Experience with a two-staged pedicled flexor tendon graft

Experience with a two-staged pedicled flexor tendon graft

Experience with a two-staged pedicled flexor tendon graft E. Brug and H. W. Stedtf~ld EXPERIENCE WITH A TWO-STAGED PEDICLED FLEXOR TENDON GRAFT E. BR...

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Experience with a two-staged pedicled flexor tendon graft E. Brug and H. W. Stedtf~ld

EXPERIENCE WITH A TWO-STAGED PEDICLED FLEXOR TENDON GRAFT E. BRUG and H. W. STEDTFELD, Mtinster, Germany SUMMARY A two-staged technique for flexor tendon grafting in Zone 2 is described using a silicone rubber rod which is replaced at the second stage by a somersaulted superficialis tendon graft sutured end-to-end to profundus tendon at the lumbrical level. The results are analysed.

INTRODUCTION The main purpose of a flexor tendon grafting is the transfer of the suture lines from " n o man's l a n d " to more strategic sites, such as the region of the distal phalanx and the palm or the forearm. Here, adhesions are less troublesome, yet are adequate for survival of the tendon graft. However, neither the transplantation of short grafts with the proximal suture in the palm nor that of long grafts with the suture at the forearm have so far been fully satisfactory and the same in principle, can be said regarding the two-staged tenoplasties. We have found that good results were not always obtained by the application of silicone rubber rod nor by the method initiated by Paneva-Holevich 0965) who sutured the profundus tendon end-to-end to superflcialis. PRINCIPLES AND TECHNIQUE: Therefore, we have tried to combine these two techniques on the reasoning that, in a preformed, clean-coated tendon bed a pedicled; partly vascularised graft is less liable to adhesion. First stage The surgical technique used for the first stage procedure follows the description by Hunter (1970) with the exception of some minor modifications. For the excision of the two tendons the tendon sheath is opened like a gate between the pulleys where the tendon sheath is still intact. The profundus tendon is excised up to the origin of the lumbrical; the superficialis tendon remains 2 or 3 cms longer. The two tendon stumps then are joined end-to-end in a hair-pin shaped loop. The suture itself is covered by some lumbrical fibres. We approximate the two stumps with a buried monofilament 4/0 prolene suture and two 6/0 mattress sutures. (Fig. 1). The silicone rod is now led through the pulleys which, if necessary, are reconstructed by using remnants o f the flexor tendons which have been excised. The open tendon sheath is closed with Some interrupted 6/0 sutures. The silicone rod is fixed with some stitches at the distal profundus stump of about l / 2 cm length. With slight tension, the rod is led through the proximal tendon loop and is joined side-to-side to itself to make a further loop. We latterly have done without this rod loop because we have found that in certain cases it may cause necrosis or at least some pressure at the turning point of the tendon loop. After the first procedure there is a two week period o f immobilisation with a piaster splint. Subsequently, passive movement of the joints is encouraged.

E. Brug, Prof., Dr., Chirurgische Klink der Westf~lischen Wilhelms Universitat, D44 Mfinster, Jungeblodtplatz 1, Germany. 198

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Experience with a two-staged pedicled flexor tendon graft 13. Brug and H. IV. Stedtfeld

Fig. 1. First stage of operation. Junction between the longer superficialis and the shorter profundus stump at the level of lumbrical origin. The distal tendon stumps are resected. One pulley has been reconstructed. The silastic rod is still to be inserted. Fig. 2. Secondstageof operation. Onlysmall exposurein the palm. The figure showsthe "linkage" between tendon loop and that of the rod.

Second Stage The second stage of the operation usually follows after eight to ten weeks, or some weeks earlier if the optimum of passive flexion has been obtained. During the second stage of the operation, the tendon loop is first exposed through a small skin incision in the palm (Fig. 2). From another small skin incision at the forearm, the superficialis tendon then is cut at the tendon-muscle junction and is drawn into the palm. The new distal end of the superficialis tendon is temporarily fixed with one stitch to the proximal end of the rod and, with it, is pulled into the tendon bed and led out through another small incision at the distal phalanx. (Figs. 3, 4). After having been shortened, the graft is fixed side-to-side to the distal profundus stump by means of a pull-out wire and some extra sutures of 5/0 prolene.

