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Early active motion following a beveled technique of flexor tendon repair: Report on fifty cases
Early active motion following a beveled technique of flexor tendon repair: Report on fifty cases In an effort to overcome restrictive adhesions following flexor tendon repair, a technique involving beveling of the tendon ends and fin e compressive suturing was used in 50 patients (110 tendons) . Free early active motion was allowed. There were 70% good-to-excellent results, with a 10% rupture rate.
Hilton Becker, F.R.C.S., Fetti Orak, M.D., and Erik Duponselle, M.D., Johannesburg, S. Africa
Full function is not often achieved following flexor tendon repair within the fibro-osseous canal. Restrictive adhesions appear to be the main limiting factor. The studies of Furlow! and others 2 - 4 suggest that early active motion may favorably influence tendon healing and may permit gliding, provided that rupture and gap formation do not occur. We previously reported on investigations on cadavers and baboons utilizing a bevel technique of tendon From the Department of Plastic and Reconstructive Surgery, University of the Witwatersrand, Johannesburg, S. Africa. Supported by the University Councils Faculty of Medicine Research Grant and the Medical Faculty Research Endowment Fund Grant. Received for publication Nov. 15 , 1978. Revised for publication April 9, 1979. Reprint requests: Hilton Becker, F.R.C.S., Division of Plastic and Reconstructive Surgery, Medical College of Virginia, MCV Station, Box 154, Richmond, VA 23298 (804-786-9318).
repair which had greater tensile strength and less gap formation, and which, when placed under tension, showed less strangulation of tendon ends, than standard techniques . 5 We have now used this technique of tendon suture combined with early active motion on 50 patients (110 tendons).
Method Under a tourniquet the tendon sheath is exposed through a Bruner incision. A flap of sheath is raised to expose the tendons, preserving pulleys where possible. Both flexor tendons are always repaired. With the aid of magnification (four times), the cut tendon ends are beveled on reciprocal surfaces for approximately 0.75 cm, carefully preserving the vincula. A fine-toothed forceps is used to grasp the tendon while curved Iris scissors is used to bevel the desired amount of tissue (Fig. 1). The two beveled tendon ends are than
Fig. 1. Method of beveling tendon ends. The fine-toothed forceps are used to grasp the tendon and an Iris scissors is used to cut the bevel. 454
THE JOURNAL OF HAND SURGERY
0363-5023179/040454+07$00.7010 © 1979 American Society for Surgery of the Hand
Vol. 4, No . 5 September, 1979
Beveled technique of flexor tendon repair
t
(
...... _........-......-....'..."_' _ .. i ;;;:i ':tT#ii ""... iiI ·
. . ..
.._~~' t' !'
' ' ' "'--'®
'_H:~~~~C~ . "_ @
Fig. 2. Diagramatic representation of suture method . A, Cut tendon ends. B, Tendon ends beveled reciprocally for 0.75 cm . C, Tendon "flaps" overlapped and secured with three placing sutures on each side . D, Reinforcing lateral running suture (suture material No. 6-0 or 7-0 Prolene).
Fig. 2, cont'd. E, Healing tendon at 2 weeks (no pseudotendon); note the new vessel formation.
455
456
The Journal of HAND SURGERY
Becker, Orak, Duponselle
Fig. 3. A, A 26-year-old man sustained an extensive injury to the right index finger, severing both flexor tendons, digital nerves and fracturing the neck of the proximal phalanx. B, A roentgenogram showing fracture . C, Flexion at 1 week following repair. D, Extension at 1 week following repair.
Table I. Criteria for grading results* Results Excellent Good Fair
Poor
Flexion Less than I cm to distal palmar crease Able to touch palm Unable to touch the palm, but less than 3 cm from the distal palmar crease Worse than above criteria or rupture
Table II. Results in fifty patients Extension
Less than 15° lack of extension 15° to 30° lack of extension More than 30° but less than 50° lack of extension
·From Lister GD, Kleinert HE. Kutz JE. Atasoy E: Primary flexor tendon repair followed by immediate controlled mobilization. J HAND SURG 2:441-51 , 1'TT7.
overlapped and held in position by three sutures of No. 6-0 or 7-0 Prolene. These stay sutures are placed laterally on each side of the bevel, thus compressing the flaps (Fig. 2) . A reinforcing running suture is woven along the edges of the bevel, starting a few millimeters proximal to the overlapping tendon ends, and extending
Results
I
No.
