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Primary repair of flexor tendons in no-man's land using the becker repair
PRIMARY
REPAIR OF FLEXOR TENDONS IN NO-MAN’S LAND USING THE BECKER REPAIR J. J. PRIBAZ, W. A. MORRISON and A. M. MACLEOD From the Plastic Surgery Unit, St. Vincent’s Hospital, Melbourne, Australia
Forty-three digits with severed flexor tendons in no-man’s land have been repaired using a modified Becker’s technique. The results are analysed according to the type of laceration and associated injuries. Using White’s method, 70% obtained satisfactory, 8% fair, and 22% poor results. There were three ruptures but most poor results were due to stiffness after crushing injuries or when both vascular bundles had been divided.
Journal of Hand Surgery (British Volume, 1989) 148: 400-40.5 In 1978, Becker described a new technique for flexor tendon repair in no-man’s land. This technique was said , to preserve the longitudinal and vincular vascularity of the flexor tendons and be strong enough to allow early movement, preventing adhesion formation. The procedure started by bevelling the tendon ends and then overlapping them for approximately 7 mm. A continuous running suture of fine prolene was then placed along each side of the tendon, extending beyond the area of overlap both proximally and distally for a distance of 3 or 4 mm. No sutures were placed in the centre of the tendon, to minimise interference with the blood supply. Materials and methods
The age range was from 2 to 58 years, with young men predominating. 23 patients were male and four female. The nature of the injury was classified according to the type of laceration and associated injuries. The lacerations were divided into two categories : 1. Sharp injuries-23 of 37 digits (62%) 2. Crushing injuries: more severe and caused by blunt trauma, presses, etc.-l4 of 37 digits (38%). Associated injuries: 27 of 37 digits (73%) had severed nerves as well as tendons, 11 of 37 digits (30%) had divided both neurovascular bundles and three of 37 digits (8%) had underlying fractures. Operative technique
This study reports the results of 43 flexor tendon repairs in 31 consecutive patients. All patients had severed tendons in no-man’s land and were treated according to the same protocol during a 15 month period. 27 patients (37 digits) were available for follow-up (Fig. 1). In 29 digits, both flexor tendons were divided; in four, only the flexor digitorum profundus tendon was divided and four patients had severed the flexor pollicis longus tendon. All but two operations were performed by the same operator.
The operative technique was a modification of Becker’s method, in that the tendon ends were step-cut rather than bevelled and stronger sutures were used. Through a Bruner incision, the flexor sheath was exposed and opened with a flap at the planned site of tendon repair. Pulleys were preserved wherever possible. The divided tendon ends were advanced into the wound, preserving the vincula, and both profundus and superficialis repaired in all cases. The profundus was repaired by the modified Becker technique (Fig. 2) and the thin superficialis slips by a Kessler repair. The profundus tendon ends were step-cut, overlapped, held by fine stay sutures and repaired with two laterally placed continuous criss-crossed 5/O prolene sutures extending beyond the area of overlap by 3 or 4 mm. No sutures were placed across the volar side of the tendon. The flexor sheath flap was carefully replaced and sutured with 6-O nylon sutures. Post-operative management
27 PATIENTS
Fig. 1
400
Distribution
and location
DIGITS
of divided
flexor tendons.
All the repairs were protected by a dorsal plaster splint extending from the upper forearm to the fingertips, with the wrist in 30” of flexion and MP joints in 90” flexion. Becker originally advised placing the wrist in a neutral position but in a subsequent publication (Becker, et al., 1979) he reported a 10% incidence of rupture and he then advocated immobilisation in 30” of wrist flexion. THE JOURNAL
OF HAND SURGERY
BECKER
REPAIR OF FLEXOR TENDONS
a
b
POOR
Fig. 3
e
Fig. 2
Modified Becker technique of flexor tendon repair. The tendon ends are: (a) Approximated and edges trimmed. (b) Step cut. (c) Overlapped and secured with four stay sutures at each corner. (d) Lateral continuous crisscross sutures are placed on each side of the tendon. (e) Lateral view, showing sutures extending 3 or 4 mm beyond the area of overlap.
