- Email: [email protected]
Flexor Tendon Pulley Reconstruction
SURGICAL TECHNIQUE
Flexor Tendon Pulley Reconstruction Tod A. Clark, MD, Kshamata Skeete, MD, Peter C. Amadio, MD
HE DIGITAL PULLEY system guides flexor tendon excursion into efficient and useful motion at the interphalangeal (IP) joints. Damage or resection of the pulleys results in volar displacement of the flexor tendons and decreases their effectiveness on IP joint motion. The 2 most important pulleys are known to be the A2 and A4 structures.1,2 When half or more of these pulleys are damaged, bowstringing and loss of IP joint function can occur, especially if the adjacent A1, A3, and A5 pulleys are also injured.3
T
INDICATIONS AND CONTRAINDICATIONS Patients with spontaneous pulley insufficiency will often exhibit local tenderness; volunteer that they have pain with gripping, especially hook grip; and report that a ring or other support helps the symptoms. Such cases most commonly affect the A2 pulley, and with other pulleys intact, symptoms might be manageable with a ring or other support. Many such patients injure their pulleys as a result of climbing activities. Patients with postoperative pulley insufficiency—which can occur after aggressive trigger release, tendon repair or tenolysis, or simply as a result of an initial severe open injury—will often present with a flexion contracture. Regardless of etiology, imaging modalities such as ultrasound or magnetic resonance imaging will typically confirm the pulley loss and demonstrate bowstringing From the Mayo Clinic College of Medicine, Rochester, MN. Received for publication February 3, 2010; accepted July 25, 2010. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Peter C. Amadio, MD, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905; e-mail: [email protected]. 0363-5023/10/35A10-0021$36.00/0 doi:10.1016/j.jhsa.2010.07.029
of the tendon, either at the joint or simply over the normal bow of the phalanx (Fig. 1). Two main techniques are available for pulley reconstruction: weaving the pulley graft through the remaining pulley rim, or making an entirely new pulley loop around bone (Fig. 2). The repair to the available rim appears to be weaker, based on cadaver studies,4 whereas the around-bone technique can, in some cases, create focal bony ischemia and result in late phalangeal fracture.5 It has been our preference to use the aroundbone method in most cases. Active infection and IP joint contractures must be treated before proceeding. Probably the main relative contraindication is an ischemic digit, with injury to one or both neurovascular bundles, because postoperative fibrosis is more likely in such cases. Digits with poor skin cover are also generally poor candidates; it is usually not wise to pass a pulley graft under a skin graft, for example. We also hesitate to perform a pulley reconstruction when doing a tendon graft; if both procedures are indicated, then we prefer a staged reconstruction.6 SURGICAL ANATOMY The flexor tendon pulley system includes 5 annular and 3 cruciate pulleys (Fig. 3). The most crucial annular pulleys are the bony A2 and A4 pulleys, which arise from the proximal and middle phalanges, respectively. The A1, A3, and A5 pulleys are smaller in width and lie volar to the flexor tendons at the metacarpophalangeal, proximal IP, and distal IP joints, respectively. The cruciate pulleys are single or double oblique in shape, and include the C1, C2, and C3 pulleys. These lie between the A2-A3, A3-A4, and A4-A5 pulleys, respectively.
© Published by Elsevier, Inc. on behalf of the ASSH. 䉬 1685
Surgical Technique
Flexor tendon pulley reconstruction is relatively uncommon, and many technical treatment options have been described. The paucity of evidence in the literature supporting one technique can make these surgical decisions and surgeries challenging. Here, we present a focused review of the triple loop pulley reconstruction technique. (J Hand Surg 2010;35A:1685–1689. © 2010 Published by Elsevier Inc. on behalf of the American Society for Surgery of the Hand.) Key words Flexor tendon pulley system, pulley reconstruction, triple loop technique.
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FLEXOR TENDON PULLEY RECONSTRUCTION
Surgical Technique FIGURE 1: A T2-weighted sagittal magnetic resonance image. Flexor tendon bowstringing is evident, with high-intensity signal between phalanx and tendon.
