FLEXOR TENDON METHOD OF REPAIR
REPAIR USING A “SIX STRAND” AND EARLY ACTIVE MOBILISATION R. SAVAGE and G. RISITANO
From the CardifSRoyal Injrmary
A “six-strand” method of tendon repair has been used to treat 36 fingers with flexor tendon lacerations. Following surgery, active mobilisation in a protective splint was begun immediately. 63% of lacerations were in zone 2 and 27% in zone 1. 69% and 100% respectively achieved an excellent or good result using Buck-Gramcko’s assessment method. 81% of all the fingers were rated excellent or good. Journal of Hand Surgery (British Volume, 1989) 14B: 396-399 The present vogue for early movement of the fingers after primary flexor tendon repair seems to have improved the results. Amongst other factors, this has been achieved by using the technique of controlled dynamic mobilisation (Lister et al., 1977), but deficiencies have been brought to light when the method is used in other centres; patients do not move the finger within the splint as much as the surgeon believes appropriate (Phillips et al., 1985), the excellent results that Lister reports cannot be reproduced (Earley and Milward, 1982) and gapping at the repair has been shown to be associated with a poor range of movement and reduced power of the finger (Ejeskar and Irstam, 198 1). A “six stranded” suture technique is thought to be strong enough to allow early active movement of the finger (Savage, 1985), and thus to avoid some of the problems of controlled dynamic mobilisation. Preliminary results were encouraging and we now report our experience of 36 injured digits for which the suture technique has been used. During the study period, attitudes to sheath closure have changed and a new system of post-operative mobilisation has evolved; both are based on experimental work (Savage, 1988 and unpublished data).
Materials and method Patients All patients presenting to the authors with acute flexor tendon lacerations were treated by primary repair. Their site was classified by Leddy’s (1982) modification of Verdan’s zone system. Between 1983 and 1989, 37 patients with 41 significantly injured digits were treated (lacerations of F.D.S. and F.D.P., F.D.P. alone and F.P.L.). Five cases failed to attend follow-up after three weeks, and also failed to return a postal questionnaire, so could not be reviewed. Thus there were 32 patients available for review, with 36 significantly injured digits (Table 1). There were ten injuries in zone 1, 23 injuries in zone 2, two injuries in zone 3, no injuries in zone 4 and one injury in zone 5. The 396
Table l-Details Patient 1
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 2.5 26 27 28 29 30 31 32
of individual patients and scores
Sex
Finger
R/L
Age
F F M M F F M M M M M M F F F M M
middle ring little middle middle middle little index middle ring index little middle middle ring little index middle little ring thumb ring little little ring ring ring little little little ring little ring index thumb thumb
R R R R R L R R R R L R R R L R
39 39 37 45 21 20 24 34 34 34 37 44 21 19 42 28 47 63 23 54 32 19 26 26 19 55 20 27 50 49 11 11 20 42 15 28
M
M M M M M M M M M F M F M M M M F F
L
L R R R R R R L R L R R L R R R L R R
Score
Zone Tendon 1 1 2 1 2 3 5 2 2 2 1 2 1 3 2 2 2 2 2 1 2 1 2 2 1 1 2 2 2 2 2 2 2 1 2 2
F.D.P. F.D.P. F.D.P. F.D.P. F.D.P. F.D.P. F.D.P. F.D.P. F.D.P. F.D.P. F.D.P. F.D.P. F.D.P. F.D.P. F.D.P. F.D.P. F.D.P. F.D.P. F.D.P. F.D.P. F.P.L. F.D.P. F.D.P. F.D.P. F.D.P. F.D.P. F.D.P. F.D.P. F.D.P. F.D.P. F.D.P. F.D.P. F.D.P. F.D.P. F.P.L. F.P.L.
& F.D.S. & & & & &
F.D.S. F.D.S. F.D.S. F.D.S. F.D.S.
& F.D.S. & F.D.S.
& F.D.S. & F.D.S.
& F.D.S. & F.D.S. & F.D.S. & F.D.S. & F.D.S. & F.D.S. & F.D.S.
