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One hundred tendon grafts for isolated flexor digitorum profundus injuries
ORIGINAL COMMUNICATIONS
One hundred tendon grafts for isolated flexor digitorum profundus injuries One hundred cases of isolated flexor profundus tendon laceration or rupture were repaired by tendon graft over a 30-year period. Thirteen patients were over 40 years of age with the age range in the study from llh to 60 years. Unless the flexor profundus tendon remained in the decussation of the superficialis, all grafts were placed around the superficialis tendon decussation. Measurements of passive tendon excursion were considered critical in the selection of a motor for the tendon graft. All but two profundus graft motors could be passively extended to 30 mm. Average active distal interphalangeal (IP) joint flexion was 48 degrees following surgery. In thirteen patients the results were considered unsuccessfUL, with loss of greater than 20 degrees from preoperative proximal IP joint flexion or distal IP joint flexion less than 20 degrees. We suggest that, in properly motivated patients, tendon graft replacement of isolated profUndus tendon injuries can give satisfactory results even in the older age group.
Michael A. McClinton, M.D., Raymond M. Curtis, M.D., and E. F. Shaw Wilgis, M.D., Baltimore, Md.
SeCondary tendon grafting for isolated flexor digitorum profundus injuries should not be undertaken lightly. Many, in fact, most authors have cautioned against the use of this procedure. Robertson flatly advised against its use in a letter to members of the Society for Surgery of the Hand in 1971, warning that all four cases seen recently by him in consultation were disasters and he had never seen a really good result from the procedure. Holm and Embrick! thought that only exceptional cases justified the use of a secondary plantaris or palmaris graft to restore profundus function in the presence of a functioning superficialis. Goldner and Coonrad 2 were not so pessimistic but believed that the procedure should be used only in the growing child or young adult and probably not in older patients. Stark et al. 3 agreed with this concept and advised surgery for the 10- to 21-year age group but only in selected cases below 10 years of age and greater than 21. Despite excellent results in a group of 33 patients, Pulvertaft4 recommended the procedure routinely only in the index and long fingers for preservation of good pinch and in children. One hundred fingers treated by two surgeons were
Table I. Age range of patients (in years) Age 0-10 11-20 21-30 31-40 41-50 51-60 Total
I
No. of patients 12 31 16 24 8
-.l 96
Note: Youngest patient was l'h years of age, and oldest was 60 years of age.
Table II. Time from injury to operation (in months) Time
No. of patients
0-1 2-3 4-6 7-12 Greater than 12 Total
8 38 30 15 5 96
studied to determine the safety of the procedure, emphasize a technical modification of tendon flassage, and describe a successful but stringent postoperative regimen.
From the Division of Hand Surgery, Union Memorial Hospital, Baltimore, Md.
Material
Received for publication Dec. 29, 1980; revised Nov. 4, 1981.
All subjects were patients of the senior authors. We had sufficient follow-up of one hundred tendon grafts in 96 patients to critically evaluate the procedure.
Reprint requests: Michael A. McClinton, M.D., 5820 York Rd., Baltimore, MD 21212.
224
THE JOURNAL OF HAND SURGERY
0363-5023/82/030224+06$00.6010
© 1982 American Society for Surgery of the Hand
Vol. 7, No . 3 May 1982
Grafts for flexor digitorum profundus
225
Table III. Tendon graft donor site Site
No. of grafts
Palmaris longus Extensor digitorum communis Extensor indicis proprius Toe extensor Plantaris Flexor digitorum superficialis Total
80
to 4 4
100
The oldest patient was 60 years of age, and the youngest was I V:z years of age. Thirteen patients were older than 40 years of age, and five patients were older than 50 years of age (Table J). All fingers were represented in the series, with distribution as follows: 15 index, 28 long, 33 ring, and 24 small . Seventy-six patients sustained lacerations of the profundus tendon, and 22 tendons were ruptured. Seventy-one operations were performed up to 6 months after injury, with five procedures after 1 year (Table Il) . Follow-up was at least 6 months in all patients. Twenty patients had associated injury to one of the digital nerves. No patients in this series had severe skin loss or fractures. The palmaris longus tendon was used as a donor 80 times (Table III) . Preoperatively, all patients had full passive digital joint motion. Some patients had less than full active motion at the proximal IP joint. A recent case illustrates the principles involved in this operation (Figs. 1 and 2). Intra- and postoperative technique Surgical exposure was carried out through a midlateral incision in all patients, keeping the neurovascular bundle in the palmar flap . In all cases, 2.5 magnification loops were used . The distal profundus stump could usually be delivered from the sheath with traction after an opening of the sheath was made. All but 0.5 centimeter of the distal stump was excised . The retracted profundus stump was usually found in the palm; and, depending on the time from injury , moderate scarring was often noted . The proximal profundus tendon was freed until at least 25 mm of passive tendon excursion in a child or 30 mm of passive excursion in an adult were obtained (Fig. 3). Measurement of passive excursion assured adequate motor amplitude for the graft . The A4 pulley was saved in most cases except when badly scarred or stenotic. There was a recorded tendolysis of superficialis tendon in 17 patients. The operative notes were reviewed, and we found that the graft was passed around the decussation in 93 cases and through the decussation in 7 cases (Fig . 4).
