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Endoscopic retrieval of severed flexor tendons
Endoscopic Retrieval of Severed Flexor Tendons KaMing Li, MD, Dennis R. Banducci, MD, Stephen H. Kahler, MD, Randy M. Hauck, MD, Donald R. Mackay, MD, Ernest K. Manders, MD
Retrieval of the proximal end of severed flexor tendons can be a c c o m p l i s h e d using several techniques. L.2 Flexion of the wrist and metacarp phalangealjoints along with proximal-to-distal massage of the forearm and palm can bring the tendon into view. A grasping instrument, such as a hemostat, can deliver the tendon. When these maneuvers fail, proximal incisions to locate the tendon becomes necessary. H o w e v e r , these incisions extend the surgical wound and increase the scar burden. We describe a t e c h n i q u e for f l e x o r t e n d o n r e t r i e v a l that eliminates the need for proximal incisions.
Materials and Methods A 3.1 m m d i a m e t e r f l e x i b l e O l y m p u s u r e t e r o scope with a 1.2 mm instrumentation channel is used for endoscopic retrieval of severed flexor tendons (Olympus Corp. Columbia, MD). Studies were performed on three cadaver limbs retrieving flexor pollicis longus tendons and both flexor digitorum profundus and superficialis tendons in the same finger. The technique was then successfully used on three patients with severed flexor pollicis longus tendons, which were unable to be retrieved by standard blind techniques. The endoscope is connected to a light source and irrigation in the standard fashion. A Cook urologic stone forcep is passed through the instrumentation channel and the endoscope is passed into the tendon From the Division of Plastic and Reconstructive Surgery, Pennsylvania State University, Milton S. Hershey Medical Center, Hershey, PA. Received for publication Feb. 25, 1994; accepted in revised form Aug. 2, 1994. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Dennis R. Banducci, MD, Division of Plastic and Reconstructive Surgery, The Milton S. Hershey Medical Center, 500 University Drive, P.O. Box 850, Hershey, PA 17033. 278 The Journal of Hand Surgery
sheath at the level of the laceration or injury. Under continuous low pressure irrigation with normal saline, direct visualization of the cut end of the flexor tendon is easily achieved. The severed tendon end is then grasped with the endoscopic forcep and pulled distally to deliver the tendon into the wound for definitive repair.
Discussion E q u i p m e n t f o r e n d o s c o p i c t e n d o n r e t r i e v a l is readily available in most operating rooms that support a urological service. Successful use of this technique depends on a number of factors. E n d o s c o p e size is critical since the tendon sheath and its attendant pulleys limit the size of endoseopes that may pass. An e n d o s c o p e with an instrument channel is important because we have not been able to manipulate a t e n d o n retrieval f o r c e p alongside an endoscope with ease. Rigid endoscopes have also been difficult to manipulate. For these reasons, we reco m m e n d using a flexible endoscope approximately
Figure 1. Open jaws of alligator forcep at distal end of flexible endoscope.
The Journal of Hand Surgery / Vol. 20A No. 2 March 1995
Figure 2. Endoscopic view of open alligator forcep in position to grasp end of severed flexor pollicis longus tendon. (Note: Image quality limited by size of endoscope). 3 mm in diameter and containing an instrumentation channel. Visualization of the severed tendon end is greatly enhanced by irrigation and removal of any blood in the tendon sheath. Continuous irrigation can best be provided by perfusing saline through the endoscope's instrument channel. The perfusion can be accomplished by connecting standard intravenous infusion tubing to the instrumentation channel of the endoscope using a Bard Y connector. Gravity or syringe-driven irrigation can be used. We have used the endoscope in cadavers to retrieve flexor digitorum superficialis and flexor digitorum profundus tendons. There is enough space to pass an endoscope alongside an intact tendon to grasp a cut flexor digitorum superficialis or flexor digitorum profundus tendon. Clinically, we have only used the endoscope on severed flexor pollicis longus tendons be-
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Figure 3. Patient with severed flexor pollicis longus tendon retrieved by endoscopic technique. cause we have not encountered a tendon that could not be retrieved using standard techniques on digits other than the thumb since this technique became available. Knowledge of the equipment and anticipating the need for endoscopic tendon retrieval enhances the likelihood of success. We believe that indications for this technique are limited to those instances when positioning, massage, and blind retrieval fail. Tendon endoscopy provides an alternative to the surgical extension of hand wounds for the purpose of locating retracted tendons.
References 1. Strickland JW. Flexor tendon injuries: Part II: Flexor tendon repair. Orthop Rev 1986;15:701-21. 2. Leddy JP. Flexor Tendons--Acute Injuries. In: Green DP, ed. operative hand surgery, 3rd ed. New York: Churchill Livingstone, 1993:1823-51.