SURGICAL TECHNIQUE The patient is positioned supine with the arm supported on a hand table. Surgery can be done under tourniquet hemostasis or using local anesthesia with epinephrine.7 The latter technique allows for better adjustment of pulley tension over an intact tendon, because the patient can actively flex the finger after the pulley is reconstructed, and it is our preference in those cases. General or regional anesthetic can be used, but tensioning is more difficult, as only passive motion can be assessed intraoperatively. If a tourniquet is used, it should not be placed on the forearm, as this could impede a proper assessment of flexor tendon tension intraoperatively. In addition, this impedes harvesting of the palmaris longus should it be the autograft of choice. Standard prepping and draping of the upper extremity is performed. Preoperative antibiotic prophylaxis depends on the surgeon and the procedure. A lead hand or other finger holding device is useful. The affected finger is approached volarly via either standard Bruner or midaxial incisions, often dictated by the presence of previous incisions. The digital neuro-
vascular bundles must be identified and protected. The pulley system is explored, with specific attention focused on the A2 and A4 pulleys. All scarred pulley tissue should be resected; it is mechanically abnormal and will not withstand normal forces. If the flexor tendons require additional inspection, this can be done via the cruciate windows or damaged annular tissues. It is also critically important to excise all scar posterior to the tendon, until the phalanges and volar plates in the bowstrung area are clearly exposed. Typically, a wedge of scar forms behind the bowstrung tendon; if this is not identified and excised, the pulley will be rebuilt over an unreduced tendon and the procedure will fail. After all scar is excised, active bowstringing and the presence of proximal or distal adhesions can be assessed, by allowing the patient to actively flex the digit. All adhesions must be released and full tendon gliding restored before pulley reconstruction; maintenance will be assessed again after the pulley has been reconstructed. The ulnar and radial borders of the proximal or middle phalanx are also dissected, ensuring adequate room for passage of the tendon graft deep to the neurovascular bundles. Care should be taken to preserve the vessels from the digital arteries feeding the tendon sheath and vincula; otherwise, the procedure can devascularize the tendon and predispose to postoperative adhesions. In cases of closed rupture, we prefer a palmaris longus autograft, although the extensor retinaculum is also reasonable and allows preservation of a synovialized pulley surface. In cases in which the pulley is being reconstructed over a tendon implant in a staged reconstruction, or when the flexor digitorum superficialis tendon is being excised, the flexor digitorum superficialis tendon can also be used. In cases in which none of these are available, a plantaris or even a flexor allograft can be considered. Local anesthetic at the wrist crease allows harvesting of the palmaris tendon with a Brand tendon stripper (George Tiemann & Co., Hauppauge, NY). The entire tendinous portion should be harvested, ensuring adequate length for a 3-loop construct. Regardless of source, the graft should be tagged with 3-0 nonabsorbable suture at both ends to facilitate passage and stored in moist, saline-soaked gauze until ready for use. A dorsal incision over the involved phalanx is usually not necessary. For the proximal phalanx, the extensor is retracted dorsally, allowing passage of the graft deep to the extensor mechanism. For the middle phalanx, the graft is passed superficial to the extensor. If at all possible, the reconstructed pulley should be placed where the original pulley (A2 or A4) was located. We normally do not reconstruct the A1, A3, or
JHS 䉬 Vol A, October
FLEXOR TENDON PULLEY RECONSTRUCTION
1687
FIGURE 3: Normal anatomy of the flexor tendon pulley system. The A2 and A4 components are the most critical. Copyrighted and used with permission of Mayo Foundation for Medical Education and Research.
A5 pulleys, although in cases of staged grafting, these pulleys can be relatively easily reconstructed over the tendon implant using the Karev belt-loop technique.8 This method has the advantage of keeping the tendon graft close to the axis of motion of the joint, even closer than normal. This provides a shorter lever arm, and thus, based on the radian concept, better joint motion
for a given amount of tendon excursion, which can be especially useful in such reconstructions.9 The pulley graft is passed around the phalanx circumferentially. A curved suture passer or right-angle hemostat is useful in passing the graft (Fig. 4). We strive for 3 loops around the proximal phalanx because laboratory studies suggest that this is the strongest construct.4 Usually only 2 loops can be passed over the middle phalanx. The extensor and neurovascular structures should be reassessed at this time, ensuring that they remain free from the tendon loops. Tensioning of the construct is crucial and should be assessed both visually and by palpation. The flexor tendons should remain in close contact to the phalangeal surface but have free unimpeded motion during active digital flexion. The graft is then fixed to the remnants of the normal pulley, and to itself, using 3-0 or 4-0 nonabsorbable suture (Fig. 5). If the pulley is built around intact tendons, active tendon motion should be tested again at this time. Active motion can be worse after surgery than intraoperatively, but it will not be better. This is the surgeon’s last, best chance to be sure that the new pulley is located and tensioned correctly and that the underlying tendon or implant is not restricted in its motion, either by the pulley construct or by adhesions proximally or distally. It is imperative that excellent hemostasis be achieved before wound closure, as hematoma will compromise wound healing, promote adhesions, and be a source of postoperative pain. All wounds should be thoroughly irrigated with saline and closed with nonabsorbable sutures. Dressing application consists of nonadherent gauze and a dorsal blocking splint, fabricated in the intrinsic plus position. The palmar aspect of the finger joints should be free of restricting tape or dressings, so that any active flexion will not encounter resis-
JHS 䉬 Vol A, October
Surgical Technique
FIGURE 2: A, B Two common techniques for flexor tendon pulley reconstruction. Copyrighted and used with permission of Mayo Foundation for Medical Education and Research.