15 15 15 15 15 15 15 9 9 15 15 15 15 11 14 15 9 11 12 15 15 15 15 15 15 14 11 13 4 9 15 15 3 12 8 15
age range was from 11-63; there were 23 men and 10 women. In seven cases (5, 10, 12, 13, 14, 18 and 32), a single digital nerve was divided and in one case (6) the main ulnar nerve was divided in zone 5. In cases 16,27 and 28, there was division of both digital nerves and in case 15, there was division of both digital nerves and both digital arteries. In case 15, there was laceration of the volar plate of the P.I.P. joint. THE JOURNAL
OF HAND
SURGERY
FLEXOR
TENDON
REPAIR
USING
SIX STRAND
METHOD
Technique of repair and mobilisation All repairs were carried out within 24 hours of injury, under general anaesthetic and tourniquet. The wound was cleaned with aqueous Savlon 1% and hydrogen peroxide. Where necessary, but rarely, crushed and contaminated tissues were excised. Penicillin and flucloxacillin were prescribed for one week. The wound was extended, using the “zig-zag” technique of Bruner (1967) where possible. The tendon ends were retrieved and the proximal end transfixed by a needle. The opening in the digital fibrous flexor sheath was extended at the site for repair so that about 13 cm of tendon was exposed. Earlier in the series, complete incision of the A2 and A4 pulleys was avoided, but later these pulleys were cut if necessary. The tendon repair (Savage, 1985) comprised three grasping stitches in each tendon end and six strands of 4/ 0 Ethibond suture material (braided polyester, Ethicon Ltd, Edinburgh). To make the grasping stitch (Fig. la), the needle entered the tendon end, emerged at A, reentered at B, emerged opposite D, re-entered at C, emerged opposite C, re-entered at D, emerged opposite B, re-entered at E and finally came out of the tendon end. Six such grasping stitches, each about 1 to 1.5 mm diameter and about 5 to 10 mm from the tendon end, were made sequentially (Fig. lb) around the tendon (Fig. lc). A practical point was to grip the tendon end with toothed forceps whilst inserting the suture, putting a small bundle of tendon fibres in tension where the grasping stitch was made. This method of using three grasping stitches in a continuous fashion was applied to plump, oval or round tendons; for flat tendons interrupted sutures were used, for small tendons (e.g. profundus of the little finger) two grasps were used and for very thin tendons (e.g. superficialis distal to its division) only one grasp was used. Following the work of Wade et al., (1986), a fine “epitenon” suture of 6/O Prolene was used in the second half of the series. The fibrous tendon sheath was repaired, but only if snagging of the tendon could be avoided. After release of the tourniquet, bleeding was stopped and the wound was closed. Light dressings and a dorsal plaster-of-Paris splint were applied with the wrist straight, the M.P. joints at 90” and the I.P. joints straight. Any restraining bandages on the palmar side of the fingers were removed and gentle active and assisted active movements begun the day after surgery, trying to aim for repeated small-force movements through a range that was easy. The splint was removed after three to four weeks. At this stage, attempts were made to obtain a full range of movement with gentle to moderate active flexion and extension exercises. After six weeks, more vigour could be used if necessary. According to the patient’s needs, this included active, passive, resisted and blocked exercises. VOL.
14-B No. 4 NOVEMBER
1989
Tendon -_-
Ii9I +
\
a
_ ____________~\
IE tA
\ /’ % *’ ‘\ xj tB
tD tC
--
11
Tendon
Tendon
-7
____----
b
C Fig. 1
blood vessels
Technique for the six-strand repair. (a) Insertion of one of the grasping stitches. (b) Six sequential stitches are used in this way. (c) They are distributed around the circumference of the tendon, avoiding the vincular area. (With permission of the Editor of the Journal ofHand Surgery.)