Fig. 1. Preoperative sites of lacerations in ring and small fingers.
Bunnell pullout wires were used for the distal juncture, and either Pulvertaft tendon weave or Bunnell tendon suture was used proximally. Tension was adjusted after the proximal juncture was completed so that the finger assumed its normal flexed posture relative to the non injured fingers . At no time was a two-stage technique using a Silas tic rod judged necessary. Following the doctrine of "primum non nocere , " scrupulous adherence to the postoperative regimen was required. When possible preoperatively, patients received instruction in flexion of the proximal IP joint without flexing the distal IP joint. One week after operation, full passive range of motion of the proximal IP joint was carried out with metacarpophalangeal (MP) joint flexed (Fig. 5). In addition, patients were instructed in active superficialis motion without distal IP joint flexion. The MP joint was held in flexion during this exercise to protect the repair. During the next 2 weeks , the patients carried out these exercises at home and supplemented them with office visits. At three weeks, light passive extension of the proximal IP joint was undertaken by the patient. Active flexion of proxi-
226
The Journal of HAND SURGERY
McClinton, Curtis , and Wilgis
Fig. 2. Preoperative attempted full flexion.
Fig. 3. Measurement of passive tendon excursion (30 mrn) .
mal and distal IP joints was encouraged, and the hand was protected only by a dorsal splint. Pullout wires were removed at 4 weeks postoperatively . Full flexion and extension of the digit were encouraged at 4 weeks. Resisted motion was allowed at 8 weeks. The goal of this postoperative regimen was normal proximal IP joint motion at 4 weeks following the operation (Figs. 6 and 7). The senior authors have used the measurement of passive tendon excursion to assure adequate motor amplitude in over 400 tendon grafts . The arm tourniquet remains inflated during the measurements, which are performed in the palm with the wrist in a neutral position. The proximal profundus tendon and lumbrical are freed of adhesions until 30 mm of passive
excursion is obtained for adults. If 30 mm of motion is not achieved after complete release of proximal palmar adhesions, a new motor is selected. Using this technique, the tendon graft tension is adjusted so that the finger occupies its normal flexed position in the digital cascade after proximal and distal junctures are made.
Results A combination of methods was used to evaluate results. The key questions regarding postoperative results were: Did the proximal IP joint lose motion and did the distal IP joint gain significant active motion? Fifty-five patients flexed their fingers to the distal palmar crease postoperatively, and 24 fingers were within 1.3 cm. Fifteen digits flexed between 1.:1 and
Vol. 7, No.3
May 1982
Grafts for flexor digitorum profundus
227
Table IV. Active flexion: Distance from distal palmar crease (in centimeters) Distance
No. offingers
0 Up to 1.3 1.4-2.5 2.6-5
55 24 15 6 100
Table V. Active distal interphalangeal motion Degrees of motion
No. offingers
0-20 21-40 41-60 Greater than 60
7 24 48 21 100
Note: Average active flexion was 48 degrees.
Table VI. Active distal interphalangeal joint motion (by finger)
Finger
No. offingers with less than 40 degrees
No. offingers with greater than 40 degrees
Index Long Ring Small Total
6 5 8 6 25
9 24 23 19 75
Total 15 29 31 ~
100
2.5 cm, and six were between 2.5 and 5 cm from the distal palmar crease (Table IV). More than 90% of the fingers flexed greater than 20 degrees, 80% greater than 30 degrees, and 21% of the patients had greater than 60 degrees of active flexion. The average active flexion of distal IP joint in all patients was 48 degrees (Table V). Loss of less than 10 degrees of proximal IP joint extension occurred in 55 patients. Three patients lost between 11 and 20 degrees, and six patients lost between 21 and 30 degrees. Age influenced results to the extent that 86% of the patients under 20 years of age had flexion greater than 40 degrees at the distal IP joint. However, 50% (6 of 12) of patients over 40 years of age had greater than 40 degrees of flexion at the distal IP joint. According to Stark's criteria, greater than 90% of cases are satisfactory with 24 of 100 patients flexing to within 1. 3 cm and 55 of 100 patients flexing to the distal palmar crease. 3
Fig. 4. Tendon graft around superficialis decussation.