The arm was elevated in a sling and the patient instructed to start moving his fingers actively within the limits of the plaster splint as soon as the regional anaesthetic had worn off. Rubber band traction was not used in any of these patients. The plaster splint was left in place for two weeks (three weeks in cases of associated neurovascular repair). When the splint was removed, active and passive range of motion hand therapy was commenced. The patient was instructed not to flex against any resistance for a period of six weeks from the time of repair.
LESS FLEXlON
The range of movement measurements were analysed and grouped according to White’s method (Fig. 3) which is a combination of composite angular movement, flexion 1989
POOR
-LESS
EXTENSlON
White’s method of grading results of flexor tendon surgery. (F.D. =flexion deficit from finger pulp to distal palmar crease)
deficit of the finger pulp to the distal palmar crease and measurement of the extensor deficit (White, 1956). This method of evaluation is similar to that of Lister et al. (1977) which was used by Becker to evaluate his series, but White’s method is more detailed and includes a method for evaluating the thumb. White compared the active movement of the interphalangeal joint with the opposite normal thumb. If the range was equal to or greater than 70x, the result was considered excellent; if 60 to 70% good; if 4.0to 60% fair; and less than 40% poor (Fig. 3). Excellent and good results have been grouped together as satisfactory. Results
Using these criteria, a good or excellent result (i.e. satisfactory result) was achieved in 70% of all digits treated (Table 1 and Figs 4 and 5). This is similar to Becker’s results. A fair result was obtained in 8% and a poor result in 22%. Most of the poor results were associated with joint stiffness. There were three ruptures. When grouping the tendons according to type of laceration, it was found that 20 of 23 digits (87%) Table l-Results
in 37 digits Percentage
Good Excellent
Evaluation
VOL. 14-B No. 4 NOVEMBER
__)
1 19
19 51 >
Fair
3
8
/Ruptures ‘Oor\Stiffness
3 5
8 14
70
22
401
J. J. PRIBAZ,
Fig. 4
W. A. MORRISON
A 33-year-old man, who had cut both flexor tendons to his right middle finger at the level of the P.I.P. joint, seen six months (a) Shows excellent extension. (b) Excellent flexion. (c) Independent profundus action. (d) Independent superficialis action.
Table 2-Analysis
after repair.
of results (37 digits) Type of laceration
No.
Satisfactory
Fair
Poor
5
Sharp
23
20
Crushing
14
6
3
12
11
1
15
I
2
6
4
3
_
1
3
4
Associated injuries One Nerves divided’ ‘Both /Repaired Both arteries Fracture
3
divided, Not repaired
402
AND A. M. MACLEOD
I 3
2
1
THE JOURNAL
OF HAND SURGERY
BECKER
REPAIR
OF FLEXOR
Fig. 5
VOL.
14-B No. 4 NOVEMBER
1989
TENDONS
(a) X-ray of the left hand of a 5%year-old man injured by a circular saw which completely amputated his thumb and little fingers, incompletely amputated his ring finger and devascularised his index and middle fingers with lacerations down to bone. The thumb and ring fingers were replanted and the digits revascularised. Modified Becker repairs were performed on both superficialis and profundus tendons to each finger. (b) Extension six months later. (c) Flexion.
403
J. J. PRIBAZ.
W. A. MORRISON
sustaining sharp lacerations had a satisfactory result, but only 6 of 14 (42%) with a crushing injury achieved a satisfactory result (Table 2). Division of one neurovascular bundle made little difference, as 11 of 12 digits (91%) still achieved a satisfactory result. However, division of both neurovascular bundles yielded satisfactory results in only 7 of 15 (46%) of digits. All fingers where both digital vessels were divided and not repaired (because the digit appeared viable based on its dorsal circulation) had a poor result (Table 2). Two of three fractured fingers achieved satisfactory results.