Post-operative management After the second-stage procedure, the post-operative management requires a three-weeks' immobilisation during which the hand is protected in flexed position at the wrist and the metacarpo-phalangeal joints in a plaster using Kleinert's method. After three weeks we commence the free active flexion o f the finger, which, in The Hand-- Volume 11

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Experience with a two-stagfed pedicled flexor tendon graft E. Brug and H. IV. Stedtfeld

Fig. 3. Second stage of operation. (The arrow points to the tendon junction). The new distal end of the superficialis graft is temporarily fixed at the proximal end o f the rod .... Fig. 4 . . . . . and with it pulled into the tendon bed and led out through another small incision at the range of the DIP-joint. patie.tt

Relation digit/average age

Preop.Conditions

AGE 9 - 62yrs.

free grail deetointufl tenden jLmctton}

10

26

~verzge

2B yrs.

of

F--I

[]

POOR

6-

2-

10

20

30

/,0

50

60

70 yeors

INDEX MIDDLE RING LITTLE

INDEX MIDDLE RING LITTLE FINGER

Fig. 5. The age distribution spikes in the second decennium. The youngest patient was 9 yrs. of age, the eldest 62. In 6 cases of 34 digits the tendon junction had become insufficient and insuitable for pedicled grafting; in one case - - through some error - - the profundus tendon had been used. (See Table 5) Fig. 6. The distribution o f affected fingers was almost equal. The average age of index, middle and ringfinger is at middle twenties, o f the little finger however at over 50. Fig. 7. Exclusivdy good and very good preoperative conditions were found in the little fingers, whereas the radial fingers, if anything, showed worse conditions preoperatively, which will be later on (Table 2).

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Experience with a two-staged pedicled flexor tendon graft E. Brug and H. W. Stedtfeld

FOLLOW-UP-EXAMINATION FLEXOR TENDON TRANSFER (Lenglingers) name:

~je: 4 q ~" II[',dl

Op.- date :~,~ Ex.- date :t~.l

INDEX

MIDDLE

RING

fingertip to prox. palm. crease (cml

side

LITTLE

left

05

MP[ PIP I DIP MP] PIP[DIP MP I PIPI DIP MP] PIPI DIP ?f- ~0 6 o

flexion

right

sex

malex I

total flexion

MP I PIPIDIP

extention

subj. estimation" ]

extentiondificit

female

2

)<

4'd

total movement

3

~ints : Distance fingertip to O prox. palm. crease 2,5 total flexion 4

* (~)- "very satisfied" 2 - "satisfied" 3 - "unsatisfied"

- 2, 5cm 1>-2000 .... F.... 6 - 4, Ocm1~'180* ..... 4 - 6,0cm1->1509 . .... 2 9

6, Ocm I 150 . . . . . . . . . . O

extension deficit

O~

~

...

~' . . 3

31 ~ - 50 9 . . . . .

excellent

Valuation: .....

14.(~)points

good. . . . . . .

11-13

range of movement

7-10 -6

fair.

poor.

2

51" - 70~ . . . . . 1 > 70* . . . . . . . . . . 0

. .0

_- 160~ >-140~ r. 120" < 120~

....K. . . . . 6 ..... 4 . .... 2 ......... 0 4fe-

Fig. 8. For each of our patients examined we used this form, which is based on the follow up scheme of Buck-Gramcko. This 19 year-old patient, 9 months after little finger operation, achieved, according to these criteria, 15 points, which means an excellent result. t h e f o l l o w i n g t w o t o t h r e e w e e k s , is s t e a d i l y i n c r e a s e d u p t o t h e full r a n g e o f a c t i v e and passive movement. RESULTS

Up to now we thus have made some fifty tendon graftings. Statistical

details

T h e r e h a v e b e e n t h i r t y f o u r f i n g e r s in t w e n t y six p a t i e n t s w h i c h w e r e c o m p l e t e d sufficiently long ago for follow-up examinations. Of these twenty-six patients the The Hand--Volume l l