Excellent Good Fair Poor (rupture)
%
27 8 IO
5
a few millimeters distally. When tension is applied, longitudinal forces are thus converted into horizontal compressive forces. 5 The sheath is sutured loosely to the surrounding tissue, and the skin is closed using No. 5-0 nylon mattress sutures. The hand is dressed in a fluffed gauze dressing and protected with a dorsal slab in neutral position (wrist at 0°) . Postoperative management On the first day after operation , the dressing is removed from the nonincised portion of the fingers, and gentle active movements of the distal interphalangeal
Vol. 4, No.5
Beveled technique of flexor tendon repair
September, 1979
457
Fig. 3, cont'd. E, Flexion at 3 weeks following repair. F, Extension at 3 weeks following repair. G, Profundus action at 3 weeks following repair.
Table IV. Digits involved
Table III. Site of lesions in fifty patients with lacerated tendons Site
Middle phalanx Proximal interphalangeal joint Proximal phalanx Metacarpophalangeal joint
Digit No.
16 7 19 8
joints are initiated. Three to four days later the remaining dressing is completely removed and free active flexion and extension movements are carried out. Emphasis is placed on frequency rather than range of movements. Patients are told to move only within their pain-free range and not to force any movements. The range of movement slowly increases over the next few days, and the patients usually are able to touch their palms 2 weeks following the repair. Once edema has settled, passive movements are started, but movement against resistance is not allowed for 6 weeks (Figs. 3 through 6).
Thumb Index Middle Ring Little
No.
6 19 18 18 J3
Results
A total of 61 patients with flexor tendon lacerations within the fibro-osseous canal (no man's land) have been treated with this method during a 20-month period. Patients were not selected in this study. Indeed, the majority of the patients were of low socioeconomic status, illiterate, and unable to carry our instructions reliably. As a result, the follow-up rate was low, and only the 50 patients who were followed for a minimum of 3 weeks were included in this report. The average follow-up period was 2 months. Results were assessed on a similar basis to that of
458
Becker, Orak, Duponselle
The Journal of HAND SURGERY
Fig. 4. A, A 33-year-old woman lacerated flexor digitorum profundus to the right index finger at the mid-proximal phalyngeallevel. B, Flexion at 9 months following repair. C, Flexion (lateral view) at 9 months following repair. D, Extension at 9 months following repair.
Lister et al. (Table I). Good-to-excellent results were achieved in 70% of the patients, with a 10% rupture rate mainly occurring in the early cases (Tables II, III, and I V) . Two patients (4%) developed infections. Discussion Animal research in tendon healing suggests three biological methods of repair: by adhesion formation ,6. 7 synovial nutrition,2. 8, 9 and intrinsic healing. \, 3. 10. 11 The relative importance of these mechanisms in human injury is not fully known; however, the unfavorable adhesion method of healing seems all too frequent. Early active motion may permit intrinsic or synovial mechanisms of tendon repair to predominate, thus reducing the likelihood of restrictive adhesion formation. The striking early full functional return in some of our patients suggests that healing might have occurred with little or no adhesion formation. The pattern of recovery differs from that seen in patients treated by conventional methods. For example, most patients had a good range of motion at 1 week and
were able to touch their palms at 2 to 3 weeks. The majority of patients were able to return to work within 4 to 5 weeks after injury. The following problems have been encountered. 1. Breakdown of skin incision with early motion. Initially patients were allowed completely free movement 24 hours following operation and several cases of skin breakdown occurred. However, since commencing our new regime of gentle movements of the distal phalanx only for the first few days , we have had no further problems of this nature. If the initial laceration results in a distally based skin flap being produced, or if the laceration is ragged, movements should be delayed even longer. 2. Rupture. The incidence of rupture was 10%. All ruptures occurred in the first 2 weeks and occurred in the profundus tendon only . Our patients were not selected in this trial. We feel that some patient selection will be necessary to reduce the rupture rate. Indeed , one of our patients was found lifting wood within a week after tendon repair. Poorly motivated patients
Vol. 4, No.5 September, 1979
Beveled technique of flexor tendon repair
459
Fig. 5. A, A 22-year-old man who lacerated both flexor tendons to the left little and ring fingers. B, Flexion at 3 months after operation. C, Extension at 3 months after operation.
