Flexor tendon surgery Part 2: Free tendon grafts and tenolysis

Review Article FLEXOR

TENDON

SURGERY

Part 2: Free tendon grafts and tenolysis J. W. STRICKLAND

Clinical Professor of Orthopaedic Surgery, Indiana University School of Medicine; Chief; Section of Hand Surgery, St. Vincent’s Hospital, Indianapolis, U.S.A.

In those instances where flexor tendons divided in zone 1 or zone 2 have not been or cannot be directly repaired, conventional free tendon grafting may represent the best procedure for restoring digital function. In recent years there has been a disconcerting tendency to immediately opt for staged flexor tendon reconstruction when a digit is biologically suitable for a single stage free graft. Free flexor tendon grafts were apparently first used in the hand by Lexer in 1912 (Lexer, 1912; Adamson and Wilson, 1961; Schneider, 1985). He used grafts to repair flexor tendons after rupture, old lacerations, infections contracture. Leo and “hopeless cases” of ischaemic Mayer (1916) published three articles that have served as the basis for the present-day concepts of flexor tendon surgery. He emphasised the need for exacting operative technique, the direct juncture of the tendon to bone, the use of an adequate muscle as a motor, and the necessity of peritenon around a flexor graft. In January 1918, Sterling Bunnell published a classic article on tendon grafting in which he stressed atraumatic technique, a bloodless field, perfect asepsis and the preservation of pulleys. He preferred the palmaris longus tendon as the donor graft and described a modified corkborer that could be used as a tendon stripper. Mason and Allen carried out experiments in 1941 which indicated that tendon grafts should not be moved for 21 to 25 days. In the first edition of his textbook on surgery of the hand in 1944, Bunnell described the pull-out wire suture technique, the success of which was confirmed by Moberg in 1951. The surgical methods and results of free flexor tendon grafting have subsequently been modified and reviewed by various leaders in the field of hand surgery, including Pulvertaft in England (1948, 1956, 1959, 1960, 1965, 1975, 1984), Graham (1947) Littler (1947, 1960, 1977), Boyes (1950, 1964, 1970, 1971), Boyes and Stark (1971) and White (1956, 1960) in the United States and Rank and Wakefield (1952, 1960, 1973) in Australia. Important contributions have also been made by Verdan in Switzerland (Verdan, 1960; Verdan, 1964; Verdan, 1966; Verdan, 1972; Verdan, 1979; Verdan and Crawford, 1979; Verdan and Michon, 1961; Verdan et al., 1971) and Tubiana (1964, 1966, 1972, 1979) in France. 368

Conventional free tendon grafting Indications: The indications for conventional free tendon grafting have been well established. Pulvertaft (1975) stated that successful results from standard grafting methods are obtained only when certain rules are followed : “The hand is in good overall condition, There is no extensive scarring. Passive movements are full or nearly full. The circulation is satisfactory. At least one digital nerve in the affected digit is intact.” “A precise and gentle surgical

technique

is used.”

“The patient is co-operative. A child under three years of age is unlikely to assist in the after-care and it is wise to postpone the operation until the child is older.” Schneider and Hunter (1982) have emphasised that the surgeon must decide whether a conventional free tendon graft or a staged reconstruction is most appropriate in a particular situation. Some patients will have experienced failed primary surgery or previous efforts at flexor tendon reconstruction and the degree of scarring within the digit may preclude the realistic possibility of achieving a good result from free grafting. Tubiana (1969, 1974) has detailed the principles of flexor tendon grafting which include that only one graft should be placed in one finger, that an intact superficialis tendon is never sacrificed, that the graft should be of small calibre and that its ends should be fixed away from the tendon sheath. Tubiana also recommended the careful calculation of the tension of the graft and the sparing of at least one pulley to prevent bowstringing. The late treatment of division or rupture of flexor digitorum profundus with an intact superficialis tendon is controversial. If the patient has full, strong function of the superficialis, the functional impairment of the involved digit may not be great. Since a tendon graft brings with it the risk of compromising existing function, many surgeons have advised a conservative approach with no treatment, tenodesis or arthrodesis being preTHE JOURNAL OF HAND SURGERY

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ferred to free grafting (Carroll and Match, 1970; Leddy and Packer, 1977; Little, 1960; Nalebuff, 1979; Nichols, 1975 ; Reid, 1969 ; Wakefield, 1960). Other surgeons have demonstrated satisfactory results with tendon grafts through an intact superficialis with varying indications in carefully selected patients (Bora, 1970; Chang et al., 1972; Goldner and Conrad, 1969; Jaffe and Weckess, 1967; Pulvertaft, 1960; Schneider, 1985; Stark et al., 1977; Versaci, 1970). Although in favour of free grafting for an isolated profundus division in selected cases, Pulvertaft (1960) stated that “it should not be advised unless the patient is determined to seek perfection and the surgeon is confident of his ability to offer a reasonable expectation of success without the risk of doing harm.” He further commented that the decision as to whether or not to carry out a graft in such circumstances depended on a number of factors, including the age of the patient, the condition of the finger and hand and the occupation and wishes of the patient. In 1960, he advised tendon grafting for the index and middle fingers but felt that the procedure to be appropriate in the ring and little fingers only when the patient required that specific action because of a special interest or occupation, as in the case of a musician or skilled technician. He later changed his thinking and in 1984 considered that free tendon grafting was often appropriate in the little finger, particularly when the superficialis tendon is found to be weak. In such patients, the improvement of grip provided by the restoration of profundus function makes the procedure worthwhile. He favoured the use of the plantaris tendon in such circumstances, because it is “thin and the most rapidly revascularised and is of sufficient length to provide graft for two digits.” Stark and associates (1977) felt that the pre-requisites for grafting included a superficialis tendon that is normal, a digit with full passive motion, minimal