To date, only Wexler and Lie 5 in a small series advocate the procedure for all motivated patients if the preoperative requirements of good soft tissue coverage and limber joints are met. Honner 6 and Versaci1 recommended a two-stage approach to this problem as originally discussed by Gaisford et aLB and more recently by Wilson et al. 9 These authors thought that the pseudo sheath would decrease chances of loss of superficialis motion and were generally pleased with their results. The results of our series, however, indicate that, in ideal cases, a two-stage approach is unnecessary. Discussing Coonrad's paper in 1968, Bell was the first to mention directing the tendon graft alongside the superficialis tendon rather than through the decussa-
228
The Journal of HAND SURGERY
McClinton, Curtis, and Wilgis
Fig. 5. Protected passive extension of proximal IP joint (1 week).
Fig. 6. Postoperative flexion.
Fig. 7. Postoperative extension.
tion. 2 Since 1959, Harrison 10 excises half of the superficialis tendon to reduce chance of its inhibiting excursion of the profundus graft while decreasing chances for hyperextension deformities of the proximal IP joints, which may occur if both slips of the superficialis tendon are divided. In a detailed evaluation of tendon grafting, Thompson l l demonstrated a direct relationship between end results and the surgeon's number of years of experience. The present authors echo the sentiments of Pulvertaft4 and Goldner and Coonrad 2 that this procedure requires the skills of an experienced hand surgeon. The postoperative care following this procedure plays an overwhelming role in its success. The preoperative active superficialis function must be regained, and the preoperative and postoperative therapy regimen are directed to this end . Only when this motion is regained can undivided efforts be directed to achieving maximum distal IP joint motion .
Analysis of the results according to finger demonstrates that motion is similar in all fingers except the index (Table VI). These data were supported by Thompson, II who found that the index finger gave poorest results, with long, ring, and small fingers having equivalent results. Therefore, the decision to graft the ring or small finger must be based on grounds other than the assumption that results are poorer in the two ulnar fingers. The patients in this series were not offered this operation as a salvage procedure. Only those demonstrating strong motivation, full passive motion, and absence of bone or severe skin injuries were considered candidates. Increased patient age was not in itself considered a contraindication to surgery. REFERENCES I. Holm CL, Embrick RR: Primary treatment of tendon
injuries. J Bone Joint Surg [Am] 41:559-608, 1959
Vol. 7, No.3 May 1982
2. Goldner JL, Coonrad RW: Tendon grafting of flexor profundus in presence of completely or partially intact flexor sublimis. J Bone Joint Surg [Am] 51:527, 1969 3. Stark HH, Zemel NP, Boyes JH, Ashworth CR: Flexor tendon graft through intact superficialis tendons . JHAND SURG 2:456-61, 1977 4. Pulvertaft RG: The treatment of profundus division by free tendon graft. J Bone Joint Surg [Am] 42: 1363-80, 1960 5. Wexler MR, Lie K: Tendon grafts for isolated injuries of the flexor digitorum profundus tendon . Isr J Med Sci 10:1448-50, 1974 6. Honner R: The late management of the isolated lesion of the flexor digitorum profundus tendon. J HAND SURG 7: 171, 1975 7. Versaci AD: Secondary tendon grafting for isolated
Grafts for flexor digitorum profundus
8.
9.
10.
11.
