FLEXOR TENDON INJURIES: THE RESULTS OF PRIMARY REPA M. SINGER and S. MALOON
From the Hand Unit, Brthopaedic Department, Groote Schuur Hospital and University of Cape Town, Sourh Africa This study is a critical analysis of results obtained following primary repair and post-operative controlled mobilisation of flexor tendon injuries which were treated by registrars with up to six months experience in hand surgery. 70 (55%) of 125 patients who underwent repair of a complete flexor digitorum profundus or flexor pollicis longus tendon injury during a 14-month period attended for review and these had a total of 140 injured digits. 93 (67%) were rated Lister’s standards as an “excellent” or “good” result. 39 (28%) occurred in “no man’s land” (Zone 2) and only 19 (49%) in this area were rated “excellent” or “good”. Isolated flexor digitorum superficialis tendon injuries have been excluded from this study, as have partial tendon injuries. Hand injuries are the most frequent of all injuries and flexor tendons are commonly affected. Pulvertaft (1948) summed up the problem when he said “It is not difficult to suture tendons and prepare the ground for sound union; the real problem is to obtain a freely gliding tendon capable of restoring good function”. When severed flexor tendons are incorrectly or inadequately treated, serious loss of function of the hand frequently results. There are five zones described for flexor tendon injuries, as shown in Figure 1.
Kleinert technique. However, one should not forget the aphorism: “man’s greatest faculty is that of selfdeception.” Therefore this prospective study was undertaken to assess critically the results obtained by registrars with between 0 and 6 months experience in hand surgery who have used this highly specialised and technically difficult procedure. Registrars are responsible for virtually all the primary flexor tendon repairs at Groote Schuur Hospital. The principles of primary repair are based on an atraumatic technique of handling the tendons, the use of the Kessler-Mason Allen suture (Kessler, 1973; Mason, 1940) and early controlled mobilisation. Method and material Technique employed at Groote Schuur
Fig. 1
Zone 1: Distal to the insertion of the F.D.S. tendon into base of the middle phalanx. Zone 2: Between the insertion of the F.D.S. tendon and the Al pulley (at the level of the M.P. joints). Zone 3: Between the Al pulley and the distal edge of the flexor retinaculum. Zone 4: In the carpal tunnel. Zone 5: Proximal to the carpal tunnel.
The repair of tendons in each zone has its own problems and prognosis. The most difficult segment is Zone 2, a semi-rigid fibro-osseous tunnel containing both flexor tendons. Because of the poor results of repair in this zone, it was termed “no-man’s land” and in more recent years “some man’s land” by Harold Kleinert. For some years it has been the policy of the Hand Unit at Groote Schuur Hospital that severed flexor tendons should be repaired primarily using the Received: I September 1987 M. Singer, Department of Orthopaedic Surgery, Groote Scbuur Hospital and University of Cape Town, South Africa.
VOL. 13-B No. 3 AUGUST
1988
spitai
The tendon ends are approximated with 4/O prolene, using a Kessler-Mason-Allen suture. Care is taken to avoid puckering or leaving a gap between the tendon ends. The suture ends are left long and used to rotate the tendon atraumatically, while a running circumferential suture of 6/O nylon is placed to coapt the epitenon (Fig. 2). The flexor sheath is carefully closed with 6/O nylon unless this would impede tendon gliding, in which case the sheath is not repaired. The hand is immolbilised in a dorsal plaster slab for four weeks, with the wrist 15” short of full flexion and the affected finger or fingers semi-flexed by the application of Kleinert’s (1975) elastic bands (Fig. 3). Next day, graduated active extension against elastic resistance (Fig. 4) is started and supervised by our specialised Hand Physiotherapy and Occupational Therapy Units. This paper is a report of a prospective study commenced in December, 1984. In the 1Cmonth period December 1984 to January 1986,128 patients underwent primary repair of a complete flexor digitorum profundus or flexor pollicis longus tendon injury. Isolated flexor digitorum superficialis tendon injuries have been 269
M. SINGER AND S. MALOON
vast majority of severed flexor tendons (Table 1). All the knife wounds and more than 50% of the glass injuries were the result of violent assault. TABLE 1 Causative agent Knife: Glass: Other:
Fig. 2
Left: Approximation of tendon ends using Kessler-MasonAllen sutures. Right: Running circumferential suture to coapt epitenon.