Discussion Flexor tendons within no-man’s land have been shown by microangiographic studies to possess a longitudinal blood supply supplemented by the vincula (Caplan et al., 1975; Lundborg et al., 1977). These studies also demonstrated that most of the vessels were located on the dorsal aspect of each tendon, leaving the volar aspect less vascular. It has been suggested that the volar part of the tendon derives its nutrition from the synovial fluid (Lundborg and Rank, 1978). It is still debated if the blood supply or the synovial fluid is the more important source of tendon nutrition and therefore the more important factor in tendon healing (Lundborg, 1978, 1980; Manske et al., 1978; Matthews, 1976; Ketchum, 1977). It is desirable that the repaired tendon has adequate intrinsic blood supply, but this is only possible if the tendon ends are not devascularised and normal anatomy is restored (Ketchum, 1977; Gelberman et al., 1985). The goal is a tendon repair which does not interfere with the intrinsic blood supply and yet is smooth and strong enough to allow early mobilisation. It would appear that the Becker repair does this. It provides two large contact areas which are held by laterally placed sutures causing minimal interference to the main longitudinal blood supply and the vincula. The repair has been shown by Becker, in his studies of baboon profundus tendons, to be stronger than the Dumbell, Kessler, Kleinert or Bunnell repairs. The repair is smooth, with no “bunching up” of the tendon ends as often occurs with Bunnell and Kessler types of repairs. This allows easier flexor gliding within the tendon sheath, which is carefully preserved and repaired. Lundborg (1978) has described synovial fluid diffusion pathways within tendons and Kleinert and Smith (1982) have postulated that active finger motion acts as a pumping mechanism, forcing synovial fluid through small channels within the tendon. A smooth, strong tendon repair, like that obtained with Becker’s technique, would seem to allow this. Becker’s repair has some similarity to the lateral trap suture of Ketchum et al. (1977). This repair was 404
AND
A. M. MACLEOD
considered to cause less constriction of the tendon’s micro-circulation and to be 1.6 times stronger than the Bunnell repair. However, Ketchum found that gap formation occurred just as frequently as in other repairs. The difference between these two techniques is that in Becker’s repair the tendon ends are bevelled and overlapped, reducing the problem of gap formation. However, the Becker repair does take longer to perform than the Kessler or Kleinert type repairs. Another drawback of the Becker repair is that it causes shortening of the tendon. Williams (1965) pointed out, in a cadaver study, that excision of 1 cm of flexor tendon resulted in an extension deficit of 35” at the P.I.P. joint and 40” at the D.I.P. joint. However, this has not been borne out in clinical practice and many authors (Wagner, 1958; McCash, 1961; Kleinert et al., 1975) have found that in zone 1 tendons can be shortened up to 1 cm without developing a significant extensor deficit. This has also been the finding in this series of patients in which the profundus tendons were shortened in zone 2 by about 7 mm. The unsatisfactory results in this series were also analysed. There were three ruptures: two were due to falls in the early post-operative period and one occurred in an unreliable patient who broke his plaster splint and ruptured his flexor repair soon after the operation. This patient had a second repair, using the same technique but with a stronger suture; nevertheless, he ruptured both the plaster splint and tendon a second time and subsequently needed a tendon graft. At re-exploration of these patients it was found that the suture had broken. The tendon ends looked quite healthy and it was possible to re-do the Becker repair. Most of the stiff fingers followed crushing injuries in which both neurovascular bundles were divided. All these digits were viable but there was decreased blood flow to the digits and consequently also to the tendons. In similar injuries where at least one digital vessel was repaired, the results appeared to be better. Kleinert et al. (1982) also stress the importance of complete restoration of the anatomy and they advocate repair of divided digital arteries to obtain the best results from tenorraphy.
Conclusion 3 1 consecutive patients with 43 lacerated tendons in “noman’s land” were treated according to a prospective protocol using a modified Becker repair; 70% had satisfactory, 8% fair, and 22% poor results. Three tendons ruptured and the rest of the poor results were in patients with crush injuries and stiff joints. The Becker repair was found to be useful in repairing flexor tendons in no-man’s land. It gave a smooth and strong repair, permitting early active mobilisation and the post-operative management was simple. THE
JOURNAL
OF HAND
SURGERY
BECKER
REPAIR
OF FLEXOR
Acknowledgements We wish to express a special thanks Schnitz for the medical illustrations, preparation of the manuscript.