229
flexor digitorum profundus injury . Plast Reconstr Surg 46:57 , 1970 Gaisford JC, Hanna DC, Richardson GS: Tendon grafting: A suggested technique . Plast Reconstr Surg 38: 302-8 , 1966 Wilson RL, Carter MS, Holdeman VA , Lovett WL: Flexor profundus injuries treated with delayed twostaged tendon grafting. J Bone Joint Surg [Am] 5:74, 1980 Harrison S: A modification in the technique of flexor tendon grafting . Transactions of the Second International Conference of Plastic Surgeons, ed 4. London, 1959, E & S Livingstone, Ltd, p 217 Thompson R V: An evaluation of flexor tendon grafting. Br J Plast Surg 2:21-44, 1967
One hundred tendon grafts for isolated flexor digitorum profundus injuries One hundred cases of isolated flexor profundus tendon laceration or rupture were repaired by tendon graft over a 30-year period. Thirteen patients were over 40 years of age with the age range in the study from llh to 60 years. Unless the flexor profundus tendon remained in the decussation of the superficialis, all grafts were placed around the superficialis tendon decussation. Measurements of passive tendon excursion were considered critical in the selection of a motor for the tendon graft. All but two profundus graft motors could be passively extended to 30 mm. Average active distal interphalangeal (IP) joint flexion was 48 degrees following surgery. In thirteen patients the results were considered unsuccessfUL, with loss of greater than 20 degrees from preoperative proximal IP joint flexion or distal IP joint flexion less than 20 degrees. We suggest that, in properly motivated patients, tendon graft replacement of isolated profUndus tendon injuries can give satisfactory results even in the older age group.
Michael A. McClinton, M.D., Raymond M. Curtis, M.D., and E. F. Shaw Wilgis, M.D., Baltimore, Md.
SeCondary tendon grafting for isolated flexor digitorum profundus injuries should not be undertaken lightly. Many, in fact, most authors have cautioned against the use of this procedure. Robertson flatly advised against its use in a letter to members of the Society for Surgery of the Hand in 1971, warning that all four cases seen recently by him in consultation were disasters and he had never seen a really good result from the procedure. Holm and Embrick! thought that only exceptional cases justified the use of a secondary plantaris or palmaris graft to restore profundus function in the presence of a functioning superficialis. Goldner and Coonrad 2 were not so pessimistic but believed that the procedure should be used only in the growing child or young adult and probably not in older patients. Stark et al. 3 agreed with this concept and advised surgery for the 10- to 21-year age group but only in selected cases below 10 years of age and greater than 21. Despite excellent results in a group of 33 patients, Pulvertaft4 recommended the procedure routinely only in the index and long fingers for preservation of good pinch and in children. One hundred fingers treated by two surgeons were
Table I. Age range of patients (in years) Age 0-10 11-20 21-30 31-40 41-50 51-60 Total
I
No. of patients 12 31 16 24 8
-.l 96
Note: Youngest patient was l'h years of age, and oldest was 60 years of age.
Table II. Time from injury to operation (in months) Time
No. of patients
0-1 2-3 4-6 7-12 Greater than 12 Total
8 38 30 15 5 96
studied to determine the safety of the procedure, emphasize a technical modification of tendon flassage, and describe a successful but stringent postoperative regimen.
From the Division of Hand Surgery, Union Memorial Hospital, Baltimore, Md.
Material
Received for publication Dec. 29, 1980; revised Nov. 4, 1981.
All subjects were patients of the senior authors. We had sufficient follow-up of one hundred tendon grafts in 96 patients to critically evaluate the procedure.
Reprint requests: Michael A. McClinton, M.D., 5820 York Rd., Baltimore, MD 21212.
224
THE JOURNAL OF HAND SURGERY
0363-5023/82/030224+06$00.6010
© 1982 American Society for Surgery of the Hand
Vol. 7, No . 3 May 1982
Grafts for flexor digitorum profundus
225
Table III. Tendon graft donor site Site
No. of grafts
Palmaris longus Extensor digitorum communis Extensor indicis proprius Toe extensor Plantaris Flexor digitorum superficialis Total
80
to 4 4
100
The oldest patient was 60 years of age, and the youngest was I V:z years of age. Thirteen patients were older than 40 years of age, and five patients were older than 50 years of age (Table J). All fingers were represented in the series, with distribution as follows: 15 index, 28 long, 33 ring, and 24 small . Seventy-six patients sustained lacerations of the profundus tendon, and 22 tendons were ruptured. Seventy-one operations were performed up to 6 months after injury, with five procedures after 1 year (Table Il) . Follow-up was at least 6 months in all patients. Twenty patients had associated injury to one of the digital nerves. No patients in this series had severe skin loss or fractures. The palmaris longus tendon was used as a donor 80 times (Table III) . Preoperatively, all patients had full passive digital joint motion. Some patients had less than full active motion at the proximal IP joint. A recent case illustrates the principles involved in this operation (Figs. 1 and 2). Intra- and postoperative technique Surgical exposure was carried out through a midlateral incision in all patients, keeping the neurovascular bundle in the palmar flap . In all cases, 2.5 magnification loops were used . The distal profundus stump could usually be delivered from the sheath with traction after an opening of the sheath was made. All but 0.5 centimeter of the distal stump was excised . The retracted profundus stump was usually found in the palm; and, depending on the time from injury , moderate scarring was often noted . The proximal profundus tendon was freed until at least 25 mm of passive tendon excursion in a child or 30 mm of passive excursion in an adult were obtained (Fig. 3). Measurement of passive excursion assured adequate motor amplitude for the graft . The A4 pulley was saved in most cases except when badly scarred or stenotic. There was a recorded tendolysis of superficialis tendon in 17 patients. The operative notes were reviewed, and we found that the graft was passed around the decussation in 93 cases and through the decussation in 7 cases (Fig . 4).