Retrieval of the proximal end of severed flexor tendons can be a c c o m p l i s h e d using several techniques. L.2 Flexion of the wrist and metacarp phalangealjoints along with proximal-to-distal massage of the forearm and palm can bring the tendon into view. A grasping instrument, such as a hemostat, can deliver the tendon. When these maneuvers fail, proximal incisions to locate the tendon becomes necessary. H o w e v e r , these incisions extend the surgical wound and increase the scar burden. We describe a t e c h n i q u e for f l e x o r t e n d o n r e t r i e v a l that eliminates the need for proximal incisions.
Materials and Methods A 3.1 m m d i a m e t e r f l e x i b l e O l y m p u s u r e t e r o scope with a 1.2 mm instrumentation channel is used for endoscopic retrieval of severed flexor tendons (Olympus Corp. Columbia, MD). Studies were performed on three cadaver limbs retrieving flexor pollicis longus tendons and both flexor digitorum profundus and superficialis tendons in the same finger. The technique was then successfully used on three patients with severed flexor pollicis longus tendons, which were unable to be retrieved by standard blind techniques. The endoscope is connected to a light source and irrigation in the standard fashion. A Cook urologic stone forcep is passed through the instrumentation channel and the endoscope is passed into the tendon From the Division of Plastic and Reconstructive Surgery, Pennsylvania State University, Milton S. Hershey Medical Center, Hershey, PA. Received for publication Feb. 25, 1994; accepted in revised form Aug. 2, 1994. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Dennis R. Banducci, MD, Division of Plastic and Reconstructive Surgery, The Milton S. Hershey Medical Center, 500 University Drive, P.O. Box 850, Hershey, PA 17033. 278 The Journal of Hand Surgery
sheath at the level of the laceration or injury. Under continuous low pressure irrigation with normal saline, direct visualization of the cut end of the flexor tendon is easily achieved. The severed tendon end is then grasped with the endoscopic forcep and pulled distally to deliver the tendon into the wound for definitive repair.
Discussion E q u i p m e n t f o r e n d o s c o p i c t e n d o n r e t r i e v a l is readily available in most operating rooms that support a urological service. Successful use of this technique depends on a number of factors. E n d o s c o p e size is critical since the tendon sheath and its attendant pulleys limit the size of endoseopes that may pass. An e n d o s c o p e with an instrument channel is important because we have not been able to manipulate a t e n d o n retrieval f o r c e p alongside an endoscope with ease. Rigid endoscopes have also been difficult to manipulate. For these reasons, we reco m m e n d using a flexible endoscope approximately
Figure 1. Open jaws of alligator forcep at distal end of flexible endoscope.
The Journal of Hand Surgery / Vol. 20A No. 2 March 1995
Figure 2. Endoscopic view of open alligator forcep in position to grasp end of severed flexor pollicis longus tendon. (Note: Image quality limited by size of endoscope). 3 mm in diameter and containing an instrumentation channel. Visualization of the severed tendon end is greatly enhanced by irrigation and removal of any blood in the tendon sheath. Continuous irrigation can best be provided by perfusing saline through the endoscope's instrument channel. The perfusion can be accomplished by connecting standard intravenous infusion tubing to the instrumentation channel of the endoscope using a Bard Y connector. Gravity or syringe-driven irrigation can be used. We have used the endoscope in cadavers to retrieve flexor digitorum superficialis and flexor digitorum profundus tendons. There is enough space to pass an endoscope alongside an intact tendon to grasp a cut flexor digitorum superficialis or flexor digitorum profundus tendon. Clinically, we have only used the endoscope on severed flexor pollicis longus tendons be-
279
Figure 3. Patient with severed flexor pollicis longus tendon retrieved by endoscopic technique. cause we have not encountered a tendon that could not be retrieved using standard techniques on digits other than the thumb since this technique became available. Knowledge of the equipment and anticipating the need for endoscopic tendon retrieval enhances the likelihood of success. We believe that indications for this technique are limited to those instances when positioning, massage, and blind retrieval fail. Tendon endoscopy provides an alternative to the surgical extension of hand wounds for the purpose of locating retracted tendons.
References 1. Strickland JW. Flexor tendon injuries: Part II: Flexor tendon repair. Orthop Rev 1986;15:701-21. 2. Leddy JP. Flexor Tendons--Acute Injuries. In: Green DP, ed. operative hand surgery, 3rd ed. New York: Churchill Livingstone, 1993:1823-51.