Results The results were recorded at a minimum of three months, and evaluated by the method of Buck-Gramcko et al. (1976) which shown in Table 2. Of the 23 zone 2 injuries, 17 had laceration of both tendons; 70% of these had an excellent or good result. The remaining six zone 2 injuries had laceration of profundus only; all of these had an excellent result. Of the 36 digits, for all zones, the functional results (Table 3) were : excellent 23 (64x), good 6 (17x), fair 5 (14%) and poor 2 (5%). Results by zone are also shown in Table 3. 391
R. SAVAGE
Table Za-Scoring Gramcko, 1976)
Tip to distal palmar flexion
Extension
Composite extension
system
for assessing
crease/composite
minus
for fingers
O-2.5 cm/ > 200” 2.5-4.0 cm/> 180” 4.0-6.0 cm/> 150” >6.0 cm/i 150”
deficit
flexion deficit
results
composite
(Buck-
Score 6 4 2 0
O&30” 31-50” 51L70” z 70”
3 2 1 0
> 160” > 140” >120 < 120”
6 4 2 0
Evaluation Excellent Good Fair Poor
AND
Total score 14-15 11-13 7-10 O-6
Table Zb-Scoring Gramcko, 1976)
system
for assessing
for thumbs (Buck-
Flexion at I.P. joint
50”-70” 30”49” 1O”-29
Score 6 4 2 0
Extension
O”~10” 1 l ”-20” 21”-30” < 30”
3 2 1 0
>40” 30”-39” 20”29” < 20”
6 4 2 0
Range of movement
Total Score 14-15 11-13 7-10 O-6
Evaluation Excellent Good Fair Poor
Table >Results
Excellent Good Fair Poor
Zone I
Zone2
Zone3
Zone 5
All zones
All zones
10
23
2
I
36
%
9 1* 0 0
12* 4 5* 2
1 A
1 0 0 0
23 6 5 2
64 17 14 5
0
*Includes one thumb.
Complications
In case 11 there was good superficialis function but poor profundus function (score 11 i.e. good); re-exploration four months after injury, showed the superficialis repair 398
had elongated 0.5 cm and the profundus repair had become adherent and elongated 1.5 cm. The gap was filled with fibrous tissue. This was excised and rerepaired, using controlled dynamic splintage post-operatively. In Case 7, elongation and adherence were presumed because there was resistance to full extension with a range of only 15” of active flexion at the D.I.P. joint. There was one case (no. 29) of dehiscence. Extension deficit greater than 30” occurred in three fingers (cases 12, 14 and 16). There was delayed skin healing in cases 15 and 16 and there was one case (no. 12) of reflex sympathetic dystrophy. In case 26, tenolysis was performed two months after repair and the final score was 11 (good). Discussion
results
deficit
G. RISITANO
Even the most skilful and devoted surgeons have not achieved good results in all cases of flexor tendon repair in the hand. It is no surprise, therefore, that there are some failures in this series but we believe that there are significant advantages to the system described here. Initially, the six-stranded suture technique was devised. This trebled the strength of the repair compared to two-stranded repairs, allowing contemplation of active motion post-operatively (Savage, 1985). Addition of the “epitenon” suture improved the macroscopic appearance of the gap at the repair, making it smoother at the time of surgery and giving the expectation that the gap (now closed) would be less likely to snag on the sheath and to separate with time. The trend to preserve the flexor sheath, for biological and mechanical reasons, has encouraged surgical techniques to enable it to be fully repaired after flexor tendon surgery (Lister, 1983). However, recent work has suggested that the edges of the tough A2 and A4 pulleys are unyielding to irregularities on the tendon (Amis and Jones, 1988) such as those resulting from recent repair and that the A2 and A4 pulleys are not required mechanically when most of the rest of the sheath is intact (Savage-unpublished). Therefore, in the latter part of this series, the flexor sheath was opened where necessary and was not repaired if it was too tight, to allow free gliding of the tendon. In these cases, it was always observed that the thicker unclosed part of the flexor sheath surrounded about twothirds of the tendon. The looser parts could be closed easily without impairing tendon gliding. In the duel between adhesion and rupture, postoperative management is important, and the variations are legion. The potential advantages of active mobilisation are that it seems less complicated than controlled dynamic mobilisation (Lister et al. 1977) and that gliding of the tendon must occur if there is movement of the joints. The potential disadvantage is that rupture may occur if the patient pulls too hard. To this end, there are THE
JOURNAL
OF HAND.SURGERY
FLEXOR
TENDON
REPAIR
some important points of technique. As the study progressed, it became obvious that it is easier to mobilise the fingers actively with the wrist extended and this was supported by an experimental study (Savage, 1988). However, the M.P. joints are held flexed to prevent full extension of the fingers. The most difficult problem is to instil in the patient an understanding of how hard to pull. Reference to the balance between the tendon healing and pulling apart is made and patients are asked to pull as gently as can produce about a third or a half of the normal range, emphasis being put on regaining extension as well as flexion. It has seemed inadvisable to encourage more than this in the first three weeks. A physiotherapist was not involved in the first three to four weeks except in departments where a particular therapist gained familiarity with the technique. This did not reflect a lack of need for physiotherapy but rather a failure of the surgeons to convey to all the members of a general physiotherapy department the subtleties of the method. Most patients returned home one or two days after operation and were seen in clinic once a week in the first few weeks to check the integrity of the plaster and to give encouragement or discouragement in mobilisation efforts. For the assessment of results, the system of BuckGramcko (1976) was used because it gives credit for both flexion and extension ability (Neilsen and Jensen, 1985). Care has been taken to apply it to injured digits alone, for which it was intended. The length of follow-up was set at a minimum of three months so that any late ruptures might be included but there were none. In choosing so short a follow-up interval, some digits may have appeared falsely poor, as significant improvement was seen in some cases that were followed longer than this.