Fig. 11

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soft tissue scarring and a patient between 10 and 21 years of age. Technical considerations {Fig. 11) : While many surgeons, including Bunnell (19 18, 1922, 1944, 1956, 1967), recommended excision of most of the flexor tendon sheath with retention of only small sections of the annular pulleys, it is now felt that one should strive to preserve as much of the sheath system as possible. Eiken (1980, 1981) has even suggested transplanting synovial tissue from the toes or wrists as autograft to close open sections of the fibro-osseous canal. We have already seen that the wholesale ablation of sections of the flexor tendon sheath may have a detrimental effect on the efficiency of flexor tendons and it is important to preserve the majority of the A2 and A, annular pulleys. The reconstruction of pulleys at the time of free tendon grafting is rarely advisable and, in most instances, the finding of a deficient pulley system should serve as an indication to proceed with staged reconstruction. Incisions for flexor tendon grafting may be either the zig-zag palmar incision advocated by Bruner (1967,1975) or the mid-lateral approach, which is favoured by many surgeons (Boyes, 1964; Littler, 1947; Rank and Wakefield, 1952; Schneider and Hunter, 1982; Tubiana, 1965). The latter has the advantage of placing the scar away from the area of grafting and providing a healthy bed of subcutaneous tissue over the sheath and graft. Continuous digito-palmar incisions, as recommended by Tubiana (1969), provide wide exposure of the flexor tendon system from the mid-palm to the finger tip. Although there is some disagreement as to which donor tendons should be chosen for free flexor tendon grafting, the palmaris longus (when available) probably has the most advocates. This tendon is present in approximately 85% of all persons (Reimann et al., 1944), is of sufficient length and

Technique of free tendon grafting. (top) Following preparation of a digital canal by excision of scar tissue and careful retention of annular pulleys, a free tendon graft is attached distally to a suture and passed from the base of the distal phalanx into the palm. The appearance of the tendon in the digital bed following completion of the distal juncture is shown. The method of distal juncture for adults is usually through a drill hole in the distal phalanx, through which the tendon is drawn by a suture which is secured dorsally over the nail using a small sponge and button. The profundus stump is then sutured to the graft to secure the juncture. (bottom) Following closure of the digital wound, a Pulvertaft weave is completed in the palm under sufficient tension to flex the involved finger slightly more than its normal resting posture.

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size and is easily procured from the ipsilateral forearm by small incisions and gentle traction or the use of a tendon stripper. The plantaris tendon may also serve as a satisfactory tendon graft, particularly when length is important. It is said to be present in about 93% of all individuals (Daseler and Anson, 1943), although personal experience would suggest that it is absent somewhat more frequently. The plantaris tendon is usually 1218 cm in length and may be garnered by an incision medial to the Achilles tendon and the use of a Brand tubular tendon stripper. Other tendons that may be employed as grafts include the extensor digitorum longus tendons to the second, third, and fourth toes; the extensor indicis proprius; extensor digiti quinti proprius; and the flexor digitorum superficialis tendon to the little finger (Kyle and Eyre-Brook, 1954; White 1960). Post-operative care:

While most surgeons are more reluctant to utilise early motion programmes following grafts than they are following flexor tendon repairs, there is a growing effort on the part of some surgeons to utilise mobilisation techniques similar to those employed following primary flexor tendon repair in an effort to mobilise tendon grafts. In the past, it was felt that flexor tendon grafts should be immobilised for at least three weeks to avoid tension on the suture and to allow for revascularisation (Tubiana, 1974). An article recently published by Tonkin et al. (1988) compared recovery of digital function following free tendon grafting with either a three or four week period of immobilisation or with an immediate controlled mobilisation programme. The final motion obtained was independent of the post-operative management, although the rate of graft rupture and of tenolysis was higher in the immobilisation group. Chow et al. (1987, 1988) indicate that the post-operative regimen which they have used so successfully following flexor tendon repair is equally effective for tendon grafts although no results have been published. Complications: Many problems can develop following flexor tendon grafting including tendon adherence, joint contractures, graft rupture, bow-stringing secondary to inadequate pulley preservation or restoration, recurvaturn of the P.I.P. joint, a graft that is too short or too long and the lumbrical-plus deformity described by Parkes (1971). While the management of most of these complications is apparent and specific for that condition, a ruptured graft is a semi-emergency situation. Rupture is more common at the proximal juncture than at the insertion and occasional mid-substance disruption can occur. As with ruptures after primary tendon repair, prompt exploration and repair stands the best chance of returning reasonable function in this unfortunate situation. Results: In 1971, Boyes and Stark assessed the results of 370

1000 consecutive free tendon grafts using the method originated by Bunnell. This work unquestionably serves as the definitive analysis of the performance of this technique. They found that factors which influenced the recovery of function, in order of importance, were scar, joint involvement, age, nerve injury and the digit involved. An excellent study by McClinton et al. (1982) reviewed the results of 100 free grafts with an intact superficialis tendon. In their series, the average active flexion achieved at the D.1.P joint was 48” and only 13 patients were considered to have unsuccessful result. They concluded that, in properly-motivated patients, tendon graft replacement of isolated profundus tendon injuries could give satisfactory results even in older patients. The growth of autografted tendons has been studied by Nishijima et al. (1988) who found that chicken flexor tendon grafts demonstrated the same growth rate as control tendons. Although tendon growth was retarded compared to control tendons at 15 weeks after operation, it was not statistically different at 20 weeks, This experiment would appear to confirm the clinical impression which surgeons have long had, that flexor tendon grafts do grow and the rate of growth appears to be proportional to digital growth. Weeks and Wray (1978) studied the rate of recovery after flexor tendon grafting. Their patients had a rapid increase in recovery of motion between 4 and 22 weeks, the majority occurring at the M.P. and PIP. joints, 90% of final motion was achieved by 22 weeks after grafting. Staged flexor tendon reconstruction