1688
FLEXOR TENDON PULLEY RECONSTRUCTION
Surgical Technique
FIGURE 4: A, B. Intraoperative photographs of triple-loop pulley reconstruction. A suture passer allows circumferential passage of the tendon.
FIGURE 5: Completed triple-loop pulley reconstruction.
tance. It is helpful, however, to have some tape or other support anterior to the reconstructed pulley or pulleys. REHABILITATION AND POSTOPERATIVE CARE In the recovery area, the patient is instructed in gentle, passive flexion and (if the tendons are intact) place and hold exercises, to be performed within the postoperative dressing as comfort permits. At the first postoperative
dressing change, usually 2 to 3 days after surgery, wounds are examined and a hand therapy referral is made. A dorsal blocking splint is fabricated with a pulley strap to support the reconstructed pulley or pulleys. These will be worn between exercise sessions and at night for the first month after surgery; less if the pulley reconstruction is made over a passive tendon implant. The specific therapy prescription will depend on whether the pulley is built over an intact tendon or a tendon implant. With an intact tendon, place and hold and gentle active range of motion exercises of the IP joints are usually started at this time; these can be done out of the splint with finger support palmarly over the reconstructed pulley. Edema control measures can also be instituted at this time. Normally we recommend therapy visits 2 to 3 times per week. In patients with intact tendons, at 3 weeks after surgery, a thermoplastic pulley ring is usually fabricated, and the patient can begin to wear the ring and remove the splint more regularly, although we still recommend splint use when in public and at night for at least another week. Therapy modalities can be modified, depending on the amount of active and passive motion present at this point. The pulley ring should be used regularly for several months, as the pulley graft continues to heal. Usually by 6 weeks, the splint can be discontinued and light resistive exercises begun. At 12 weeks after surgery, heavier resistance can be instituted, and the pulley ring can be discontinued except for heavy gripping.
JHS 䉬 Vol A, October
FLEXOR TENDON PULLEY RECONSTRUCTION
COMPLICATIONS Complications are not uncommon during flexor tendon pulley reconstruction. The around-bone technique maximizes pulley strength but does not eliminate the need for careful intraoperative and postoperative monitoring to identify and address potential complications such as synovitis, stiffness, re-rupture, and infection.11 Tensioning the graft requires a close assessment of flexor tendon excursion, which, in our opinion, should be done both passively and actively. Over-tightening the graft commonly results in poor finger flexion and resultant stiffness. Poor tensioning yields a result similar to the patient’s initial presentation and is classified as a failure. Often, in our experience, this is related to inadequate excision of the scar wedge posterior to the tendon. This scar is often quite fibrotic and can be confused with the underlying phalanx. In cases in which doubt persists, lateral x-rays intraoperatively can ensure that the surgeon is indeed building the new pulley on a foundation of bone and not scar. Infection, though not common, is more common during these procedures, as they are often associated with 2-stage flexor tendon reconstructions and the placement of a tendon implant into the flexor sheath. Usually, an infected implant is preceded by synovitis, which in turn is due either to excessive activity or poor implant gliding, resulting in implant buckling.10,11 If
managed appropriately with immobilization, the synovitis can resolve without infection. Vigilance regarding synovitis is an important reason for close follow-up after the first stage of a 2-stage reconstruction. Rupture of the reconstructed pulley can occur but is not common. A second reconstruction can be performed in such cases. Most worrisome is late fracture of the phalanx beneath the pulley reconstruction. Such fractures should be treated based on the fracture anatomy, but they often compromise the final functional result. REFERENCES 1. Barton NJ. Experimental study of optimal location of flexor tendon pulleys. Plast Reconstr Surg 1969;43:125–129. 2. Doyle JR. Anatomy of the finger flexor tendon sheath and pulley system. J Hand Surg 1988;13A:473– 484. 3. Tanaka T, Amadio PC, Zhao C, Zobitz ME, An KN. The effect of partial A2 pulley excision on gliding resistance and pulley strength in vitro. J Hand Surg 2004;29A:877– 883. 4. Lin GT, Amadio PC, An KN, Cooney WP, Chao EY. Biomechanical analysis of finger flexor pulley reconstruction. J Hand Surg 1989; 14B:278 –282. 