VOL.
14-B No. 4 NOVEMBER
1989
USING
SIX STRAND
METHOD
Acknowledgment The authors thank the surgeons of Kings College Hospital, Mayday Hospital, Royal Gwent Hospital, Cardiff Royal Infirmary and Derbyshire Royal Infirmary who have allowed us to study and report their cases.
References AMIS, A. A. and JONES, M. M. (1988). The interior of the flexor tendon sheath of the finger. Journal of Bone and Joint Surgery, 70B: 4: 583-587. BRUNER, J. M. (1967). The Zig-Zag Volar-Digital Incision for Flexor-Tendon Surgery. Plastic and Reconstructive Surgery, 40: 571-574. BUCK-GRAMCKO, D., DIETRICH, F. E. and GOGGE, S. (1976). Bewertungskriterein bei Nachunterschungen van Beugesehnen-wiederherstellungen Handchirurgie, 8: 65-69. EARLEY, M. J. and MILWARD, T. M. (1982). The Primary Repair of Digital Flexor Tendons. British Journal of Plastic Surgery, 35: 2: 133-139. EJESKAR, A. and IRSTAM, L. (1981). Elongation in profundus tendon repair. A clinical and radiological study. Scandinavian Journal of Plastic and ReconstructiveSurgery, 15: 61-68. LEDDY, J. P. Flexor Tendons-Acute Injuries. In: Green, D. P. (Ed.) Operatiw Hand Surgery, 1st edn. New York, Churchill Livingstone, 1982: Vol2: 13471350. LISTER, G. (1983). Incision and closure of the flexor sheath during primary tendonrepair. The Hand. 15: 2: 123-135. LISTER, G. D., KLEINERT, H. E., KUTZ, J. E. and ATASOY, E. (1977). Primary flexor tendon repair followed by immediate controlled mobilisation. Journalof Hand Surgery, 2: 6: 441-451. NIELSON, A. B. and JENSEN, P. 0. (1985). Methods of Evaluation of the Functional Results of Flexor Tendon Repair of the Fingers. Journal of Hand Surgery, IOB: 1: 60-61. PHILLIPS, G. F., McGROUTHER, D. A. and ANDREW&B. J. (1985). Finger Mobility Following Flexor Tendon Repair. Journal of Hand Surgery, IOB: 3: 337-339. SAVAGE, R. (1985). In Vitro Studies of a New Method of Flexor Tendon Repair. Journal of Hand Surgery, IOB: 2: 135-141. SAVAGE, R. (1988). The influence of wrist position on the minimum force required for active movement of the interphalangealjoints. Journal of Hand Surgery, 13B: 3: 262-268. WADE, P. 3. F., MUIR, I. F. K., HUTCHESON, L. L. (1986). Primary Flexor Tendon Repair; The Mechanical Limitations of the Modified Kessler Technique. Journal of Hand Surgery, 11B: 1: 71-76.
Accepted: 9 May, 1989 Mr. R. Savage, 6 Bryngwyn 0
1989 The British
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