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FLEXOR SHEATH DILATATION WITH A FOGARTY CATHETER
FLEXOR SHEATH DILATATION WITH A FOGARTY CATHETER W. T. JARVIS, A. C. CAMPBELL and S. SINHA From the Department of Orthopaedic Surgery, Monklands Hospital, Airdrie, Scotland, UK
The use of a Fogarty catheter to dilate a constricted flexor sheath is described. This relatively atraumatic method of dilating a constricted flexor sheath, may sometimes allow a one-stage rather than a two-stage tendon graft procedure. Journal of Hand Surgery (British and European Volume, 2002) 27B: 5: 487–488
INTRODUCTION
Operative technique
Successful repair of divided flexor tendons is challenging, especially when the injury involves Zone 2 of the flexor sheath and is long standing with significant scarring and narrowing of the sheath. Tendon grafting is the technique of choice for delayed flexor tendon reconstruction and instances when there is significant damage to the tendon system (Colville, 1973; Pulvertaft, 1965a). This is frequently carried out as a two-stage procedure. In the first stage, the flexor sheath is prepared for the graft, usually by dilating the scarred sheath with relatively crude instruments, and then placing a silicone-Dacron reinforced implant in situ (Hunter, 1965; Hunter and Salisbury, 1971). The sheath usually heals and provides an acceptable bed for the tendon graft that is inserted approximately 3 months later (Green et al., 1999). We believe that a one-stage rather than a two-stage procedure can be considered, provided the flexor sheath can be dilated in an atraumatic manner: the balloon flexor sheathplasty.
Under general anaesthesia with proximal tourniquet control, the flexor tendon system was exposed using a zig-zag palmar incision (Bruner, 1967). The base of the distal phalanx was roughened to take the distal end of the graft. The flexor sheath was opened proximal to the A3 pulley, and distally, and a size 4 French gauge Fogarty catheter (Bard SA Croydon) was inserted in an antegrade direction. The catheter was inflated to maximum capacity of 1 ml (Fig 1), left for approximately 1 min to equilibrate, and then deflated and retracted 1–2 cm. The principles here are similar to performing an angioplasty, hence sheathplasty. The process was repeated until the entire sheath was dilated. The partially inflated catheter was then passed through the sheath to check adequate dilation. A zig-zag incision was made in the palm to isolate the flexor digitorum stump (Fig 2). The palmaris longus tendon was harvested from the same arm and anchored to the base of the distal phalanx using a pullout suture over a dental roll (Green et al., 1999). The graft was then passed proximally through the sheath by suturing it to the distal end of the deflated Fogarty catheter. Its proximal end was attached to the flexor digitorum profundus stump using a Pulvertaft weave (Pulvertaft, 1965b). The skin was closed with 4-O nylon and a Kleinert traction splint was applied with the wrist flexed.
CASE REPORT A 39-year-old, right-handed man who worked as an auto-glass technician and also played a keyboard was referred with a 1-year history of unusual triggering of his left ring finger. He had felt a click in the finger one day at work and it had then gradually become stiff over the ensuing months. He was unable to actively bend the distal interphalangeal joint. Physical examination revealed a supple finger with loss of active flexion at the distal interphalangeal joint, but a good passive range of motion. There was also triggering of the proximal interphalangeal joint of the finger. At exploration, it was found that the flexor digitorum profundus tendon had been avulsed and was lying at the level of the head of the metacarpal. It was adherent to the superficialis tendon as it passed under the A1 pulley. The incision was closed and the patient was informed that he might benefit from a tendon graft. He was brought back 4 months later for his flexor tendon reconstruction.
Fig 1 Testing balloon during dilatation. 487
488
Fig 2 Flexor digitorum profundus stump isolated through a separate incision.
Post-operative management was with early mobilization within the splint using the Kleinert traction. At 2 weeks he was provided with a night splint, but continued with Kleinert traction during the day until the 6th postoperative week. He was discharged at 4 months with 0–901 metacarpophalangeal, 0–1021 proximal interphalangeal and 20–501 distal interphalangeal active motion.