to Curtis Guy for the photography, and Dr Elof Eriksson who advised
Gary in the
References BECKER, H. (1978). Primary repair of flexor tendons in the hand without Immobilization-Preliminary report. The Hand, 10: 1: 37-47. BECKER, H., ORAK, F. and DUPONSELLE, E. (1979) Early active motion following a bevelled technique of flexor tendon repair: Report on fifty cases. Journal of Hand Surgery, 4: 5 : 454-460. CAPLAN, H. S., HUNTER, J. M. and MERKLIN, R. J. Intrinsic vascularization of flexor tendons. In: American Academy of Orthopedic Surgeons Symposium on Tendon Surgery in the Hand. St. Louis, C. V. Mosby Co., 1975: 48-58. GELBERMAN, R. H., VANDEBERG, J. S., MANSKE, P. R. and AKESON, W. H. (1985) The early stages of flexor tendon healing: A morphologic study ofthe first fourteen days. Journal of Hand Surgery, 10A: 6: 776-784. KETCHUM, L. D. (1977) Primary tendon healing: a review. Journal of Hand Surgery, 2: 6: 428-435. KETCHUM, L. D., MARTIN, N. and KAPPEL, D. (1977) Experimental evaluation of factors affecting the strength of tendon repairs. Plastic and ReconstructiveSurgery, 59: 5: 708-719. KLEINERT, H. E., FORSHEW, F. C. and COHEN, M. J. Repair of Zone I Flexor Tendon Injuries. In: American Academy of Orthopedic Surgeons Symposium on Tendon Surgery in the Hand. St. Louis, C. V. Mosby Co., 1975: 15-122. KLEINERT, H. E. and SMITH, D. J. Primary and secondary repairs of flexor and extensor tendon injuries. In: Flynn, J. E. (Ed.). Hand Surgery, 3rd ed. Baltimore, Williams and Wilkins Co., 1982: 220-242. LISTER, G. D., KLEINERT, H. E., KUTZ, J. E. and ATASOY, E. (1977). Primary flexor tendon repair followed by immediate controlled mobilization. Journalof Hand Surgery, 2: 6: 441-451.
VOL.
14-B
No.
4 NOVEMBER
1989
TENDONS
LUNDBORG, G., MYRHAGE, R. and RYDEVIK, B. (1977). The vascularization of human flexor tendons within the digital synovial sheath regionstructural and functional aspects. Journal of Hand Surgery, 2: 6: 417-427. LUNDBORG, G. and RANK, F. (1978) Experimental intrinsic healing of flexor tendons based on synovial fluid nutrition. Journal of Hand Surgery, 3 : 1: 2131. LUNDBORG, G., HANSSON, H.-A., RANK, F. and RYDEVIK, B. (1980) Superficial repair of severed flexor tendons in synovial environment. An experimental ultrastructural study on cellular mechanisms. Journal of Hand Surgery,5:5:451-461. MANSKE, P. R., WHITESIDE, L. A. and LESKER, P. A. (1978). Nutrient pathways to flexor tendons using hydrogen washout technique. Journal of Hand Surgery, 3: 1: 32-36. MATTHEWS, P. (1976). The fate of isolated segments of flexor tendons within the digital sheath-A study of synovial nutrition. British Journal of Plastic Surgery, 29: 216-224. McCASH. C. R. (19611. The immediate reoair of flexor tendons. British Journal of Plastic S&ery,‘l4: 53-58. ’ WAGNER, C. J. (1958). Delayed Advancement in the Repair of Lacerated Flexor Profundus Tendons: Journal of Bone and Joint-Surgery, 40A: 6: 1241-1244. WHITE, W. L. (1956). Secondary Restoration of Finger Flexion by Digital Tendon Grafts. An evaluation of seventy-six cases. American Journal of Surgery, 91: 662-668. WILLIAMS, S. B. (1965). New dynamic concepts in the grafting of flexor tendons. Plastic and Reconstructive Surgery, 36: 4: 377-419.