Fig. 1. Preoperative sites of lacerations in ring and small fingers.
Bunnell pullout wires were used for the distal juncture, and either Pulvertaft tendon weave or Bunnell tendon suture was used proximally. Tension was adjusted after the proximal juncture was completed so that the finger assumed its normal flexed posture relative to the non injured fingers . At no time was a two-stage technique using a Silas tic rod judged necessary. Following the doctrine of "primum non nocere , " scrupulous adherence to the postoperative regimen was required. When possible preoperatively, patients received instruction in flexion of the proximal IP joint without flexing the distal IP joint. One week after operation, full passive range of motion of the proximal IP joint was carried out with metacarpophalangeal (MP) joint flexed (Fig. 5). In addition, patients were instructed in active superficialis motion without distal IP joint flexion. The MP joint was held in flexion during this exercise to protect the repair. During the next 2 weeks , the patients carried out these exercises at home and supplemented them with office visits. At three weeks, light passive extension of the proximal IP joint was undertaken by the patient. Active flexion of proxi-
226
The Journal of HAND SURGERY
McClinton, Curtis , and Wilgis
Fig. 2. Preoperative attempted full flexion.
Fig. 3. Measurement of passive tendon excursion (30 mrn) .
mal and distal IP joints was encouraged, and the hand was protected only by a dorsal splint. Pullout wires were removed at 4 weeks postoperatively . Full flexion and extension of the digit were encouraged at 4 weeks. Resisted motion was allowed at 8 weeks. The goal of this postoperative regimen was normal proximal IP joint motion at 4 weeks following the operation (Figs. 6 and 7). The senior authors have used the measurement of passive tendon excursion to assure adequate motor amplitude in over 400 tendon grafts . The arm tourniquet remains inflated during the measurements, which are performed in the palm with the wrist in a neutral position. The proximal profundus tendon and lumbrical are freed of adhesions until 30 mm of passive
excursion is obtained for adults. If 30 mm of motion is not achieved after complete release of proximal palmar adhesions, a new motor is selected. Using this technique, the tendon graft tension is adjusted so that the finger occupies its normal flexed position in the digital cascade after proximal and distal junctures are made.
Results A combination of methods was used to evaluate results. The key questions regarding postoperative results were: Did the proximal IP joint lose motion and did the distal IP joint gain significant active motion? Fifty-five patients flexed their fingers to the distal palmar crease postoperatively, and 24 fingers were within 1.3 cm. Fifteen digits flexed between 1.:1 and
Vol. 7, No.3
May 1982
Grafts for flexor digitorum profundus
227
Table IV. Active flexion: Distance from distal palmar crease (in centimeters) Distance
No. offingers
0 Up to 1.3 1.4-2.5 2.6-5
55 24 15 6 100
Table V. Active distal interphalangeal motion Degrees of motion
No. offingers
0-20 21-40 41-60 Greater than 60
7 24 48 21 100
Note: Average active flexion was 48 degrees.
Table VI. Active distal interphalangeal joint motion (by finger)
Finger
No. offingers with less than 40 degrees
No. offingers with greater than 40 degrees
Index Long Ring Small Total
6 5 8 6 25
9 24 23 19 75
Total 15 29 31 ~
100
2.5 cm, and six were between 2.5 and 5 cm from the distal palmar crease (Table IV). More than 90% of the fingers flexed greater than 20 degrees, 80% greater than 30 degrees, and 21% of the patients had greater than 60 degrees of active flexion. The average active flexion of distal IP joint in all patients was 48 degrees (Table V). Loss of less than 10 degrees of proximal IP joint extension occurred in 55 patients. Three patients lost between 11 and 20 degrees, and six patients lost between 21 and 30 degrees. Age influenced results to the extent that 86% of the patients under 20 years of age had flexion greater than 40 degrees at the distal IP joint. However, 50% (6 of 12) of patients over 40 years of age had greater than 40 degrees of flexion at the distal IP joint. According to Stark's criteria, greater than 90% of cases are satisfactory with 24 of 100 patients flexing to within 1. 3 cm and 55 of 100 patients flexing to the distal palmar crease. 3
Fig. 4. Tendon graft around superficialis decussation.