Restoration of flexor tendon performance in badly scarred digits has always been difficult. Several authors have reported the use of single-stage tendon grafts in these situations with only modest functional recovery (Butler etal., 1968; McCormacket al., 1962). Tendon homografts and allografts have been used with varying success (Cameron et al., 1970; Cameron et al., 1971; Peacock, 1959; Potenza, 1963 ; Potenza and Melone, 1977; Stark et al., 1977), although a small number of composite sheath-tendon allografts were shown to provide a surprisingly good return (Peacock et al., 1971). Unfortunately, technical difficulties with regard to securing, preserving, and implanting these grafts were significant obstacles to their widespread use. An ingenious staged flexor tendon repair was described by Paneva-Holevich (1965, 1969). In this technique, the severed proximal ends of the profundus and superficialis are sutured to each other in the palm. At the second stage, the flexor superficialis is cut at the musculotendinous junction, delivered distally through the flexor sheath, and sutured to the distal phalanx as a pedicle graft. Alms (1973) and Brug and Stedtfeld (1979) successfully employed the procedure and the technique THE JOURNAL OF HAND SURGERY

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has been combined with the use of silicone prosthesis implanted in the digital sheath during the first stage to prepare a bed for the subsequent distal pedicle transfer (Chong et al., 1972; Chuinard et al., 1980; Kessler, 1972). The procedure can apparently provide satisfactory results in either acute or salvage conditions, but it is not widely used in the United States. In an effort to improve the bed in which tendon grafts may be later placed, materials such as celloidin (Mayer, 1940), glass or metal (Milgram, 1960; Thatcher, 1939) have been used, but these materials apparently led to joint stiffness because their rigidity did not allow for passive digital motion while a pseudo-sheath was being formed around the implant (Chang et al., 1972). Bassett and Carroll (1963) began using flexible silicone rubber rods to build pseudo-sheaths in badly scarred flexor tendons in the 1950’s. Helal(l969,1973) alsoused silicone rubber tendon implants clinically as early as 1966 for two-staged flexor reconstruction. The implant and method which currently enjoys the most popularity has largely resulted from the work of Hunter and his associates (1965, 1970, 1971, 1975, 1977, 1984). The procedure has proved to be an extremely important addition to the armamentarium of the hand surgeon for reconstructing flexor tendon function in the badly damaged digit. Numerous reports have now been published that attest to the excellent performance of the technique in otherwise difficult or unsalvageable situations.

/

Indications: To achieve optimal results, one must carefully

follow the advice provided by the developers of the technique (Hunter and Schneider, 1975 ; Hunter and Schneider, 1977). Schneider and Hunter (1982) emphasise that this procedure should only be carried out after many factors have been taken into consideration. The patient should be informed of the complexity of the problem, the length and magnitude of the surgery, and the need for extensive post-operative therapy. Not all patients’ digits will be candidates for this lengthy and demanding procedure and, in some cases, arthrodesis or even amputation may be a more practical approach. It is emphasised that patients with severe neurovascular impairment are poor candidates for staged tendon reconstruction. Technical considerations (Fig. 12) : While most surgeons prefer to implant the silicone rod from the distal forearm to the tip of the digit, others prefer to carry staged tendon reconstruction from the tip to the palm which, when the palm has not been involved in the original or subsequent surgery, may be satisfactory (Rowland, 1975; Strickland, 1987). Schneider (1985) now recommends the use of an implant that closely corresponds to the size of the expected graft. A 4 mm implant is frequently appropriate. It should be threaded through the remaining pulleys and free gliding should be demonstrated before its distal insertion is secured. At this point, deficiencies in the annular pulley system may be overcome by pulley

c

i Fig. 12

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Staged flexor tendon reconstruction. (a) Stage one: appearance of the silicone rubber rod following its implantation. Pulleys have been reconstructed over the proximal and middle phalanges and that the implant has been left free to glide proximally. (b) In the second stage, a long tendon graft is attached to the distal silicone implant through a small incision. The implant and graft are then passed proximally through the pseudo-sheath and the distal tendon-bone juncture is carried out in a manner similar to that depicted for conventional free tendon grafting. (c) The digital wound is closed and the proximal weave through the profundus (or superficialis) motor tendon is completed.

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reconstruction. There are currently two techniques available for the distal implant juncture and each surgeon must make his own decision as to which he prefers (Schneider and Hunter, 1982; Schneider, 1985). One design (manufactured by Holter-Housner) has a metal end-piece on the implant, which may be fixed to bone beneath the profundus stump with a 2 mm Woodruff selftapping screw. Direct suture of the silicone rod to the retained profundus stump is carried out more frequently than the more demanding anchorage using the terminal screw. After approximately three months, when full resolution of the digital scars has been achieved and the best possible passive motion has been restored, it is appropriate to proceed with the second stage of the reconstructive process. The replacement of the silicone-Dacron implant by a free tendon graft may be carried out through the terminal portions of the scars on the digit and distal forearm used for the first stage. Unfortunately, the palmaris longus is usually not long enough for the staged reconstruction technique when it must extend from the forearm to the finger tip. When present, the plantaris tendon makes a better graft for this procedure because it is thin and long. The tendon graft is attached to the distal end of the implant and pulled proximally through the pseudo-sheath into the proximal incision. Distal and proximal connections and graft tension are essentially the same as those employed for conventional free tendon grafting. Post-operative care: Although Schneider and his associ-