5. Lin GT. Bone resorption of the proximal phalanx after tendon pulley reconstruction. J Hand Surg 1999;24A:1323–1326. 6. Hunter JM. Staged flexor tendon reconstruction. J Hand Surg 1983; 8:789 –793. 7. Thomson CJ, Lalonde DH, Denkler KA, Feicht AJ. A critical look at the evidence for and against elective epinephrine use in the finger. Plast Reconstr Surg 2007;119:260 –266. 8. Karev A. The “belt loop” technique for the reconstruction of pulleys in the first stage of flexor tendon grafting. J Hand Surg 1984;9A: 923–924. 9. Amadio PC, An KN, Eieskar A, Guimberteau JC, Harris S, Savage R, et al. IFSSH Flexor Tendon Committee report. J Hand Surg 2005;30B:100 –116. 10. Mehta V, Phillips CS. Flexor tendon pulley reconstruction. Hand Clin 2005;21:245–251. 11. Wehbe MA, Mawr B, Hunter JM, Schneider LH, Goodwyn BL. Two stage flexor tendon reconstruction. Ten year experience. J Bone Joint Surg 1986;68A:752–763.
JHS 䉬 Vol A, October
Surgical Technique
In patients with pulley reconstruction over a tendon implant, buddy taping is usually instituted at 3 to 4 weeks, and the patient can gradually resume light activity as the surgeon awaits scar softening for stage 2 surgery. The surgeon must be vigilant at all times for signs of synovitis, which is the most common complication after stage 1 surgery.10
1689
Flexor Tendon Pulley Reconstruction Tod A. Clark, MD, Kshamata Skeete, MD, Peter C. Amadio, MD
HE DIGITAL PULLEY system guides flexor tendon excursion into efficient and useful motion at the interphalangeal (IP) joints. Damage or resection of the pulleys results in volar displacement of the flexor tendons and decreases their effectiveness on IP joint motion. The 2 most important pulleys are known to be the A2 and A4 structures.1,2 When half or more of these pulleys are damaged, bowstringing and loss of IP joint function can occur, especially if the adjacent A1, A3, and A5 pulleys are also injured.3
T
INDICATIONS AND CONTRAINDICATIONS Patients with spontaneous pulley insufficiency will often exhibit local tenderness; volunteer that they have pain with gripping, especially hook grip; and report that a ring or other support helps the symptoms. Such cases most commonly affect the A2 pulley, and with other pulleys intact, symptoms might be manageable with a ring or other support. Many such patients injure their pulleys as a result of climbing activities. Patients with postoperative pulley insufficiency—which can occur after aggressive trigger release, tendon repair or tenolysis, or simply as a result of an initial severe open injury—will often present with a flexion contracture. Regardless of etiology, imaging modalities such as ultrasound or magnetic resonance imaging will typically confirm the pulley loss and demonstrate bowstringing From the Mayo Clinic College of Medicine, Rochester, MN. Received for publication February 3, 2010; accepted July 25, 2010. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Peter C. Amadio, MD, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905; e-mail: [email protected]. 0363-5023/10/35A10-0021$36.00/0 doi:10.1016/j.jhsa.2010.07.029
of the tendon, either at the joint or simply over the normal bow of the phalanx (Fig. 1). Two main techniques are available for pulley reconstruction: weaving the pulley graft through the remaining pulley rim, or making an entirely new pulley loop around bone (Fig. 2). The repair to the available rim appears to be weaker, based on cadaver studies,4 whereas the around-bone technique can, in some cases, create focal bony ischemia and result in late phalangeal fracture.5 It has been our preference to use the aroundbone method in most cases. Active infection and IP joint contractures must be treated before proceeding. Probably the main relative contraindication is an ischemic digit, with injury to one or both neurovascular bundles, because postoperative fibrosis is more likely in such cases. Digits with poor skin cover are also generally poor candidates; it is usually not wise to pass a pulley graft under a skin graft, for example. We also hesitate to perform a pulley reconstruction when doing a tendon graft; if both procedures are indicated, then we prefer a staged reconstruction.6 SURGICAL ANATOMY The flexor tendon pulley system includes 5 annular and 3 cruciate pulleys (Fig. 3). The most crucial annular pulleys are the bony A2 and A4 pulleys, which arise from the proximal and middle phalanges, respectively. The A1, A3, and A5 pulleys are smaller in width and lie volar to the flexor tendons at the metacarpophalangeal, proximal IP, and distal IP joints, respectively. The cruciate pulleys are single or double oblique in shape, and include the C1, C2, and C3 pulleys. These lie between the A2-A3, A3-A4, and A4-A5 pulleys, respectively.