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Experience with a two-staged pedicled flexor tendon graft E. Brug and 14. W. Stedtfeld

youngest was nine years of age, the eldest sixty-two years. The average age was twenty-eight years (Fig. 5). In twenty-one operations a single finger was concerned. On some occasions more than one finger was operated on at the same time. As to the fingers affected, the distribution was almost equal: The index finger was involved ten times, the middle nine, the ring finger eight and the little finger seven times. For the index and ring fingers the average age of twenty-two to twentyseven years was nearly corresponding to the general average age, but for the little finger the average age of fifty-five years was surprisingly higher. (Fig. 6). As regards the preoperative status, the cases examined were diverse. Seventeen fingers showed preoperatively very good or good conditions for the planned tendon transplant, whereas the same number were badly suited for a grafting from the very start (Fig. 7). In these cases either re-implanted fingers were concerned or such fingers which, after a pyogenic tendon necrosis with heavy scar formations or joint destruction, needed a joint replacement at the same time. In most cases a silicone rod o f 4 m m diameter was used. In four out of seven flexor tendon graftiugs in the little finger, the superficialis tendon of the ring finger was used for the pedicled graft. The flexor tendon of the little finger is too small for this procedure. In one case, by error, the profundus tendon was used.

Complications A m o n g thirty-four single fingers - - mainly a m o n g the first ones operated - - we had six cases where during the second stage operation we found intraoperatively some insufficiency or complete absence of any consolidation of the profundussuperficialis junction. (Fig. 5). Presumably the cause was atrophic damage caused by the rod loop. In these six cases the proximal stump and the end of the graft were freshened and the second stage of the operation was completed as a free grafting. Leaving these complications out of consideration, another case of ruptured distal attachment and the case o f profundus as graft, there remained twenty-six cases of pedicled graftings for follow-up. Follow-up Examination We used the follow-up scheme described by Buck-Gramcko (Fig. 8). This scheme estimates the full range of flexion and extension. An assessment of "Excellent" is equivalent to 14-15 points. For less than 6 points the resulting value is " P o o r " . The follow-up examinations were made between four months and three years after the last operation. O f twenty-seven fingers - - including one profundus graft - - seven (26 per cent) showed each an excellent and good result, and six (22 per cent) a " f a i r " one. In seven cases (26 per cent) the result was " P o o r " . (Table I). These disappointing seven cases will be discussed separately. Considering the results for the different fingers, the little finger with 83 per cent excellent and good results clearly ranks at the top of the scale. Remarkably worse are the results for the index and middle finger. The worst result was obtained for the ring finger (Table 2).

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Experience with a t wo-staged pedicled flexor tendon graft E. Brug and H. W. Stedtfeld

TABLE 1

TABLE 2 RESULTS DEPENDING ON AFFECTED FINGERS

OVERALL RESULTS

(total)

INDEX

MIDDLE

RING

LM'LE

excellent

7

(26 %)

excellent

37. 5 %

25 %

good

7

(26%)

good

12,5%

25%

33%

50%

fair

6

(22 %)

fair

37, 5 ~

12, 5 ok

16 %

16 ok

poor

7

(26%)

poor

12, 5 ok

37, 5 ok

5ook

-

-

33 %

Table 1. Excellent and good results could be achieved in more than 50%. Table 2. According to the good preoperative conditions (see Fig. 7) the little finger with 83% excellent and good results ranks at the top of the scale.

In an analysis regarding the " a g e " it is striking that six of seven bad results are in the age group over fifty years (Table 3). The preoperative state considerably affects the result (Table 4). If the initial situation is good, namely if there is a free flexibility o f the joints with onlY minor scar formation, the results obtained are clearly better. BAD RESULTS Seven fingers showing a very poor operative result had been unsuitable for g r a f t i n g b e c a u s e o f t h e i r b a d p r e o p e r a t i v e state. A butcher of twenty-seven years of age had previously undergone u n s u c c e s s f u l c o n v e n t i o n a l t e n o p l a s t y . M o r e o v e r the f i n g e r was a l r e a d y i n f e c t e d .

an

T h e o t h e r six f i n g e r s c o n c e r n e d t h r e e p a t i e n t s o v e r f i f t y y e a r s o f age. A p a t i e n t o f t h e age o f s i x t y - t w o s u f f e r e d a n e x t e n s i v e tissue c r u s h i n g f o l l o w e d by h e a v y scar f o r m a t i o n . M o r e o v e r t h e silastic r o d we a p p l i e d was t o o t h i n for the superficialis graft. TABLE 4

TABLE 3

RESULTS D E P E N D I N G O N P R E O P . C O N D I T I O N S

RESULTS DEPENDING ON AGE less than 50 yrs.

good t

over 50 yrs.

excellent

5 (27, 8 %)

good

7 (38, 9 %)

(12,5%)

1

fair

5 (27,8%)

(12,5%)

1

poor

1 (5,5%)

(75,0%)

6

peor **

excellent

6

46.1 *I,

7, 7 q,

1

good

5

38,5%

15,3 ok

2

fair

2

15, 4 q,

23,1%

3

poor

-

53, 8 ok

7

-

* Free or nearly free passive joint movement.