ates now favour an early protected motion programme starting three days after the second-stage grafting procedure, many surgeons feel that three to four weeks of immobilisation are more appropriate, given the salvage nature of the procedure and the drastic effect which rupture would have on the effort to return tendon function. Complications : Complications after staged tendon reconstruction may include synovitis around the rod, infection or wound breakdown, and disruption of the distal implant-bone or tendon juncture after stage 1. Stage 2 complications include rupture of the graft, a graft that is too loose or too tight, the development of an intrinsicplus phenomenon and flexion deformities at the D.I.P. or PIP. joint or both (Chamay, 1978). Finally, adhesions of the graft may prevent successful recovery of digital motion and may require tenolysis (LaSalle and Strickland, 1983). The complications of either stage of the reconstructive process may severely compromise the result and must be dealt with accordingly. Results: In 1971, Hunter and Salisbury presented

their preliminary results after staged flexor tendon reconstruction. Our results (LaSalle and Strickland, 1983) support

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the value of the technique as the best reconstructive option for severely damaged digits. While they were not as good as those reported by the original authors, we were able to obtain an excellent or good result in 39% of the digits which underwent the procedure and this was improved to 65% in the excellent or good category following tenolyses in 47% of our patients. This 47% tenolysis rate was considerably greater than that reported by Hunter and Salisbury (197 1) and Chamay et al. (1979) (27%). Subsequent studies by WehbC et al. (1986), evaluating the Philadelphia experience, found 150 fingers to have regained a total active motion of 176”and a mean grip strength of 79% compared to a pre-operative 102” and 20%. Complications included a flexion contracture of varying degrees in 41% of the fingers, rupture of the tendon graft in 14% and infection in 4%. Amadio et al. (1988) evaluated 130 fingers in 101 patients treated between 1973 and 1984. Overall, a 54% good or excellent result was achieved utilising a T.A.M. percentage method, although only 19% had a final T.A.M. of greater than 180” in the P.I.P. and D.I.P. joints. Their complications included infection in 15x, rupture in 4%, amputation in 4% and reflex sympathetic dystrophy in 1%. 16% of their patients required tenolysis after stage 2. The factors associated with a poor result included injury in zones 1 or 2 in patients who are less than 10 years of age. Versaci (1970), Honner (1975) and Wilson (1980) all described promising results of the use of staged flexor tendon grafts for isolated profundus injury. A dissenting experience, however, was reported by Sullivan (1986): only seven of his 16 cases achieved a “satisfactory” result and five major complications occurred in four patients. He concluded that the overall results were no better than the results obtained by single-stage tendon grafting through an intact superficialis. Sullivan believed that there was no advantage of staged flexor tendon grafts over unstaged grafts for isolated profundus loss. Flexor tenolysis

Despite our best efforts at flexor tendon repair, free tendon grafting or staged reconstruction, adhesion formation and consequent restriction of tendon excursion occurs all too frequently. When satisfactory function cannot be restored, it may be necessary to proceed with tenolysis in an effort to improve tendon movement. The biological basis and clinical efficacy of this procedure have been questioned by some authors (Brooks, 1970; Bunnel, 1967; Peacock and Van Winckle, 1970; Rank, et al., 1973) but others believe that, when carried out properly, it is a worthwhile operation (Fetrow, 1967; Hunter et al., 1982; James, 1969; Schneider and Hunter, 1975; Schneider and Hunter, 1982; Schneider and Mackin, 1978; Schneider and Mackin, 1984; Strickland, 1982; Strickland, 1983; Strickland, 1985; Whitaker et THE JOURNAL OF HAND SURGERY

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al., 1977). Tenolysis must always be approached as a major surgical effort with careful patient selection and great attention to the details of the operative procedure and the post-operative mobilisation programme. Tenolysis is probably the most demanding of all flexor tendon procedures and, if it is to be successful, there must be close co-operation between the patient, the doctor and the therapist. Indications: Tenolysis may be indicated following flexor tendon repair or grafting when the passive range of digital flexion significantly exceeds active flexion. The decision to carry out the procedure should be based on serial joint measurements which show that there has been no appreciable improvement for several months despite a vigorous therapy programme and the conscientious efforts of the patient. The pre-requisites for tenolysis as set forth by Fetrow (1967), Hunter et al. (1982), Schneider and Hunter (1975) and Schneider and Mackin (1978, 1985) should be closely adhered to. All fractures should be healed and wounds must have reached “equilibrium” with soft, pliable skin and subcutaneous tissues and minimal reaction around scars. Joint contractures must have been mobilised and a normal or near-normal passive range of digital motion achieved. Satisfactory sensation and muscle strength should be regained and the patient must be carefully informed of the objectives, surgical techniques, postoperative course and pitfalls of the procedure. Many patients will be content with less than normal active digital motion, whereas others who have regained a fairly good range may want near-normal function and, in most circumstances, should be offered the operation. When a patient elects to undergo tenolysis, he must understand that if the findings at surgery preclude the possibility of returning satisfactory function, it may be necessary to proceed with the implantation of a silicone rod as the first step of a staged flexor tendon reconstruction sequence. Timing: The proper timing for tenolysis following tendon repair or graft is somewhat controversial. Wray et al. (1978) concluded from an experiment on chicken tendons that waiting for 12 weeks appeared to be optimum as it did not weaken the tendon and resulted in an increased blood supply. Fetrow and Pulvertaft (1967) recommended waiting three months after a primary tendon repair and six months after a flexor tendon graft before performing tenolysis. Rank et al. (1973) advocated waiting six to nine months following tendon grafting for those patients in whom serial examinations revealed no significant improvement. It is now generally accepted that one may consider tenolysis three months or more after repair or graft, providing the other criteria for the procedure had been satisfied and there has been no measurable VOL. 14-B No. 4 NOVEMBER

