus and flexor digitorum superficialis sutured by this method, attained good recovery of function as shown in Figs. 3, 4 and 5. The result in Case 5 is shown in Figs. 6, 7 and 8. 142

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Fig. 3. Case 3 attempting flexion before operation. Fig. 4. Case 3. Flexion after operation. Fig. 5. Case 3. Extension after operation.

Fig. 6. Pre-operative photograph of case 5. Fig. 7. Flexion of case 5 eight months after operation. Fig. 8. Extension of case 5 eight months after operation. DISCUSSION

In order to provide the divided flexor tendon with a soft and healthy bed, the author has also tried silicone rod; "millipore microweb m e m b r a n e " for enveloping sutured tendons; pedicle skin flap prior to tendon grafting; and recently suture of the divided tendon (end to end) with a buried nylon stitch and with a grafted fascial sheet around. With delayed reconstruction of divided flexor tendons in the digital sheath under conditions less than o p t i m u m for conventional tendon grafting, the described method will be recommended. Especially, this method will be useful in cases where (1) the fingers are graded as " s e a r " of Boyes' classification f r o m incorrect initial treatment, (2) less than one centimetre resection of the tendon is necessary, (3) the patient has tendon division in multiple fingers, and (4) the patient is younger. The Hand--Vol. 8

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Delayed Flexor Tendon Repair--K. Suzuki REFERENCES

BOYES, J. H. and STARK, H. H. (1971) Flexor-Tendon Grafts in the Fingers and Thumb; A Study of Factors Influencing Results in 1000 Cases. Journal of Bone and Joint Surgery, 53-A: 1332-1342. CHACHA, P. (1974) Free Autologous Composite Tendon Grafts for Division of Both Flexor Tendons within the Digital Theca of the Hand. Journal of Bone and Joint Surgery, 56-A: 960-978. GAISFORD, J. C., HANNA, D. C., and RICHARDSON, G. S. (1969) Tendon Grafting: Silicone Rod Technique. Journal of Bone and Joint Surgery, 51-A: 789-790. HUNTER, J. M., SALEM, A. W., STEINDEL, C. R., and SALISBURY, R. E. (1969) The Use of Gliding Artificial Tendon Implants to Form New Tendon Beds. Journal of Bone and Joint Surgery, 51-A: 790. HUNTER, J. M., and SALISBURY, R. E. (1971) Flexor-Tendon Reconstruction in Severely Damaged Hands; A Two-Stage Procedure Using a Silicone-Dacron Reinforced Gliding Prosthesis Prior to Tendon Grafting. Journal of Bone and Joint Surgery, 53-A: 829-858. PEACOCK, E. E., Jr. (1960) Homologous Composite Tissue Grafts Of The Digital Flexor Mechanism In Human Beings. Plastic and Reconstructive Surgery, 25: 418421. SUZUKI, K. (1971) Flexor Tendon Injury of the Hand; Reconstructive Surgery and Evaluation. Journal of Japanese Orthopaedic Association, 45: 651-662. SATO, K., SUZUKI, K., SHIRASU, T., YAMAUCHI, Y., LI, K., NANJO, B., SUGIURA, Y. and ABE, S. (1962) Autologous Tendon Graft and Its Surrounding Tissue. Orthopaedic Surgery, 13: 1017-1018.

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