Accepted: 25 November 1988 Julian J. Pribaz, M.D., Harvard/Brigham/Children’s Street, 0
Boston,
Massachussetts,
1989 The British
Society
Division
of Plastic
Surgery,
75 Francis
02115, U.S.A.
for Surgery
of the Hand
405
REPAIR OF FLEXOR TENDONS IN NO-MAN’S LAND USING THE BECKER REPAIR J. J. PRIBAZ, W. A. MORRISON and A. M. MACLEOD From the Plastic Surgery Unit, St. Vincent’s Hospital, Melbourne, Australia
Forty-three digits with severed flexor tendons in no-man’s land have been repaired using a modified Becker’s technique. The results are analysed according to the type of laceration and associated injuries. Using White’s method, 70% obtained satisfactory, 8% fair, and 22% poor results. There were three ruptures but most poor results were due to stiffness after crushing injuries or when both vascular bundles had been divided.
Journal of Hand Surgery (British Volume, 1989) 148: 400-40.5 In 1978, Becker described a new technique for flexor tendon repair in no-man’s land. This technique was said , to preserve the longitudinal and vincular vascularity of the flexor tendons and be strong enough to allow early movement, preventing adhesion formation. The procedure started by bevelling the tendon ends and then overlapping them for approximately 7 mm. A continuous running suture of fine prolene was then placed along each side of the tendon, extending beyond the area of overlap both proximally and distally for a distance of 3 or 4 mm. No sutures were placed in the centre of the tendon, to minimise interference with the blood supply. Materials and methods
The age range was from 2 to 58 years, with young men predominating. 23 patients were male and four female. The nature of the injury was classified according to the type of laceration and associated injuries. The lacerations were divided into two categories : 1. Sharp injuries-23 of 37 digits (62%) 2. Crushing injuries: more severe and caused by blunt trauma, presses, etc.-l4 of 37 digits (38%). Associated injuries: 27 of 37 digits (73%) had severed nerves as well as tendons, 11 of 37 digits (30%) had divided both neurovascular bundles and three of 37 digits (8%) had underlying fractures. Operative technique
This study reports the results of 43 flexor tendon repairs in 31 consecutive patients. All patients had severed tendons in no-man’s land and were treated according to the same protocol during a 15 month period. 27 patients (37 digits) were available for follow-up (Fig. 1). In 29 digits, both flexor tendons were divided; in four, only the flexor digitorum profundus tendon was divided and four patients had severed the flexor pollicis longus tendon. All but two operations were performed by the same operator.
The operative technique was a modification of Becker’s method, in that the tendon ends were step-cut rather than bevelled and stronger sutures were used. Through a Bruner incision, the flexor sheath was exposed and opened with a flap at the planned site of tendon repair. Pulleys were preserved wherever possible. The divided tendon ends were advanced into the wound, preserving the vincula, and both profundus and superficialis repaired in all cases. The profundus was repaired by the modified Becker technique (Fig. 2) and the thin superficialis slips by a Kessler repair. The profundus tendon ends were step-cut, overlapped, held by fine stay sutures and repaired with two laterally placed continuous criss-crossed 5/O prolene sutures extending beyond the area of overlap by 3 or 4 mm. No sutures were placed across the volar side of the tendon. The flexor sheath flap was carefully replaced and sutured with 6-O nylon sutures. Post-operative management
27 PATIENTS
Fig. 1
400
Distribution
and location
DIGITS
of divided
flexor tendons.
All the repairs were protected by a dorsal plaster splint extending from the upper forearm to the fingertips, with the wrist in 30” of flexion and MP joints in 90” flexion. Becker originally advised placing the wrist in a neutral position but in a subsequent publication (Becker, et al., 1979) he reported a 10% incidence of rupture and he then advocated immobilisation in 30” of wrist flexion. THE JOURNAL
OF HAND SURGERY
BECKER
REPAIR OF FLEXOR TENDONS
a
b
POOR
Fig. 3
e
Fig. 2
Modified Becker technique of flexor tendon repair. The tendon ends are: (a) Approximated and edges trimmed. (b) Step cut. (c) Overlapped and secured with four stay sutures at each corner. (d) Lateral continuous crisscross sutures are placed on each side of the tendon. (e) Lateral view, showing sutures extending 3 or 4 mm beyond the area of overlap.