© Published by Elsevier, Inc. on behalf of the ASSH. 䉬 1685
Surgical Technique
Flexor tendon pulley reconstruction is relatively uncommon, and many technical treatment options have been described. The paucity of evidence in the literature supporting one technique can make these surgical decisions and surgeries challenging. Here, we present a focused review of the triple loop pulley reconstruction technique. (J Hand Surg 2010;35A:1685–1689. © 2010 Published by Elsevier Inc. on behalf of the American Society for Surgery of the Hand.) Key words Flexor tendon pulley system, pulley reconstruction, triple loop technique.
1686
FLEXOR TENDON PULLEY RECONSTRUCTION
Surgical Technique FIGURE 1: A T2-weighted sagittal magnetic resonance image. Flexor tendon bowstringing is evident, with high-intensity signal between phalanx and tendon.
SURGICAL TECHNIQUE The patient is positioned supine with the arm supported on a hand table. Surgery can be done under tourniquet hemostasis or using local anesthesia with epinephrine.7 The latter technique allows for better adjustment of pulley tension over an intact tendon, because the patient can actively flex the finger after the pulley is reconstructed, and it is our preference in those cases. General or regional anesthetic can be used, but tensioning is more difficult, as only passive motion can be assessed intraoperatively. If a tourniquet is used, it should not be placed on the forearm, as this could impede a proper assessment of flexor tendon tension intraoperatively. In addition, this impedes harvesting of the palmaris longus should it be the autograft of choice. Standard prepping and draping of the upper extremity is performed. Preoperative antibiotic prophylaxis depends on the surgeon and the procedure. A lead hand or other finger holding device is useful. The affected finger is approached volarly via either standard Bruner or midaxial incisions, often dictated by the presence of previous incisions. The digital neuro-
vascular bundles must be identified and protected. The pulley system is explored, with specific attention focused on the A2 and A4 pulleys. All scarred pulley tissue should be resected; it is mechanically abnormal and will not withstand normal forces. If the flexor tendons require additional inspection, this can be done via the cruciate windows or damaged annular tissues. It is also critically important to excise all scar posterior to the tendon, until the phalanges and volar plates in the bowstrung area are clearly exposed. Typically, a wedge of scar forms behind the bowstrung tendon; if this is not identified and excised, the pulley will be rebuilt over an unreduced tendon and the procedure will fail. After all scar is excised, active bowstringing and the presence of proximal or distal adhesions can be assessed, by allowing the patient to actively flex the digit. All adhesions must be released and full tendon gliding restored before pulley reconstruction; maintenance will be assessed again after the pulley has been reconstructed. The ulnar and radial borders of the proximal or middle phalanx are also dissected, ensuring adequate room for passage of the tendon graft deep to the neurovascular bundles. Care should be taken to preserve the vessels from the digital arteries feeding the tendon sheath and vincula; otherwise, the procedure can devascularize the tendon and predispose to postoperative adhesions. In cases of closed rupture, we prefer a palmaris longus autograft, although the extensor retinaculum is also reasonable and allows preservation of a synovialized pulley surface. In cases in which the pulley is being reconstructed over a tendon implant in a staged reconstruction, or when the flexor digitorum superficialis tendon is being excised, the flexor digitorum superficialis tendon can also be used. In cases in which none of these are available, a plantaris or even a flexor allograft can be considered. Local anesthetic at the wrist crease allows harvesting of the palmaris tendon with a Brand tendon stripper (George Tiemann & Co., Hauppauge, NY). The entire tendinous portion should be harvested, ensuring adequate length for a 3-loop construct. Regardless of source, the graft should be tagged with 3-0 nonabsorbable suture at both ends to facilitate passage and stored in moist, saline-soaked gauze until ready for use. A dorsal incision over the involved phalanx is usually not necessary. For the proximal phalanx, the extensor is retracted dorsally, allowing passage of the graft deep to the extensor mechanism. For the middle phalanx, the graft is passed superficial to the extensor. If at all possible, the reconstructed pulley should be placed where the original pulley (A2 or A4) was located. We normally do not reconstruct the A1, A3, or
JHS 䉬 Vol A, October
FLEXOR TENDON PULLEY RECONSTRUCTION
1687
FIGURE 3: Normal anatomy of the flexor tendon pulley system. The A2 and A4 components are the most critical. Copyrighted and used with permission of Mayo Foundation for Medical Education and Research.