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improvement in active motion during the preceding four to eight weeks (Strickland, 1985; Strickland, 1987). Technical considerations (Fig. 13) : Schneider, Hunter and associates (1975, 1978, 1982, 1984, 1985) have popularised the use of local anaesthetic supplemented by intravenous analgesia and tranquilising drugs for tenolysis. This allows the patient to demonstrate the completeness of the lysis by actively flexing the involved digit during surgery. They also believe that it is important to allow the patient to observe the improved digital motion during surgery to provide motivation for the maintenance of that motion during the rigorous post-operative therapy programme. Most surgeons now agree that the advantages of local anaesthesia and active patient participation are enormous and recommend its use whenever possible (Fig. 14). The use of a sterile paediatric tourniquet applied to the mid-forearm has proved an effective method of dealing with the problems of muscle paralysis and tourniquet pain (Strickland, 1985; Strickland, 1987). Despite the earlier recommendation by Verdan (1979) that the sheath be widely excised at the time of tenolysis, most surgeons now prefer to preserve as much of the pulley system as possible. If portions of the pulley system have been damaged by injury or previous surgery, the forces acting on the smaller remaining pulleys during active flexion will be much greater with an increase in the likelihood of pulley rupture. It is therefore imperative to make every effort to maintain the majority of each of the annular pulleys. Hunter et al. (1972) have emphasised the importance of critical assessment of the quality of the flexor tendons at the time of surgery. They state that if 30% of the tendon width has been lost, or if the continuity of the tendon is through a small segment of scar tissue, it is questionable whether or not tenolysis should be carried out. They suggest that when the quality of the tendon is

Fig. 13

Digital tenolysis of adherent flexor tendons is illustrated; careful release of adhesions beneath the pulleys is facilitated by the use of small knife blades and elevators.

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rapid and aggressive re-formation of scar tissue or for those who are undergoing repeat lysis. In those instances, several millilitres of triamcinolone may be administered locally at the time of wound closure (Strickland, 1985 ; Strickland, 1987). One should be wary of the possibility of delayed wound healing or infection when using steroids in conjunction with this procedure. Hunter et al. (1982) and Schneider, Mackin et al. (1978, 1984) have reported on the use of an indwelling polyethylene catheter or a Jackson-Pratt soft silastic catheter to allow the intermittent administration of bupivacaine to provide pain relief during the first few days of therapy after tenolysis. Post-operative considerations: Although

Fig. 14

Tenolysis is concluded restraining adhesions has “traction check” through preferably, by the active iocal anesthetic (bottom). tenolysis, Hand Clinics, W. B. Saunders Co., with

when a complete release by all been achieved by either a proximal a separate wrist incision (top) or, participation of the patient under (From Strickland, J. W., Flexor Vol. 1: No 1: pp. 121-132, 1985, permission.)

seriously in doubt, it may be better to proceed with a staged reconstruction utilising an active or passive Hunter tendon implant. Various mechanical barriers have been used to limit the re-formation of peritendinous adhesions following tenolysis. There are conflicting opinions as to the usefulness of these materials. Boyes (1971) advocated silicone inlays in certain instances, and Bunnell (1967), Fetrow (1967) and Verdan (1979) have recommended peritenon and fascial inlays and reported satisfactory results. Bora et al. (1972) reviewed the results of fascia, vein, and cellophane around tenorrhaphy sites and concluded that these materials failed to prevent the reformation of adhesions and, in fact, acted as foreign bodies, promoting additional scarring as well as obstructing the revascularisation process. The most common indications for silicone interposition at present are in cases of repeat tenolysis in which the re-formation of adhering scar tissue over a long distance would seem to be almost inevitable (Strickland, 1985; Strickland, 1987). The use of steroid preparations in an effort to modify the quality and quantity of tendon adhesions following tenolysis has provoked considerable debate. Wrenn et al. (1954), Rank et al. (1973), Carstam (1953), James (1959) and Whitaker et al. (1977) have indicated that locally instilled cortisone drugs may be of some value. Conversely, Fetrow (1967), Brooks (1970) and Verdan et al. (1971, 1979) believe that they do not improve the results of the tenolysis. The adhesion-limiting property of triamcinolone, as demonstrated by Ketchum (1971), makes this drug appear to be a logical adjunct to the preservation of tendon gliding. It is probably best to reserve it for patients who have shown a propensity to 314