The arm was elevated in a sling and the patient instructed to start moving his fingers actively within the limits of the plaster splint as soon as the regional anaesthetic had worn off. Rubber band traction was not used in any of these patients. The plaster splint was left in place for two weeks (three weeks in cases of associated neurovascular repair). When the splint was removed, active and passive range of motion hand therapy was commenced. The patient was instructed not to flex against any resistance for a period of six weeks from the time of repair.
LESS FLEXlON
The range of movement measurements were analysed and grouped according to White’s method (Fig. 3) which is a combination of composite angular movement, flexion 1989
POOR
-LESS
EXTENSlON
White’s method of grading results of flexor tendon surgery. (F.D. =flexion deficit from finger pulp to distal palmar crease)
deficit of the finger pulp to the distal palmar crease and measurement of the extensor deficit (White, 1956). This method of evaluation is similar to that of Lister et al. (1977) which was used by Becker to evaluate his series, but White’s method is more detailed and includes a method for evaluating the thumb. White compared the active movement of the interphalangeal joint with the opposite normal thumb. If the range was equal to or greater than 70x, the result was considered excellent; if 60 to 70% good; if 4.0to 60% fair; and less than 40% poor (Fig. 3). Excellent and good results have been grouped together as satisfactory. Results
Using these criteria, a good or excellent result (i.e. satisfactory result) was achieved in 70% of all digits treated (Table 1 and Figs 4 and 5). This is similar to Becker’s results. A fair result was obtained in 8% and a poor result in 22%. Most of the poor results were associated with joint stiffness. There were three ruptures. When grouping the tendons according to type of laceration, it was found that 20 of 23 digits (87%) Table l-Results
in 37 digits Percentage
Good Excellent
Evaluation
VOL. 14-B No. 4 NOVEMBER
__)
1 19
19 51 >
Fair
3
8
/Ruptures ‘Oor\Stiffness
3 5
8 14
70
22
401
J. J. PRIBAZ,
Fig. 4
W. A. MORRISON
A 33-year-old man, who had cut both flexor tendons to his right middle finger at the level of the P.I.P. joint, seen six months (a) Shows excellent extension. (b) Excellent flexion. (c) Independent profundus action. (d) Independent superficialis action.
Table 2-Analysis
after repair.
of results (37 digits) Type of laceration
No.
Satisfactory
Fair
Poor
5
Sharp
23
20
Crushing
14
6
3
12
11
1
15
I
2
6
4
3
_
1
3
4
Associated injuries One Nerves divided’ ‘Both /Repaired Both arteries Fracture
3
divided, Not repaired
402
AND A. M. MACLEOD
I 3
2
1
THE JOURNAL
OF HAND SURGERY
BECKER
REPAIR
OF FLEXOR
Fig. 5
VOL.
14-B No. 4 NOVEMBER
1989
TENDONS
(a) X-ray of the left hand of a 5%year-old man injured by a circular saw which completely amputated his thumb and little fingers, incompletely amputated his ring finger and devascularised his index and middle fingers with lacerations down to bone. The thumb and ring fingers were replanted and the digits revascularised. Modified Becker repairs were performed on both superficialis and profundus tendons to each finger. (b) Extension six months later. (c) Flexion.
403
J. J. PRIBAZ.
W. A. MORRISON
sustaining sharp lacerations had a satisfactory result, but only 6 of 14 (42%) with a crushing injury achieved a satisfactory result (Table 2). Division of one neurovascular bundle made little difference, as 11 of 12 digits (91%) still achieved a satisfactory result. However, division of both neurovascular bundles yielded satisfactory results in only 7 of 15 (46%) of digits. All fingers where both digital vessels were divided and not repaired (because the digit appeared viable based on its dorsal circulation) had a poor result (Table 2). Two of three fractured fingers achieved satisfactory results.