Fig. 6. A, A 49-year-old man lacerated both flexor tendons to the index, middle, and ring fingers plus the profundus tendon to the little finger. B, Flexion at 3 months following repair. C, Extension at 3 months following repair.
who cannot follow instructions should have hands immobilized or placed in dynamic protective splintage. We also plan to place all patients in a protective dorsal plaster splint in 30° of wrist flexion, which we hope will minimize the rupture rate. 3. Slow return of extension. Injuries of the profundus tendon in zone I are commonly treated by advancement and reinsertion. It has been shown that the
profundus tendon may be shortened as much as 1.5 cm without a flexion deformity resulting. 12 However, extension returned more slowly than flexion in our patients. A few patients had permanent lack of some extension; but this did not create a significant functional problem. This optimal range of early safe active movements is not known. Each patient was managed individually and somewhat intuitively. We are now at-
460
The Journal of HAND SURGERY
Becker, Orak, Duponselle
tempting to standardize a more protective postoperative regimen, with the hope that further experience will show an improved range of movement and reduced rupture rate.
Conclusion
5.
6.
A method of flexor tendon repair is described which gives sufficient strength to allow early active motion. With unrestricted free motion, 10% of cases ruptured. It seems likely, however, that with better patient selection, a more cautious postoperative regime of active motion, and protective splintage, the incidence of rupture might be lessened.
7.
8.
9. REFERENCES
I. Furlow LT Jr: The role of tendon tissue in tendon healing. Plast Reconstr Surg 57:39, 1976 2. Lundborg G, Rank F: Experimental intrinsic healing of flexor tendons based upon synovial fluid nutrition. J HAND SURG 3:21-31, 1978 3. Matthews P, Richards H: The repair potential of digital flexor tendons-an experimental study. J Bone Joint Surg [Br] 56:618-25, 1974 4. McDowell CL, Snyder DM: Tendon healing: An ex-
10.
11. 12.
peri mental model in the dog. J HAND SURG 2: 122-6, 1977 Becker H: Primary repair of flexor tendons in the hand without immobilization-preliminary report. Hand 10: 37-47, 1978 Peacock EE Jr: Biological principles in healing of long tendons. Surg Clin North Am 45:461-76, 1965 Potenza AD: Tendon healing within the flexor digital sheath in the dog-an experimental study. J Bone Joint Surg [Am] 44:49-64, 1962 Lundborg G, Myrhage R, Rydevik B: The vascularization of human flexor tendons within the digital synovial sheath region-structural and functional aspects. J HAND SURG 2:417-27, 1977 Manske PR, Whiteside LA, Lesker PA: Nutrient pathways to flexor tendons using hydrogen washout technique. J HAND SURG 3:32-6, 1978 Bergljung L; Vascular reactions in tendon healingstreomicroangiographic studies of tendon suturing. Angiology 21:375-84, 1970 Ketchum LD: Primary tendon healing: A review. J HAND SURG 2:428-35. 1977 Kleinert HE, Forshew FL, Cohen MJ: Repair of zone 1 flexor tendon injuries. AAOS Symposium of tendon surgery in the hand. St. Louis, 1975, The CV Mosby Co, pp 115-22
Information for Authors Most of the provisions of the Copyright Act of 1976 became effective on January 1, 1978. Therefore, all manuscripts must be accompanied by the following written statement, signed by one author: "The undersigned author transfers all copyright ownership of the manuscript (title of article) to the American Society for Surgery of the Hand in the event the work is published. The undersigned author warrants that the article is original, is not under consideration by another journal, and has not been previously published. I sign for and accept responsibility for releasing this material on behalf of any and all co-authors." Authors will be consulted, when possible, regarding republication of their material.