some authors have advocated immediate motion following flexor tenolysis, others have recommended starting therapy in several days or “as soon as soft tissue healing permits.” The rapid formation of new adhesions can probably be discouraged by methods which produce early tendon movement and immediate motion, compatible with wound healing, is desirable. It is probably best to initiate digital motion within the first 12 hours after flexor tenolysis whenever possible. If the tenolysed tendon has diminished calibre, is badly scarred or has been judged to be of poor quality at the time of surgery, the risk of tendon rupture may be considerable. Impending rupture may also be suspected in some patients who develop palpable crepitation in the digit during the early mobilisation programme. In both instances, therapy should be designed to diminish the tensile strength demand on the involved tendon while preserving the excursion achieved at surgery. In those instances, a “frayed tendon programme” has been suggested (Cannon and Strickland, 1985; Strickland, 1985; Strickland, 1987): this involves passively manipulating the digit into the fully flexed position and then asking the patient to actively maintain that flexion (Fig. 15). If the digit retains its flexed position following the removal of the manipulating finger, muscle contracture and tendon movement has been confirmed. In this manner, the tendon moves through its maximal excursion but with much less likelihood of rupture. Complications: Complications of tenolysis include wound breakdown and infection, for which the treatment is obvious. Rupture of the tendon is an infrequent but catastrophic complication. When this occurs, the surgeon must decide whether the appropriate option for that patient is an immediate repair or whether the patient’s previous surgery and the status of his flexor tendon system mitigate against an effort at repair. In some instances, the additional surgical insult may be too great and it may be better to allow the finger to rest and to proceed at a later date with staged flexor tendon reconstruction or to abandon the effort to restore movement and settle for arthrodesis or amputation. THE JOURNAL

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T.P.M.l = total passive motion (P.I.P. + D.I.P. -extension deficit) before surgery T.A.M.,=totalactivemotion(P.I.P.+D.I.P.-extension deficit) before surgery T.A.M.2 = total active motion (P.I.P. + D.I.P. - extension deficit) after surgery

Fig. 15

“Frayed tendon programme”: technique of post-operative mobilisation of the digit following flexor tenolysis. Full passive flexion of all three digital joints is carried out (top), followed by active attempts to maintain flexion (bottom). Tendon excursion is the same as that produced by active digital flexion with less tensile loading. This technique is particularly valuable for patients with somewhat stiffenedjoints or tendons of poor quality. (From Strickland, J. W., Hand Clinics Vol. 1: No. 1: pp 121, 1985. W. B. Saunders Co., with permission.)

Results: In 1977, we reviewed our results of flexor tenolysis in zone 2 for which a technique involving thorough delicate release of all restraining adhesions and immediate motion was used (Whitaker and Strickland, 1977). It was recognised that the results of this procedure could not be evaluated by comparison with the function of a normal finger but, rather, must take into account the pre-operative limitations to the ultimate function as determined by the passive range of motion. We concluded that any system to evaluate the performance of tenolysis accurately should be expressed as the percentage of the pre-operative difference between active and passive motion that was actively achieved by the procedure. The formula that we employed at the time of that study was based on the total passive motion and total active motion values advocated by the American Society for Surgery of the Hand. Since the publication of that report, we have chosen to omit the falsifying influence of the M.P. joint and have limited the evaluation to the composite flexion at the P.I.P. and D.I.P. joints while the patient attempts to make a fist, minus extension deficits at these joints. The resultant formula for evaluation of flexor tenolysis is : 100_T.P.M.l -T.A.M.2 x 100 = % of pre-operative T.P.M., -T.A.M., passive motion in excess of active motion actively achieved by tenolysis Where, T.P.M. = total passive motion (P.I.P. +D.I.P. - extension deficit) T.A4.M. = total active motion (PIP. +D.I.P. -extension deficit) VOL.

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Since our initial report, we have added additional cases of tenolysis of flexor tendon repairs or flexor tendon grafts (single stage or two-stage) and have studied the results of the procedure using the revised formula and a classification system compatible with that employed for other flexor tendon procedures. These findings indicate that tenolysis can be expected to restore at least 50% of the pre-operative discrepancy between active and passive motion at the P.I.P. and D.I.P. joints in 65% of digits that undergo the procedure. An additional 15% gained fair function, whereas 20% failed to benefit appreciably from the operation. A rupture rate of 8% remains disconcerting and is a calculated risk that must be explained to the patient prior to surgery. In our early study, we advocated the use of locally administered triamcinolone at the conclusion of the operative tendon mobilisation, an adjunct that we have largely abandoned in recent years. Although we have not specifically studied the results of lysis with or without the addition of local steroids, we do not believe that there has been any appreciable difference.

Flexor pulley reconstruction The importance of maintaining strong pulley support at the A2 and A4 levels has been emphasised earlier in this review. Various methods have been advocated for the reconstruction of deficient annular pulleys at the time of flexor tendon grafting, staged reconstruction or the restoration of a four-pulley system may ensure the best functional recovery. IReconstructed pulleys must hold the tendon as close to the underlying bone as possible without restricting its gliding (Boyes, 1964; Bunnel, 1962). It has been suggested that the pulley be reconstructed just distal to the M.P. and P.I.P. joints and at the bases of the proximal and middle phalanges (Schneider, 1985). Methods of pulley reconstruction include the use of a superficialis stump to reconstruct the A3, distal A2, or proximal A4 pulleys. Encircling tendon grafts may be employed and grafts may be placed through drill holes in the phalanx (Doyle and Blythe, 1975). Extensor retinaculum from the dorsum of the wrist may also be employed (Lister, 1979) and tendon grafts can be woven through the retained rim of a previous pulley (Kleinert and Bennett, 1978). In some instances, slits in the palmar plate may be effectively developed into pulleys during the first stage of tendon reconstruction using a “belt loop” procedure, as advocated by Karev (1984). Artificial materials used to recreate pulleys have included knitted 37s

J. W. STRICKLAND

Dacron arterial graft (Wray and Weeks, 1974) and silicone rubber sheeting (Bader et a1.1968) as shown in Fig. 16. Permanent active tendon implant