To date, only Wexler and Lie 5 in a small series advocate the procedure for all motivated patients if the preoperative requirements of good soft tissue coverage and limber joints are met. Honner 6 and Versaci1 recommended a two-stage approach to this problem as originally discussed by Gaisford et aLB and more recently by Wilson et al. 9 These authors thought that the pseudo sheath would decrease chances of loss of superficialis motion and were generally pleased with their results. The results of our series, however, indicate that, in ideal cases, a two-stage approach is unnecessary. Discussing Coonrad's paper in 1968, Bell was the first to mention directing the tendon graft alongside the superficialis tendon rather than through the decussa-
228
The Journal of HAND SURGERY
McClinton, Curtis, and Wilgis
Fig. 5. Protected passive extension of proximal IP joint (1 week).
Fig. 6. Postoperative flexion.
Fig. 7. Postoperative extension.
tion. 2 Since 1959, Harrison 10 excises half of the superficialis tendon to reduce chance of its inhibiting excursion of the profundus graft while decreasing chances for hyperextension deformities of the proximal IP joints, which may occur if both slips of the superficialis tendon are divided. In a detailed evaluation of tendon grafting, Thompson l l demonstrated a direct relationship between end results and the surgeon's number of years of experience. The present authors echo the sentiments of Pulvertaft4 and Goldner and Coonrad 2 that this procedure requires the skills of an experienced hand surgeon. The postoperative care following this procedure plays an overwhelming role in its success. The preoperative active superficialis function must be regained, and the preoperative and postoperative therapy regimen are directed to this end . Only when this motion is regained can undivided efforts be directed to achieving maximum distal IP joint motion .
Analysis of the results according to finger demonstrates that motion is similar in all fingers except the index (Table VI). These data were supported by Thompson, II who found that the index finger gave poorest results, with long, ring, and small fingers having equivalent results. Therefore, the decision to graft the ring or small finger must be based on grounds other than the assumption that results are poorer in the two ulnar fingers. The patients in this series were not offered this operation as a salvage procedure. Only those demonstrating strong motivation, full passive motion, and absence of bone or severe skin injuries were considered candidates. Increased patient age was not in itself considered a contraindication to surgery. REFERENCES I. Holm CL, Embrick RR: Primary treatment of tendon
injuries. J Bone Joint Surg [Am] 41:559-608, 1959
Vol. 7, No.3 May 1982
2. Goldner JL, Coonrad RW: Tendon grafting of flexor profundus in presence of completely or partially intact flexor sublimis. J Bone Joint Surg [Am] 51:527, 1969 3. Stark HH, Zemel NP, Boyes JH, Ashworth CR: Flexor tendon graft through intact superficialis tendons . JHAND SURG 2:456-61, 1977 4. Pulvertaft RG: The treatment of profundus division by free tendon graft. J Bone Joint Surg [Am] 42: 1363-80, 1960 5. Wexler MR, Lie K: Tendon grafts for isolated injuries of the flexor digitorum profundus tendon . Isr J Med Sci 10:1448-50, 1974 6. Honner R: The late management of the isolated lesion of the flexor digitorum profundus tendon. J HAND SURG 7: 171, 1975 7. Versaci AD: Secondary tendon grafting for isolated
Grafts for flexor digitorum profundus
8.
9.
10.
11.
229
flexor digitorum profundus injury . Plast Reconstr Surg 46:57 , 1970 Gaisford JC, Hanna DC, Richardson GS: Tendon grafting: A suggested technique . Plast Reconstr Surg 38: 302-8 , 1966 Wilson RL, Carter MS, Holdeman VA , Lovett WL: Flexor profundus injuries treated with delayed twostaged tendon grafting. J Bone Joint Surg [Am] 5:74, 1980 Harrison S: A modification in the technique of flexor tendon grafting . Transactions of the Second International Conference of Plastic Surgeons, ed 4. London, 1959, E & S Livingstone, Ltd, p 217 Thompson R V: An evaluation of flexor tendon grafting. Br J Plast Surg 2:21-44, 1967