**Joint impairment heavy scarlormation due to infection replantation.

Table 3. The age group before fifty was with 66% good and excellent results striking better than the group over fifty, which didn't yield an excellent result at all, however, in 6 of 8 cases a "poor" result. Table 4. How important and essential for tenoplasty the preoperative conditions are is made clear by 84% excellent and good results after good conditions. A poor preoperative state seems to let each way of tenoplasty only a random chance. The H a n d m Volume 11

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Experience with a t wo-staged pedicled flexor tendon graft E. Brug and H. W. Sted(feld

TABLE 5 RESULTS OF COMPLICATED CASES insufficient tendon iunction : total no.

6

follow up exam. excellent

free graft

2, profundus insteadof superfic. (pedicled)

of superfic,

palm, long.

4

3

1

l

]

I

good fair

I

'

I

3. postop, rupture of {list,~achm.:

L,ir

I

I

free graff of p.I.

I

l j

poor

Table 5. Five out o f six cases of insufficient tendon junction and succeeding free graft could be examined. They showed as well good results as also the case of prof. transplantation (by error). A free palmaris longus tenoplasty after post-operative rupture o f distal attachment of a pedicled graft yielded only a fair result.

A woman of fifty-three also had already undergone three previous operations for a tendovaginitis stenosans. To get her fingers in a passably operable condition, we first had to m a k e several skin Z-plasties in the two fingers which were contracted in full flexion. The fourth patient, sixty-two years of age, suffered from one total and two partial finger amputations following an accident with a circular saw. Here the grafting was made after a successful replantation. With nearly all these fingers several factors coincided each of which in itself meant a bad indication for any kind of a flexor tendon grafting, namely age of the patient, preoperative status and serial transplantation. COMPLICATED CASES The tendon junction had to be freshened six times (Table 5). In every case the preoperative conditions had been the best for a grafting. Four times the superficialis tendon of the same finger was grafted in a free transplantation, once that of the fourth finger into the little finger and once the tendon of the palmaris longus. All these cases showed results nearly as good as those obtained with the pedicled tendon graftings for which, for comparison, the preoperative state had been ideal (Table 6). DISCUSSION

The success of any grafting depends not so much on the method applied but in the first instance on the initial status and on the operative technique. In the first-stage operation, we have lately avoided any resection of the adhesions around the proximal stump in order not to jeopardize its nutrition. This has proved to be the right procedure, for the adhesions in the region of the loop, which might have induced other surgeons to abandon this technique after the first attempts, have since been seen less often than before. The number of our patients is still too small for a final assessment of this method. Comparisons with other authors are also difficult due to the fact that different schemes have been used for the follow-up investigations. Kessler (1972) 204

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Experience with a two-staged pedicled flexor tendon graft E. Brug and H. W. Stedtfeld

a n d a l s o C h o n g (1972) r e p o r t e d six cases all in 1972. H o w e v e r , in o u r o w n e x p e r i e n c e s w e c o n s i d e r the t w o s t a g e p e d i c l e d f l e x o r t e n d o n g r a f t i n g t o b e g o o d e n o u g h to o b t a i n at l e a s t slightly b e t t e r results t h a n w i t h c o n v e n t i o n a l p l a s t i e s . REFERENCES

CHONG, J. K., CRAMER, L. M., CULF, N. K. (1972) Combined Two-Stage Tenoplasty With Silicone Rods For Multiple Flexor Tendon Injuries in The Journal of Trauma, 12: 104-121. HUNTER, J. M., SALISBURY, R. E. (1970) Use of Gliding Artificial Implants To Produce Tendon Sheaths. Techniques and Results in Children. Plastic and Reconstructive Surgery 45: 564-572. KESSLER, F. B. (1972) Use of a Pedicled Tendon Transfer With A Silicone Rod In Complicated Secondary Flexor Tendon Repairs. Plastic and Reconstructive Surgery, 49: 439-443. PANEVA-HOLEVITCH, E. (1965) Two-Stage Plasty In Flexor Tendon Injuries Of Fingers Within The Digital Synovial Sheath. (Report 1). Acta Chirurgiae Plasticae 7:112-124.

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