Three-quarters (Table 2).
35 30 5
(50%) (43%) (7%)
of the patients were unskilled workers
TABLE 2
Occupation
excluded from this study, as have partial tendon injuries, because it has been demonstrated that these injuries do well as compared to F.D.P. injuries or combined complete F.D.P. and F.D.S. severances. 70 of the 128 patients (55%) attended for review: these had a total of 140 injured digits and are the subject of this study. There was an average of two injured digits per patient, whereas Lister et al. (1977) in their series had 1.5 injured digits per patient and Ejeskar (1984) l-1 injured digits per patient, signifying that hand injuries in Cape Town are slightly more extensive. The patients’ ages ranged from 5 to 72, with a mean of 28.7 years. The follow-up period was from 10 weeks to 18 months, with a mean of 10 months. There was quite a high percentage (37%: 26 patients) of females involved. In 57%(40) the dominant hand was involved and in 43% (30) the non-dominant hand was injured. In this series, knife wounds and glass injuries were responsible for the
48% of the severed tendons occurred in Zone 5, and the next most frequent area of injury was in Zone 2 (Table 4).
Fig. 3
Fig. 4
270
Kleinert elastic bands in situ with hand repose.
Unskilled: Semi-skilled:
52 18
There was a fairly even distribution (Table 3).
(74%) (26%)
amongst the digits
TABLE 3 Digit injured Thumb Index Middle Ring Little
= = = = =
21 30 28 33 28
Kleinert band stretched by active extension of affected finger. THE JOURNAL OF HAND SURGERY
PRIMARY REPAIR OF FLEXOR TENDON INJURIES TABLE 4 Site of injury
Results
Zone !
II
=
8%
Zone 2
39
=
28%
Zone 3
10
=
1%
Zone 4
12
=
9%
zone 5
68
=
48%
140
=
100%
Total
These results have been assessed in each digit according to Lister’s method (Lister et al., 1 77) using flexion and extension deficits, which can be accurately assessed clinically with a ruler and goniometer. The flexion deficit is the minimum distance between the centre of the digital pulp and the distal palmar crease when the finger has been actively flexed (Fig. 5).
It was found that in 81% of F.D.P. injuries there was an associated F.D.S. injury. In addition, there were many significant associated injuries in this series (Table 5). TABLE 5 Associated injuries Arteries Radial Artery ULnar Artery
10 IS
‘v’erves Median Ulnar Digital Total
17 17 29 88
Fig. 5
Flexion and extension deficits are measured easily using a ruler and goniometer. Flexion deficit is measured from pulp to the distal palmar crease. Extension deficit is the total loss of extension at the M.P., PAP. and D.I.P. joints.
The main complication encountered was sepsis, occurring in 21% of cases. This was minimal in ten patients, only requiring premature removal of sutures, with no disruption of post-operative routine, but in five patients there was major sepsis which required formaI surgical drainage. Only four tendons (3%) ruptured in the post-operative period: these were designated poor results irrespective of the grading after secondary repair or flexor tendon graft (Table 6).