DISCUSSION The indications for two-stage tendon reconstruction include severe trauma, crushing injuries with associated fractures or skin damage, failed primary flexor tendon surgery, delayed diagnosis and excessive scarring of the tendon bed (Green, 1999). Sometimes the pulley system may be lost, either at the time of injury or as a result of scarring. One-stage tendon grafting with flexor sheath dilatation using a Fogarty catheter obviously has its limitations. It appears to be ideal when the flexor sheath is reasonably intact, even if it is narrowed by scar tissue. If the flexor sheath needs reconstruction, then we would advocate a two-stage graft, utilizing a temporary sili-
THE JOURNAL OF HAND SURGERY VOL. 27B No. 5 OCTOBER 2002
cone implant (Bassett and Carroll, 1963; Hunter and Salisbury, 1971). Although we exposed most of the flexor sheath system (Fig 1), we now believe that, as one becomes more experienced, only the proximal and distal ends need to be exposed to facilitate passage of the Fogarty catheter and suturing. Careful consideration and much caution are advised before offering the patient a free tendon graft to restore distal joint function. In a finger with a severed flexor digitorum profundus but an intact and fully functional flexor digitorum superficialis, much of the useful arc of motion is maintained. There is considerable risk to this function if while passing the tendon graft one injures the delicate system and adhesions intervene, resulting in overall loss of function (Green et al., 1999). Consequently, this procedure should be restricted to young people with supple joints and a reasonable need for active distal interphalangeal joint function. References Bassett AL, Carroll RE (1963). Formation of tendon sheaths by silicone rod implants. In: Proceedings of American Society for surgery of the hand; Journal of Bone and Joint Surgery, 45A: 884. Bruner JM (1967). The zigzag volar-digital incision for flexor tendon surgery. Plastic and Reconstructive Surgery, 40: 571–574. Colville J (1973). Tendon graft function. The Hand, 5: 152–154. Green DP, Hotchkiss RN, Pederson WC (1999). Green’s operative hand surgery. 4th edn. Churchill Livingstone, Philadelphia, PA. Hunter JM (1965). Artificial tendons: early development and application. American Journal of Surgery, 109: 325–338. Hunter JM, Salisbury RE (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, 53A: 829–858. Pulvertaft RG (1965a). Problems of flexor tendon surgery of the hand. Journal of Bone and Joint Surgery, 47A: 123–132. Pulvertaft RG (1965b). Suture materials and tendon junctures. American Journal of Surgery, 109: 346–352. Received: 15 November 2001 Accepted after revision: 26 March 2002 Mr W.T. Jarvis MD, FRCS, Specialist Registrar in Orthopaedics, Dept of Orthopaedic Surgery, Monklands Hospital, Flat 2, 10 Dorset Square, Glasgow G3 7LL, Scotland, UK. Tel.: +79 6800 6454; fax: +870 163 1607; E-mail: [email protected] r 2002 The British Society for Surgery of the Hand doi: 10.1054/jhsb.2002.0771, available online at http://www.idealibrary.com on
The use of a Fogarty catheter to dilate a constricted flexor sheath is described. This relatively atraumatic method of dilating a constricted flexor sheath, may sometimes allow a one-stage rather than a two-stage tendon graft procedure. Journal of Hand Surgery (British and European Volume, 2002) 27B: 5: 487–488
INTRODUCTION
Operative technique
Successful repair of divided flexor tendons is challenging, especially when the injury involves Zone 2 of the flexor sheath and is long standing with significant scarring and narrowing of the sheath. Tendon grafting is the technique of choice for delayed flexor tendon reconstruction and instances when there is significant damage to the tendon system (Colville, 1973; Pulvertaft, 1965a). This is frequently carried out as a two-stage procedure. In the first stage, the flexor sheath is prepared for the graft, usually by dilating the scarred sheath with relatively crude instruments, and then placing a silicone-Dacron reinforced implant in situ (Hunter, 1965; Hunter and Salisbury, 1971). The sheath usually heals and provides an acceptable bed for the tendon graft that is inserted approximately 3 months later (Green et al., 1999). We believe that a one-stage rather than a two-stage procedure can be considered, provided the flexor sheath can be dilated in an atraumatic manner: the balloon flexor sheathplasty.
Under general anaesthesia with proximal tourniquet control, the flexor tendon system was exposed using a zig-zag palmar incision (Bruner, 1967). The base of the distal phalanx was roughened to take the distal end of the graft. The flexor sheath was opened proximal to the A3 pulley, and distally, and a size 4 French gauge Fogarty catheter (Bard SA Croydon) was inserted in an antegrade direction. The catheter was inflated to maximum capacity of 1 ml (Fig 1), left for approximately 1 min to equilibrate, and then deflated and retracted 1–2 cm. The principles here are similar to performing an angioplasty, hence sheathplasty. The process was repeated until the entire sheath was dilated. The partially inflated catheter was then passed through the sheath to check adequate dilation. A zig-zag incision was made in the palm to isolate the flexor digitorum stump (Fig 2). The palmaris longus tendon was harvested from the same arm and anchored to the base of the distal phalanx using a pullout suture over a dental roll (Green et al., 1999). The graft was then passed proximally through the sheath by suturing it to the distal end of the deflated Fogarty catheter. Its proximal end was attached to the flexor digitorum profundus stump using a Pulvertaft weave (Pulvertaft, 1965b). The skin was closed with 4-O nylon and a Kleinert traction splint was applied with the wrist flexed.