Discussion Flexor tendons within no-man’s land have been shown by microangiographic studies to possess a longitudinal blood supply supplemented by the vincula (Caplan et al., 1975; Lundborg et al., 1977). These studies also demonstrated that most of the vessels were located on the dorsal aspect of each tendon, leaving the volar aspect less vascular. It has been suggested that the volar part of the tendon derives its nutrition from the synovial fluid (Lundborg and Rank, 1978). It is still debated if the blood supply or the synovial fluid is the more important source of tendon nutrition and therefore the more important factor in tendon healing (Lundborg, 1978, 1980; Manske et al., 1978; Matthews, 1976; Ketchum, 1977). It is desirable that the repaired tendon has adequate intrinsic blood supply, but this is only possible if the tendon ends are not devascularised and normal anatomy is restored (Ketchum, 1977; Gelberman et al., 1985). The goal is a tendon repair which does not interfere with the intrinsic blood supply and yet is smooth and strong enough to allow early mobilisation. It would appear that the Becker repair does this. It provides two large contact areas which are held by laterally placed sutures causing minimal interference to the main longitudinal blood supply and the vincula. The repair has been shown by Becker, in his studies of baboon profundus tendons, to be stronger than the Dumbell, Kessler, Kleinert or Bunnell repairs. The repair is smooth, with no “bunching up” of the tendon ends as often occurs with Bunnell and Kessler types of repairs. This allows easier flexor gliding within the tendon sheath, which is carefully preserved and repaired. Lundborg (1978) has described synovial fluid diffusion pathways within tendons and Kleinert and Smith (1982) have postulated that active finger motion acts as a pumping mechanism, forcing synovial fluid through small channels within the tendon. A smooth, strong tendon repair, like that obtained with Becker’s technique, would seem to allow this. Becker’s repair has some similarity to the lateral trap suture of Ketchum et al. (1977). This repair was 404
AND
A. M. MACLEOD
considered to cause less constriction of the tendon’s micro-circulation and to be 1.6 times stronger than the Bunnell repair. However, Ketchum found that gap formation occurred just as frequently as in other repairs. The difference between these two techniques is that in Becker’s repair the tendon ends are bevelled and overlapped, reducing the problem of gap formation. However, the Becker repair does take longer to perform than the Kessler or Kleinert type repairs. Another drawback of the Becker repair is that it causes shortening of the tendon. Williams (1965) pointed out, in a cadaver study, that excision of 1 cm of flexor tendon resulted in an extension deficit of 35” at the P.I.P. joint and 40” at the D.I.P. joint. However, this has not been borne out in clinical practice and many authors (Wagner, 1958; McCash, 1961; Kleinert et al., 1975) have found that in zone 1 tendons can be shortened up to 1 cm without developing a significant extensor deficit. This has also been the finding in this series of patients in which the profundus tendons were shortened in zone 2 by about 7 mm. The unsatisfactory results in this series were also analysed. There were three ruptures: two were due to falls in the early post-operative period and one occurred in an unreliable patient who broke his plaster splint and ruptured his flexor repair soon after the operation. This patient had a second repair, using the same technique but with a stronger suture; nevertheless, he ruptured both the plaster splint and tendon a second time and subsequently needed a tendon graft. At re-exploration of these patients it was found that the suture had broken. The tendon ends looked quite healthy and it was possible to re-do the Becker repair. Most of the stiff fingers followed crushing injuries in which both neurovascular bundles were divided. All these digits were viable but there was decreased blood flow to the digits and consequently also to the tendons. In similar injuries where at least one digital vessel was repaired, the results appeared to be better. Kleinert et al. (1982) also stress the importance of complete restoration of the anatomy and they advocate repair of divided digital arteries to obtain the best results from tenorraphy.
Conclusion 3 1 consecutive patients with 43 lacerated tendons in “noman’s land” were treated according to a prospective protocol using a modified Becker repair; 70% had satisfactory, 8% fair, and 22% poor results. Three tendons ruptured and the rest of the poor results were in patients with crush injuries and stiff joints. The Becker repair was found to be useful in repairing flexor tendons in no-man’s land. It gave a smooth and strong repair, permitting early active mobilisation and the post-operative management was simple. THE
JOURNAL
OF HAND
SURGERY
BECKER
REPAIR
OF FLEXOR
Acknowledgements We wish to express a special thanks Schnitz for the medical illustrations, preparation of the manuscript.