Hilton Becker, F.R.C.S., Fetti Orak, M.D., and Erik Duponselle, M.D., Johannesburg, S. Africa
Full function is not often achieved following flexor tendon repair within the fibro-osseous canal. Restrictive adhesions appear to be the main limiting factor. The studies of Furlow! and others 2 - 4 suggest that early active motion may favorably influence tendon healing and may permit gliding, provided that rupture and gap formation do not occur. We previously reported on investigations on cadavers and baboons utilizing a bevel technique of tendon From the Department of Plastic and Reconstructive Surgery, University of the Witwatersrand, Johannesburg, S. Africa. Supported by the University Councils Faculty of Medicine Research Grant and the Medical Faculty Research Endowment Fund Grant. Received for publication Nov. 15 , 1978. Revised for publication April 9, 1979. Reprint requests: Hilton Becker, F.R.C.S., Division of Plastic and Reconstructive Surgery, Medical College of Virginia, MCV Station, Box 154, Richmond, VA 23298 (804-786-9318).
repair which had greater tensile strength and less gap formation, and which, when placed under tension, showed less strangulation of tendon ends, than standard techniques . 5 We have now used this technique of tendon suture combined with early active motion on 50 patients (110 tendons).
Method Under a tourniquet the tendon sheath is exposed through a Bruner incision. A flap of sheath is raised to expose the tendons, preserving pulleys where possible. Both flexor tendons are always repaired. With the aid of magnification (four times), the cut tendon ends are beveled on reciprocal surfaces for approximately 0.75 cm, carefully preserving the vincula. A fine-toothed forceps is used to grasp the tendon while curved Iris scissors is used to bevel the desired amount of tissue (Fig. 1). The two beveled tendon ends are than
Fig. 1. Method of beveling tendon ends. The fine-toothed forceps are used to grasp the tendon and an Iris scissors is used to cut the bevel. 454
THE JOURNAL OF HAND SURGERY
0363-5023179/040454+07$00.7010 © 1979 American Society for Surgery of the Hand
Vol. 4, No . 5 September, 1979
Beveled technique of flexor tendon repair
t
(
...... _........-......-....'..."_' _ .. i ;;;:i ':tT#ii ""... iiI ·
. . ..
.._~~' t' !'
' ' ' "'--'®
'_H:~~~~C~ . "_ @
Fig. 2. Diagramatic representation of suture method . A, Cut tendon ends. B, Tendon ends beveled reciprocally for 0.75 cm . C, Tendon "flaps" overlapped and secured with three placing sutures on each side . D, Reinforcing lateral running suture (suture material No. 6-0 or 7-0 Prolene).
Fig. 2, cont'd. E, Healing tendon at 2 weeks (no pseudotendon); note the new vessel formation.
455
456
The Journal of HAND SURGERY
Becker, Orak, Duponselle
Fig. 3. A, A 26-year-old man sustained an extensive injury to the right index finger, severing both flexor tendons, digital nerves and fracturing the neck of the proximal phalanx. B, A roentgenogram showing fracture . C, Flexion at 1 week following repair. D, Extension at 1 week following repair.
Table I. Criteria for grading results* Results Excellent Good Fair
Poor
Flexion Less than I cm to distal palmar crease Able to touch palm Unable to touch the palm, but less than 3 cm from the distal palmar crease Worse than above criteria or rupture
Table II. Results in fifty patients Extension
Less than 15° lack of extension 15° to 30° lack of extension More than 30° but less than 50° lack of extension
·From Lister GD, Kleinert HE. Kutz JE. Atasoy E: Primary flexor tendon repair followed by immediate controlled mobilization. J HAND SURG 2:441-51 , 1'TT7.
overlapped and held in position by three sutures of No. 6-0 or 7-0 Prolene. These stay sutures are placed laterally on each side of the bevel, thus compressing the flaps (Fig. 2) . A reinforcing running suture is woven along the edges of the bevel, starting a few millimeters proximal to the overlapping tendon ends, and extending
Results
I
No.