Hunter continues to pursue the creation of a permanent active tendon implant. A prototype that he has developed is now in use on an experimental basis. His most recent report, in November of 1988, evaluated the results of 45 active flexor tendon implants which were placed in scarred tendon beds. The implant was constructed of silicone rubber with a Dacron core terminating in a loop proximally and a metal plate distally. Modification of the implant during the period of study was felt to have improved its reliability and longevity. The improvement and total active motion averaged 72” during implant functioning (stage 1) in a group of digits that before operation was classified as 78% Boyes grade 5 (salvage). The complication rate during stage 1 was 11% (5 out of 45). Of the 27 digits evaluated after implant replacement by tendon autograft (stage 2) there was an overall improvement of 62” total active motion 70% of the digits being Boyes grade 5. The authors believe that this demonstrates the feasibility of an active tendon implant and the possibility of a permanent prosthesis. The implant is still considered as a temporary device which will be removed for second-stage grafting at the time of failure. Problems in developing permanent fixation

between the implant and the host tissues remain, although strides being made in clinical studies using active implants are encouraging. In time, a permanent active tendon implant will probably be developed which will solve many of the problems involved in the restoration of flexor tendon function in the severely damaged digit. Rehabilitation

Tremendous strides have been made in the management of flexor tendon injuries over the past 40 years. Improvements in the understanding of the anatomy, biomechanits, and healing, together with refinements in surgical technique, have contributed to improved functional recovery following injury. However, perhaps the most important advancement has resulted from the combined efforts of hand surgeons and therapists to establish effective pre-operative and post-operative treatment programmes which greatly enhance the results of flexor tendon surgery. The therapist’s involvement with a patient who has sustained the loss of flexor tendon function begins before operation with treatment to increase joint motion, desensitise painful areas, improve muscle strength and prepare the patient psychologically for the surgical procedure. A close liaison between surgeon, therapist and patient is essential and should include discussions in hospital or in the office. These conversations serve to provide a much clearer understanding of the realistic

Scxxl’h

MANUS’

-....

b

MANUS’ ,fcC”N/EL

Fig. 16

316

Technique for pulley restoration using circumferential tendon grafts. (a) Marked bow-stringing and tendon inefficiency resulting from the loss of all annular pulleys from the proximal A2 to the A5 level. Note the vertical displacement of flexor tendon and the need for increased tendon excursion to produce digital tlexion. (b) The use of a circumferential ligature carrier beneath the extensor tendon at the midproximal phalanx or over it at the middle phalanx to prepare a channel for the passage of a tendon graft. (c) Appearance of the pulley grafts after the juncture site has been rotated either to the side or dorsum of the digit. The proximal phalanx pulley has been reconstructed by two tendon loops to give a wider pulley restoration. (d) Improved mechanics of the flexor tendon following the restoration of annular pulleys over the proximal and middle phalanges.

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objectives of a given procedure and the therapeutic methods that will be implemented to achieve them. The well-trained hand therapist is capable of utilising information gained from serial evaluations and objective measurements to determine the efficacy of a given therapeutic programme and make appropriate adjustments. This approach has led to a dramatic improvement over the results that were achieved when the multipurpose therapist was forced to work in many areas of rehabilitation and to implement hand programmes ordered by written prescription using brief and generalised instructions. It is probable that the emergence of sophisticated hand therapy has been more valuable for flexor tendon repair and reconstruction than in any other area of hand surgery. The techniques for early mobilisation of repaired flexor tendons have been discussed and, whether one selects early controlled active or passive methods, it is extremely important that each patient be monitored closely with treatment individualised, depending on factors unique to that patient and his injury. Similarly, the methods used to provide an optimum range of passive motion of the injured digit before tendon grafting or staged flexor reconstruction are extremely important. The judicious use of splinting to overcome joint contractures, improve muscle strength and maximise the function of adjacent uninjured digits are extremely valuable. As with flexor tendon repair, the post-operative mobilisation of tendon grafts by carefully designed and implemented therapy is of tremendous importance. Finally, the demanding preand post-operative therapy required to complete a successful flexor tenolysis has already been emphasised. Throughout the management of patients with flexor tendon injuries, the therapist must have a thorough understanding of the pathological anatomy, the findings at surgery, the quality of the flexor tendons, the presence or absence of portions of the flexor sheath system, and the realistic goals of any surgical procedure. One cannot over-emphasise the need for close co-operation and understanding between patient, surgeon and therapist and the need to approach each patient as a person with unique requirements, limitations and goals. Summary We have attempted

to review the development and current status of flexor tendon surgery. The methods of acute flexor tendon repair, conventional free tendon grafting, staged flexor tendon reconstruction, tenolysis and pulley restoration have been discussed, with the published results included for each procedure. The role of rehabilitation has also been reviewed and the ongoing quest for an active flexor tendon prosthetic implant has been briefly mentioned. It may be seen that flexor tendon surgery is a complex and difficult art which requires a thorough appreciation

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of the normal flexor tendon system, the exact status of that system following injury and surgery and a strong understanding of the techniques which may be best utilised to restore tendon gliding and digital joint motion. The procedures described require both technical skill and experience and the post-operative therapy programmes must be carefully chosen for each patient. With the important laboratory and clinical advancements occurring in many areas of flexor tendon surgery, it is realistic to believe that in the future the techniques described here will be substantially altered and modified and to hope that results will continue to improve until the patient and surgeon can expect to restore most digits to nearly full function after flexor tendon interruption. Acknowledgement The author is extremely grateful illustrations used in this article.