A5 pulleys, although in cases of staged grafting, these pulleys can be relatively easily reconstructed over the tendon implant using the Karev belt-loop technique.8 This method has the advantage of keeping the tendon graft close to the axis of motion of the joint, even closer than normal. This provides a shorter lever arm, and thus, based on the radian concept, better joint motion
for a given amount of tendon excursion, which can be especially useful in such reconstructions.9 The pulley graft is passed around the phalanx circumferentially. A curved suture passer or right-angle hemostat is useful in passing the graft (Fig. 4). We strive for 3 loops around the proximal phalanx because laboratory studies suggest that this is the strongest construct.4 Usually only 2 loops can be passed over the middle phalanx. The extensor and neurovascular structures should be reassessed at this time, ensuring that they remain free from the tendon loops. Tensioning of the construct is crucial and should be assessed both visually and by palpation. The flexor tendons should remain in close contact to the phalangeal surface but have free unimpeded motion during active digital flexion. The graft is then fixed to the remnants of the normal pulley, and to itself, using 3-0 or 4-0 nonabsorbable suture (Fig. 5). If the pulley is built around intact tendons, active tendon motion should be tested again at this time. Active motion can be worse after surgery than intraoperatively, but it will not be better. This is the surgeon’s last, best chance to be sure that the new pulley is located and tensioned correctly and that the underlying tendon or implant is not restricted in its motion, either by the pulley construct or by adhesions proximally or distally. It is imperative that excellent hemostasis be achieved before wound closure, as hematoma will compromise wound healing, promote adhesions, and be a source of postoperative pain. All wounds should be thoroughly irrigated with saline and closed with nonabsorbable sutures. Dressing application consists of nonadherent gauze and a dorsal blocking splint, fabricated in the intrinsic plus position. The palmar aspect of the finger joints should be free of restricting tape or dressings, so that any active flexion will not encounter resis-
JHS 䉬 Vol A, October
Surgical Technique
FIGURE 2: A, B Two common techniques for flexor tendon pulley reconstruction. Copyrighted and used with permission of Mayo Foundation for Medical Education and Research.
1688
FLEXOR TENDON PULLEY RECONSTRUCTION
Surgical Technique
FIGURE 4: A, B. Intraoperative photographs of triple-loop pulley reconstruction. A suture passer allows circumferential passage of the tendon.
FIGURE 5: Completed triple-loop pulley reconstruction.
tance. It is helpful, however, to have some tape or other support anterior to the reconstructed pulley or pulleys. REHABILITATION AND POSTOPERATIVE CARE In the recovery area, the patient is instructed in gentle, passive flexion and (if the tendons are intact) place and hold exercises, to be performed within the postoperative dressing as comfort permits. At the first postoperative
dressing change, usually 2 to 3 days after surgery, wounds are examined and a hand therapy referral is made. A dorsal blocking splint is fabricated with a pulley strap to support the reconstructed pulley or pulleys. These will be worn between exercise sessions and at night for the first month after surgery; less if the pulley reconstruction is made over a passive tendon implant. The specific therapy prescription will depend on whether the pulley is built over an intact tendon or a tendon implant. With an intact tendon, place and hold and gentle active range of motion exercises of the IP joints are usually started at this time; these can be done out of the splint with finger support palmarly over the reconstructed pulley. Edema control measures can also be instituted at this time. Normally we recommend therapy visits 2 to 3 times per week. In patients with intact tendons, at 3 weeks after surgery, a thermoplastic pulley ring is usually fabricated, and the patient can begin to wear the ring and remove the splint more regularly, although we still recommend splint use when in public and at night for at least another week. Therapy modalities can be modified, depending on the amount of active and passive motion present at this point. The pulley ring should be used regularly for several months, as the pulley graft continues to heal. Usually by 6 weeks, the splint can be discontinued and light resistive exercises begun. At 12 weeks after surgery, heavier resistance can be instituted, and the pulley ring can be discontinued except for heavy gripping.