Excellent Good Fair Poor (rupture)
%
27 8 IO
5
a few millimeters distally. When tension is applied, longitudinal forces are thus converted into horizontal compressive forces. 5 The sheath is sutured loosely to the surrounding tissue, and the skin is closed using No. 5-0 nylon mattress sutures. The hand is dressed in a fluffed gauze dressing and protected with a dorsal slab in neutral position (wrist at 0°) . Postoperative management On the first day after operation , the dressing is removed from the nonincised portion of the fingers, and gentle active movements of the distal interphalangeal
Vol. 4, No.5
Beveled technique of flexor tendon repair
September, 1979
457
Fig. 3, cont'd. E, Flexion at 3 weeks following repair. F, Extension at 3 weeks following repair. G, Profundus action at 3 weeks following repair.
Table IV. Digits involved
Table III. Site of lesions in fifty patients with lacerated tendons Site
Middle phalanx Proximal interphalangeal joint Proximal phalanx Metacarpophalangeal joint
Digit No.
16 7 19 8
joints are initiated. Three to four days later the remaining dressing is completely removed and free active flexion and extension movements are carried out. Emphasis is placed on frequency rather than range of movements. Patients are told to move only within their pain-free range and not to force any movements. The range of movement slowly increases over the next few days, and the patients usually are able to touch their palms 2 weeks following the repair. Once edema has settled, passive movements are started, but movement against resistance is not allowed for 6 weeks (Figs. 3 through 6).
Thumb Index Middle Ring Little
No.
6 19 18 18 J3
Results
A total of 61 patients with flexor tendon lacerations within the fibro-osseous canal (no man's land) have been treated with this method during a 20-month period. Patients were not selected in this study. Indeed, the majority of the patients were of low socioeconomic status, illiterate, and unable to carry our instructions reliably. As a result, the follow-up rate was low, and only the 50 patients who were followed for a minimum of 3 weeks were included in this report. The average follow-up period was 2 months. Results were assessed on a similar basis to that of
458
Becker, Orak, Duponselle
The Journal of HAND SURGERY
Fig. 4. A, A 33-year-old woman lacerated flexor digitorum profundus to the right index finger at the mid-proximal phalyngeallevel. B, Flexion at 9 months following repair. C, Flexion (lateral view) at 9 months following repair. D, Extension at 9 months following repair.
Lister et al. (Table I). Good-to-excellent results were achieved in 70% of the patients, with a 10% rupture rate mainly occurring in the early cases (Tables II, III, and I V) . Two patients (4%) developed infections. Discussion Animal research in tendon healing suggests three biological methods of repair: by adhesion formation ,6. 7 synovial nutrition,2. 8, 9 and intrinsic healing. \, 3. 10. 11 The relative importance of these mechanisms in human injury is not fully known; however, the unfavorable adhesion method of healing seems all too frequent. Early active motion may permit intrinsic or synovial mechanisms of tendon repair to predominate, thus reducing the likelihood of restrictive adhesion formation. The striking early full functional return in some of our patients suggests that healing might have occurred with little or no adhesion formation. The pattern of recovery differs from that seen in patients treated by conventional methods. For example, most patients had a good range of motion at 1 week and
were able to touch their palms at 2 to 3 weeks. The majority of patients were able to return to work within 4 to 5 weeks after injury. The following problems have been encountered. 1. Breakdown of skin incision with early motion. Initially patients were allowed completely free movement 24 hours following operation and several cases of skin breakdown occurred. However, since commencing our new regime of gentle movements of the distal phalanx only for the first few days , we have had no further problems of this nature. If the initial laceration results in a distally based skin flap being produced, or if the laceration is ragged, movements should be delayed even longer. 2. Rupture. The incidence of rupture was 10%. All ruptures occurred in the first 2 weeks and occurred in the profundus tendon only . Our patients were not selected in this trial. We feel that some patient selection will be necessary to reduce the rupture rate. Indeed , one of our patients was found lifting wood within a week after tendon repair. Poorly motivated patients
Vol. 4, No.5 September, 1979
Beveled technique of flexor tendon repair
459
Fig. 5. A, A 22-year-old man who lacerated both flexor tendons to the left little and ring fingers. B, Flexion at 3 months after operation. C, Extension at 3 months after operation.