The extension deficit is the sum of the angles which each joint lacked when the finger was actively extended. The results are graded as excellent, good, fair or poor (Table 8). Our results in all zones have been tabulated and compared with those of Lister et aL (1977) in. Table 9. In Table 10 the results in Zone 2 are contrasted with those of Lister (1977) and Ejeskar (1984). However, it is important to note that it is extremely difficult to compare results meaningfully between different centres due to the large number of uncontroile
TABLE 6 Complications
TABLE 8 Grading of results
Minimal sepsis Major sepsis Rupture
10 patients 5 patients 4 tendons
Result
(14%) (7%) (3%)
25 of the 70 patients who returned for review (35%) had defaulted from our post-operative management regime (Table 7). TABLE 7 Defaulters 15/70 defaulted in POP and Kleinert bands 10170 defaulted after the POP was removed
21% 14%
less than less than less than more than
Extension deficit
lcm
Less than Lass than less than more than
1 - 1.5cm
1.6 - 3cm 3cm
15” 15 - 30” 31- 50” 50”
TABLE 9 Results in all Zones Result
The large number who defaulted before and immediately after the period of immobilisation was completed indicates that many patients in this group failed to appreciate the magnitude and seriousness of their injuries. VOL. 13-B No. 3 AUGUST 1988
Excellent Good Fair Poor
FIexion deficit
Number (GSH)
% (GSH)
9 (Listerp
Excellent
72
52%
67%
Good
21
15%
13%
Fair
11
Poor
36
8p7o 25%
8% 12%
140
* Lister (1977) included isolated F.D.S. injuries in his results: 17/140 (8%)
271
M. SINGER AND S. MALOON TABLE 10 Results in Zone 2 (no-man’s
Result
Number (GSH)
Excellent Good
% (GSH)
land)
% (Lister)
% (Ejeskor)
14
36%
53%
38%
5
13%
21%
23%
Fair
3
8%
I
21%
Poor
17
43%
18%
12%
N.B. Ejeskar (1984) m-sutured four tendons and tenolysed five in his series before assessing his results i.e..9/60 (15%).
Discussion There were several factors in our series tending towards a poor prognosis: the considerable number of associated injuries, poor patient compliance, and a number of injured digits per patient which was more than that of Lister (1977) and double those of Ejeskar (1984). In addition, the registrars had very limited experience in the treatment of hand injuries and they usually operated unassisted, and often at the end of a long day’s routine work. Despite all this, our results compare reasonably with other Hand Centres where the circumstances and the types of injuries analysed are more favourable, and where the bulk of the surgery is performed by senior and junior consultants. However, our serious infection rate is unacceptable and the high incidence of fair and poor results in Zone 2 leaves considerable room for improvement. We will endeavour to get better results by
272
insisting that primary tendon repairs are only performed in the presence of “tidy” wounds and if the patient arrives 12 hours or less after injury. In addition, registrars will not be permitted to carry out primary repairs where there are major associated injuries e.g. concomitant fractures, vessels and nerves. Conclusion If one takes into account all the adverse factors that have been mentioned, and the very critical analysis of our results, then we are reasonably satisfied with the policy of primary flexor tendon repair using Kleinert’s postulates and we will continue with it for the foreseeable future, but with the emphasis on even greater attention to technical details and more careful selection of patients for primary repair. References EJESKAR, A. (1984). Flexor tendon repair in no-man’s-land: Results of primary repair with controlled mobilisation. Journal of Hand Surgery, 9A: 2: 171-177. KESSLER, I. (1973). The “grasping” technique for tendon repair. The Hand, 5: 3: 253-255. KLEINERT, H. E., KUTZ, J. E. and COHEN, M. J. Primary repair of zone 2 flexor tendon lacerations. In A.A.O.S. Symposium on Tendon Surgery in The Hand. St. Louis, C.V. Mosby, 1975: 91-104. LISTER, G. D., KLEINERT, H. E., KUTZ, J. E. and ATASOY, E. (1977). Primary flexor tendon repair followed by immediate controlled mobilisation. Journal of Hand Surgery, 2: 6: 441-451. MASON, M. L. (1940). Primary and secondary tendon suture. A discussion of the significance of technique in tendon surgery. Surgery, Gynecology and Obstetrics, 70: 393-402. PULVERTAFT, R. G. (1948). Repair of tendon injuries in the hand. Annals of the Royal College of Surgeons of England, 3: 3-14.
THE JOURNAL OF HAND SURGERY