CASE REPORT A 39-year-old, right-handed man who worked as an auto-glass technician and also played a keyboard was referred with a 1-year history of unusual triggering of his left ring finger. He had felt a click in the finger one day at work and it had then gradually become stiff over the ensuing months. He was unable to actively bend the distal interphalangeal joint. Physical examination revealed a supple finger with loss of active flexion at the distal interphalangeal joint, but a good passive range of motion. There was also triggering of the proximal interphalangeal joint of the finger. At exploration, it was found that the flexor digitorum profundus tendon had been avulsed and was lying at the level of the head of the metacarpal. It was adherent to the superficialis tendon as it passed under the A1 pulley. The incision was closed and the patient was informed that he might benefit from a tendon graft. He was brought back 4 months later for his flexor tendon reconstruction.
Fig 1 Testing balloon during dilatation. 487
488
Fig 2 Flexor digitorum profundus stump isolated through a separate incision.
Post-operative management was with early mobilization within the splint using the Kleinert traction. At 2 weeks he was provided with a night splint, but continued with Kleinert traction during the day until the 6th postoperative week. He was discharged at 4 months with 0–901 metacarpophalangeal, 0–1021 proximal interphalangeal and 20–501 distal interphalangeal active motion.
DISCUSSION The indications for two-stage tendon reconstruction include severe trauma, crushing injuries with associated fractures or skin damage, failed primary flexor tendon surgery, delayed diagnosis and excessive scarring of the tendon bed (Green, 1999). Sometimes the pulley system may be lost, either at the time of injury or as a result of scarring. One-stage tendon grafting with flexor sheath dilatation using a Fogarty catheter obviously has its limitations. It appears to be ideal when the flexor sheath is reasonably intact, even if it is narrowed by scar tissue. If the flexor sheath needs reconstruction, then we would advocate a two-stage graft, utilizing a temporary sili-
THE JOURNAL OF HAND SURGERY VOL. 27B No. 5 OCTOBER 2002
cone implant (Bassett and Carroll, 1963; Hunter and Salisbury, 1971). Although we exposed most of the flexor sheath system (Fig 1), we now believe that, as one becomes more experienced, only the proximal and distal ends need to be exposed to facilitate passage of the Fogarty catheter and suturing. Careful consideration and much caution are advised before offering the patient a free tendon graft to restore distal joint function. In a finger with a severed flexor digitorum profundus but an intact and fully functional flexor digitorum superficialis, much of the useful arc of motion is maintained. There is considerable risk to this function if while passing the tendon graft one injures the delicate system and adhesions intervene, resulting in overall loss of function (Green et al., 1999). Consequently, this procedure should be restricted to young people with supple joints and a reasonable need for active distal interphalangeal joint function. References Bassett AL, Carroll RE (1963). Formation of tendon sheaths by silicone rod implants. In: Proceedings of American Society for surgery of the hand; Journal of Bone and Joint Surgery, 45A: 884. Bruner JM (1967). The zigzag volar-digital incision for flexor tendon surgery. Plastic and Reconstructive Surgery, 40: 571–574. Colville J (1973). Tendon graft function. The Hand, 5: 152–154. Green DP, Hotchkiss RN, Pederson WC (1999). Green’s operative hand surgery. 4th edn. Churchill Livingstone, Philadelphia, PA. Hunter JM (1965). Artificial tendons: early development and application. American Journal of Surgery, 109: 325–338. Hunter JM, Salisbury RE (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, 53A: 829–858. Pulvertaft RG (1965a). Problems of flexor tendon surgery of the hand. Journal of Bone and Joint Surgery, 47A: 123–132. Pulvertaft RG (1965b). Suture materials and tendon junctures. American Journal of Surgery, 109: 346–352. Received: 15 November 2001 Accepted after revision: 26 March 2002 Mr W.T. Jarvis MD, FRCS, Specialist Registrar in Orthopaedics, Dept of Orthopaedic Surgery, Monklands Hospital, Flat 2, 10 Dorset Square, Glasgow G3 7LL, Scotland, UK. Tel.: +79 6800 6454; fax: +870 163 1607; E-mail: [email protected] r 2002 The British Society for Surgery of the Hand doi: 10.1054/jhsb.2002.0771, available online at http://www.idealibrary.com on