Fig. 6. A, A 49-year-old man lacerated both flexor tendons to the index, middle, and ring fingers plus the profundus tendon to the little finger. B, Flexion at 3 months following repair. C, Extension at 3 months following repair.
who cannot follow instructions should have hands immobilized or placed in dynamic protective splintage. We also plan to place all patients in a protective dorsal plaster splint in 30° of wrist flexion, which we hope will minimize the rupture rate. 3. Slow return of extension. Injuries of the profundus tendon in zone I are commonly treated by advancement and reinsertion. It has been shown that the
profundus tendon may be shortened as much as 1.5 cm without a flexion deformity resulting. 12 However, extension returned more slowly than flexion in our patients. A few patients had permanent lack of some extension; but this did not create a significant functional problem. This optimal range of early safe active movements is not known. Each patient was managed individually and somewhat intuitively. We are now at-
460
The Journal of HAND SURGERY
Becker, Orak, Duponselle
tempting to standardize a more protective postoperative regimen, with the hope that further experience will show an improved range of movement and reduced rupture rate.
Conclusion
5.
6.
A method of flexor tendon repair is described which gives sufficient strength to allow early active motion. With unrestricted free motion, 10% of cases ruptured. It seems likely, however, that with better patient selection, a more cautious postoperative regime of active motion, and protective splintage, the incidence of rupture might be lessened.
7.
8.
9. REFERENCES
I. Furlow LT Jr: The role of tendon tissue in tendon healing. Plast Reconstr Surg 57:39, 1976 2. Lundborg G, Rank F: Experimental intrinsic healing of flexor tendons based upon synovial fluid nutrition. J HAND SURG 3:21-31, 1978 3. Matthews P, Richards H: The repair potential of digital flexor tendons-an experimental study. J Bone Joint Surg [Br] 56:618-25, 1974 4. McDowell CL, Snyder DM: Tendon healing: An ex-
10.
11. 12.
peri mental model in the dog. J HAND SURG 2: 122-6, 1977 Becker H: Primary repair of flexor tendons in the hand without immobilization-preliminary report. Hand 10: 37-47, 1978 Peacock EE Jr: Biological principles in healing of long tendons. Surg Clin North Am 45:461-76, 1965 Potenza AD: Tendon healing within the flexor digital sheath in the dog-an experimental study. J Bone Joint Surg [Am] 44:49-64, 1962 Lundborg G, Myrhage R, Rydevik B: The vascularization of human flexor tendons within the digital synovial sheath region-structural and functional aspects. J HAND SURG 2:417-27, 1977 Manske PR, Whiteside LA, Lesker PA: Nutrient pathways to flexor tendons using hydrogen washout technique. J HAND SURG 3:32-6, 1978 Bergljung L; Vascular reactions in tendon healingstreomicroangiographic studies of tendon suturing. Angiology 21:375-84, 1970 Ketchum LD: Primary tendon healing: A review. J HAND SURG 2:428-35. 1977 Kleinert HE, Forshew FL, Cohen MJ: Repair of zone 1 flexor tendon injuries. AAOS Symposium of tendon surgery in the hand. St. Louis, 1975, The CV Mosby Co, pp 115-22
Information for Authors Most of the provisions of the Copyright Act of 1976 became effective on January 1, 1978. Therefore, all manuscripts must be accompanied by the following written statement, signed by one author: "The undersigned author transfers all copyright ownership of the manuscript (title of article) to the American Society for Surgery of the Hand in the event the work is published. The undersigned author warrants that the article is original, is not under consideration by another journal, and has not been previously published. I sign for and accept responsibility for releasing this material on behalf of any and all co-authors." Authors will be consulted, when possible, regarding republication of their material.