to Mr. Gary

W. Schnitz

for the excellent

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(1984). A biomechanical evaluation of the function of the digital pulleys. Orthopaedic Transactions, 8: 2: 354. GRAHAM, W. C. (1947). Flexor-tendongrafts to the finger and thumb. Journal of Bone and Joint Surgery, 29 : 3 : 553-559. HADDAD, R. J., KESTER, M. A., MCCLUSKEY, G. M., BRUNET, M. E. and COOK, S. D. (1988). Comparative mechanical analysis of a loopedsu?ure tendon repair. Journal of Hand Surgery, 13A: 5: 709-713. HARMER, T. W. (1917). Tendon Suture. Boston Medical and Surgical Journal, 177: 808%810. HARMER, T. W. (1926). Cases of tendon and nerve repair. Boston Medical and Surgical Journal, 194: 16: 739-747. HARMER, T. W. (1936). Certain aspects of hand surgery. New England Journal of Medicine, 214: 13: 613-617. HARMER, T. W. (1938). Injuries to the hand. American Journal of Surgery, 42: 633-658. HELAL, B. (1969). Silastics in tendon surgery. The Hand, 1: 2: 120-121. HELAL, B. (1973). The use of silicone rubber spacers in flexor tendon surgery. The Hand, 5 : 1: 85-90. HERNANDEZ, A., VELASCO, F., RIVAS, A. and PRECIADO, A. (1967). Preliminary Report on Early Mobilization for the Rehabilitation of Flexor Tendons. Plastic and Reconstructive Surgery, 40: 4: 354-358. HONNER, R. (1975). The late management of the isolated lesion of the flexor digitorum profundus tendon. The Hand, 7: 2: 171-174. HONNER, R. and MEARES, A. (1977). A review of 100 flexor tendon reconstructions with prosthesis. The Hand, 9: 3: 226-231. HUNTER, J. M. (1965). ArtificialTendons. Early Development and Application. American Journal of Surgery, 109: 325-338. HUNTER, J. M. Staged flexor tendon reconstruction. In: Hunter, J. M., Schneider, L. H., Mackin, E. J. and Callahan, A. D. (Eds). Rehabilitation of thr Hand (2nd edn). St. Louis, C. V. Mosby, 1984: 288-313. HUNTER, J. M., COOK, J. F., OCHIAI, N., KONIKOFF, J. J., MERKLIN, R. J. and MACKIN, G. A. (1980). The pulley system. Journal of Hand Surgery, 5: 3: 283. HUNTER, J. M. and SALISBURY, R. E. (1970). Use of gliding artificial implants to produce tendon sheaths. Techniques and results in children. Plastic and Reconstructive Surgery, 45: 6: 564-572. HUNTER, J. M. andSALISBURY, R. E. (1971). Flexor-TendonReconstruction in Severely Damaged Hands: A two-stage procedure using a silicone-dacron reinforced gliding prosthesis prior to tendon grafting. Journal of Bone and Jo!nt Surgery, 53A: 5: 829-858. rIUNTER, J. M. and SCHNEIDER, L. H. Staged flexor tendon reconstruction: current status. In: American Academy of Orthopaedic Surgeons Symposium on Tendon Surgery in the Hand. St. Louis, C. V. Mosby, 1975: 271-274. HUNTER, J. M. and SCHNEIDER, L. H. Staged flexor reconstruction. American Academy of Orthopaedic Surgeon. Instructional Course Lectures, Vol26. St. Louis, C. V. Mosby, 1977: 134-144. HUNTER, J. M., SCHNEIDER, L. H., DUMONT, J. and ERICKSON, J. C. (1974). A Dynamic Approach to Problems of Hand Function Using Local Anesthesia Supplemented by Intravenous Fentanyl-Droperidol. Clinical Orthopaedics and Related Research, 104: 112-l 15. HUNTER, J. W., SEINSHEIMER, F. and MACKIN, E. J. Tenolysis: pain control and rehabilitation. In: Strickland, J. W. and Steichen, J. B. (Eds). Dzficult Problemsin Hand Surgery. St. Louis, C. V. Mosby, 1982: 312-318. HUNTER, J. M., SINGER, D. I., JAEGER, S. H. and MACKIN, E. J. (1988). Active tendon implants in flexor tendon reconstruction. Journal of Hand Surgery, 13A: 6: 849-859. HUXTER, R. H., JAEGER, S. H., ROSTOKER, W. and HUNTER, J. M. (1977). New core material for active tendon prosthesis. Orthopaedic Transactions, 1: 2: 223-224. IDLER, R. S. (1985). Anatomy and biomechanics of the digital flexor tendons. Hand Clinics, 1: 1: 3-12. IDLER, R. S. and STRICKLAND, J. W. (1986). The effects of pulley resection on the biomechanics of the proximal interphalangeal joint. University of Pennsylvania Orthopaedic Journal, 2: 20-23. IKUTA, Y. and TSUGE, K. (1985). Postoperative Results of Looped Nylon Suture Used in Injuries of the Digital Flexor Tendons. Journal of Hand Surgery, 10B : 1: 67-72. JAEGER, S. H. and MACKIN, E. H. Primary care of flexor tendon injuries. In: Hunter, J. M. Schneider, L. H., Mackin, E. J. and Callahan, A. D. (Eds). Rehabilitationofthe Hand (2nd edn). St Louis, C. V. Mosby, 1984: 261-272. JAEGER, S. H., ROSTOKER, %J. and HUNTER, J. M. (1977). Soft tissue attachmentsofactivetendonprostheses. OrthopaedicTransactions, 1: 2: 224. JAFFE, S. and WECKESSER, E. (1967). Profundus Tendon Grafting with the Sublimis Intact. An End-Result Study of Thirty Patients. Journal of Bone and Joint Surgery, 49A: 7: 1298&130X. JAMES, J. I. P. (1959). The use of cortisone in tenolysis. Journal of Bone and Joint Surgery, 41B: 1: 209.

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