to Curtis Guy for the photography, and Dr Elof Eriksson who advised
Gary in the
References BECKER, H. (1978). Primary repair of flexor tendons in the hand without Immobilization-Preliminary report. The Hand, 10: 1: 37-47. BECKER, H., ORAK, F. and DUPONSELLE, E. (1979) Early active motion following a bevelled technique of flexor tendon repair: Report on fifty cases. Journal of Hand Surgery, 4: 5 : 454-460. CAPLAN, H. S., HUNTER, J. M. and MERKLIN, R. J. Intrinsic vascularization of flexor tendons. In: American Academy of Orthopedic Surgeons Symposium on Tendon Surgery in the Hand. St. Louis, C. V. Mosby Co., 1975: 48-58. GELBERMAN, R. H., VANDEBERG, J. S., MANSKE, P. R. and AKESON, W. H. (1985) The early stages of flexor tendon healing: A morphologic study ofthe first fourteen days. Journal of Hand Surgery, 10A: 6: 776-784. KETCHUM, L. D. (1977) Primary tendon healing: a review. Journal of Hand Surgery, 2: 6: 428-435. KETCHUM, L. D., MARTIN, N. and KAPPEL, D. (1977) Experimental evaluation of factors affecting the strength of tendon repairs. Plastic and ReconstructiveSurgery, 59: 5: 708-719. KLEINERT, H. E., FORSHEW, F. C. and COHEN, M. J. Repair of Zone I Flexor Tendon Injuries. In: American Academy of Orthopedic Surgeons Symposium on Tendon Surgery in the Hand. St. Louis, C. V. Mosby Co., 1975: 15-122. KLEINERT, H. E. and SMITH, D. J. Primary and secondary repairs of flexor and extensor tendon injuries. In: Flynn, J. E. (Ed.). Hand Surgery, 3rd ed. Baltimore, Williams and Wilkins Co., 1982: 220-242. LISTER, G. D., KLEINERT, H. E., KUTZ, J. E. and ATASOY, E. (1977). Primary flexor tendon repair followed by immediate controlled mobilization. Journalof Hand Surgery, 2: 6: 441-451.
VOL.
14-B
No.
4 NOVEMBER
1989
TENDONS
LUNDBORG, G., MYRHAGE, R. and RYDEVIK, B. (1977). The vascularization of human flexor tendons within the digital synovial sheath regionstructural and functional aspects. Journal of Hand Surgery, 2: 6: 417-427. LUNDBORG, G. and RANK, F. (1978) Experimental intrinsic healing of flexor tendons based on synovial fluid nutrition. Journal of Hand Surgery, 3 : 1: 2131. LUNDBORG, G., HANSSON, H.-A., RANK, F. and RYDEVIK, B. (1980) Superficial repair of severed flexor tendons in synovial environment. An experimental ultrastructural study on cellular mechanisms. Journal of Hand Surgery,5:5:451-461. MANSKE, P. R., WHITESIDE, L. A. and LESKER, P. A. (1978). Nutrient pathways to flexor tendons using hydrogen washout technique. Journal of Hand Surgery, 3: 1: 32-36. MATTHEWS, P. (1976). The fate of isolated segments of flexor tendons within the digital sheath-A study of synovial nutrition. British Journal of Plastic Surgery, 29: 216-224. McCASH. C. R. (19611. The immediate reoair of flexor tendons. British Journal of Plastic S&ery,‘l4: 53-58. ’ WAGNER, C. J. (1958). Delayed Advancement in the Repair of Lacerated Flexor Profundus Tendons: Journal of Bone and Joint-Surgery, 40A: 6: 1241-1244. WHITE, W. L. (1956). Secondary Restoration of Finger Flexion by Digital Tendon Grafts. An evaluation of seventy-six cases. American Journal of Surgery, 91: 662-668. WILLIAMS, S. B. (1965). New dynamic concepts in the grafting of flexor tendons. Plastic and Reconstructive Surgery, 36: 4: 377-419.
Accepted: 25 November 1988 Julian J. Pribaz, M.D., Harvard/Brigham/Children’s Street, 0
Boston,
Massachussetts,
1989 The British
Society
Division
of Plastic
Surgery,
75 Francis
02115, U.S.A.
for Surgery
of the Hand
405