JHS 䉬 Vol A, October
FLEXOR TENDON PULLEY RECONSTRUCTION
COMPLICATIONS Complications are not uncommon during flexor tendon pulley reconstruction. The around-bone technique maximizes pulley strength but does not eliminate the need for careful intraoperative and postoperative monitoring to identify and address potential complications such as synovitis, stiffness, re-rupture, and infection.11 Tensioning the graft requires a close assessment of flexor tendon excursion, which, in our opinion, should be done both passively and actively. Over-tightening the graft commonly results in poor finger flexion and resultant stiffness. Poor tensioning yields a result similar to the patient’s initial presentation and is classified as a failure. Often, in our experience, this is related to inadequate excision of the scar wedge posterior to the tendon. This scar is often quite fibrotic and can be confused with the underlying phalanx. In cases in which doubt persists, lateral x-rays intraoperatively can ensure that the surgeon is indeed building the new pulley on a foundation of bone and not scar. Infection, though not common, is more common during these procedures, as they are often associated with 2-stage flexor tendon reconstructions and the placement of a tendon implant into the flexor sheath. Usually, an infected implant is preceded by synovitis, which in turn is due either to excessive activity or poor implant gliding, resulting in implant buckling.10,11 If
managed appropriately with immobilization, the synovitis can resolve without infection. Vigilance regarding synovitis is an important reason for close follow-up after the first stage of a 2-stage reconstruction. Rupture of the reconstructed pulley can occur but is not common. A second reconstruction can be performed in such cases. Most worrisome is late fracture of the phalanx beneath the pulley reconstruction. Such fractures should be treated based on the fracture anatomy, but they often compromise the final functional result. REFERENCES 1. Barton NJ. Experimental study of optimal location of flexor tendon pulleys. Plast Reconstr Surg 1969;43:125–129. 2. Doyle JR. Anatomy of the finger flexor tendon sheath and pulley system. J Hand Surg 1988;13A:473– 484. 3. Tanaka T, Amadio PC, Zhao C, Zobitz ME, An KN. The effect of partial A2 pulley excision on gliding resistance and pulley strength in vitro. J Hand Surg 2004;29A:877– 883. 4. Lin GT, Amadio PC, An KN, Cooney WP, Chao EY. Biomechanical analysis of finger flexor pulley reconstruction. J Hand Surg 1989; 14B:278 –282. 5. Lin GT. Bone resorption of the proximal phalanx after tendon pulley reconstruction. J Hand Surg 1999;24A:1323–1326. 6. Hunter JM. Staged flexor tendon reconstruction. J Hand Surg 1983; 8:789 –793. 7. Thomson CJ, Lalonde DH, Denkler KA, Feicht AJ. A critical look at the evidence for and against elective epinephrine use in the finger. Plast Reconstr Surg 2007;119:260 –266. 8. Karev A. The “belt loop” technique for the reconstruction of pulleys in the first stage of flexor tendon grafting. J Hand Surg 1984;9A: 923–924. 9. Amadio PC, An KN, Eieskar A, Guimberteau JC, Harris S, Savage R, et al. IFSSH Flexor Tendon Committee report. J Hand Surg 2005;30B:100 –116. 10. Mehta V, Phillips CS. Flexor tendon pulley reconstruction. Hand Clin 2005;21:245–251. 11. Wehbe MA, Mawr B, Hunter JM, Schneider LH, Goodwyn BL. Two stage flexor tendon reconstruction. Ten year experience. J Bone Joint Surg 1986;68A:752–763.
JHS 䉬 Vol A, October
Surgical Technique
In patients with pulley reconstruction over a tendon implant, buddy taping is usually instituted at 3 to 4 weeks, and the patient can gradually resume light activity as the surgeon awaits scar softening for stage 2 surgery. The surgeon must be vigilant at all times for signs of synovitis, which is the most common complication after stage 1 surgery.10
1689