Staged flexor tendon reconstruction using pedicled tendon graft from the flexor digitorum superficialis

Staged flexor tendon reconstruction using pedicled tendon graft from the flexor digitorum superficialis

Staged Flexor Tendon Reconstruction Using Pedicled Tendon Graft From the Flexor Digitorum Superficialis Nash H. Naam, MD, Effingham, IL The use of pe...

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Staged Flexor Tendon Reconstruction Using Pedicled Tendon Graft From the Flexor Digitorum Superficialis Nash H. Naam, MD, Effingham, IL

The use of pedicled flexor digitorum superficialis tendon as a tendon graft in the second stage of flexor tendon reconstruction has the advantage of employing local intrasynovial tendon graft and allowing early active range of motion. This method of staged flexor tendon reconstruction was used in 47 patients between 1983 and 1993. Thirty-three patients were evaluated 1 year or longer after the second stage of surgery. The follow-up period averaged 3.7 years. Sixty-four percent of the injuries were in zone If, and 30% were Boyes grade V in severity. Good to excellent results were achieved in 64% of patients. Three patients needed graft tenolysis. Postoperative persistent flexion contractures ranging from 8 ~ to 55 ~ of the proximal interphalangeal or distal interphalangeal joints or both were present in 88% of patients. Several factors that influenced the final outcome were identified: age over 25 years, zone II injuries of Boyes grade V, and the lack of a regular postoperative rehabilitation program were associated with relatively less successful final results. (J Hand Surg 1997;22A:323-327.)

In 1965, Paneva-Holevich described a two-stage pedicle technique for reconstruction of the profundus tendon using the proximal end of the flexor digitorum superficialis (FDS) as a graft. 1,2 In 1971, Hunter and Salisbury 3 reported the use of a flexible siliconeDacron-reinforced gliding implant to reconstitute a healthy tendon sheath as the first stage of profundus tendon reconstruction. In 1972, Kessler 4 published his experience with the combined use of silicone implant in the first stage and pedicled FDS tendon as a graft in six patients. Since then, several reports

From the Departmentof Plastic and ReconstructiveSurgery,Southern Illinois UniversityMedical School, Springfield,IL, and the Southern IllinoisHandCenter,Effingham,IL. Received for publication Aug. 25, 1995; accepted in revised form Aug. 15, 1996. No benefitsin any formhave been receivedor will be receivedfrom a commericalparty related directlyor indirectlyto the subject of this article. Reprintrequests:Nash H. Naam, MD, SouthernIllinoisHandCenter, 901 MedicalPark Drive,Suite 100,Effingham,IL 62401.

of the use of the combined technique have been published.5 -10

Materials and Methods Between 1983 and 1994, 47 patients underwent staged flexor tendon reconstruction using the pedicled graft technique. Of the 47 patients, 33 were available for review. There were 24 men and 9 women ranging in age from 14 to 68 years (mean, 32 years). All patients had only single-digit involvement. The index finger was involved in 13 patients, the long finger in 10, the ring finger in 4, and the little finger in 6. Injuries involved the right dominant hand in 19 patients, the left nondominant hand in 12, and the left dominant hand in 2. Twenty-one patients had the injury in zone II, 4 in zone I, 5 in zone III, and 3 in zone IV. There were no injuries in zone V. O f the 4 patients with zone I injuries, 2 had the injuries in the small finger with very poor function of the FDS. One patient had previous conventional tendon grafting with unsatisfactory results (poor excurThe Journal of Hand Surgery

323

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Naam / FDS Pedicled Tendon Graft

sion of the FDS). The fourth patient had primary repair of the profundus tendon followed by rupture and secondary repair. Subsequent tenolysis failed and the patient developed severe limitation of the active flexion of the proximal interphalangeal (PIP) joint. Three patients had their injuries in zone IV; one had previous tendon grafting with significant postoperative adhesions and the other 2 patients had multiple injuries including open fractures of the metacarpals and the phalanges. The initial injury was the result of a clean laceration in 8 patients and the result of extensive trauma, including crushing injuries, in 25 patients. The preoperative status of the finger was evaluated using a modified Boyes grading system. 11 14The distribution of the digits according to that grading system was as follows: grade I, none; grade II, 12 fingers; grade III, 4 fingers; grade IV, 7 fingers; grade V, 10 fingers. Twenty-four patients had prior treatment in the form of primary tendon repair in 9 patients, secondary tendon repair in 6 patients, tenolysis in 6 patients, and conventional one-stage tendon grafting in 3 patients. Pulley reconstruction was performed during stage 1 in 9 patients; 8 had single pulley reconstruction; and 1 had two pulleys reconstructed. Release of flexion contractures of the PIP joint was carried out in 11 patients.

Surgical Technique In the first stage, the flexor tendons are exposed through a Bruner zigzag incision extending into the palm. 15The scar tissue and the distal tendon remnants are excised (Fig. 1A). The profundus tendon is excised proximally at the level of the lumbrical origin. The A-2 and A-4 pulleys are preserved or recon-

A

structed using tendon graft from the excised tendons or.from the palmaris longus. The proximal stumps of the FDS and profundus tendons are sutured using a modified Kessler technique at the level of the lumbrical origin. A Dacron-reinforced silicone implant of appropriate size is passed through the pulley system and sutured distally to the distal profundus stump (Fig. 1B). The proximal end is left free in the palm at the level of the lumbrical origin. Pulley reconstruction, nerve repair, and release of flexion contractures are carried out in this stage. The wound is irrigated and closed. The digit is immobilized for 1 week; then passive range of motion (ROM) exercises are started. The second stage is usually performed no less than 8 weeks after the first stage, provided the patient has regained maximal passive motion of the finger joints. The palm is opened, and the proximal end of the implant is identified. The site of the profundus-tosuperficialis juncture is located. Excessive adhesions are dissected carefully to free the repair site. The FDS tendon of the involved finger is exposed through an incision on the volar aspect of the distal forearm and divided at its musculotendinous junction (Fig. 2A). The tendon is then delivered into the palmar incision and sutured to the proximal end of the silicone implant (Fig. 2B). Through a separate incision, the distal end of the implant is identified and freed from its distal attachment. By gentle distal traction on the implant, the FDS tendon graft is threaded through the new sheath and delivered into the distal wound. The free distal end of the tendon is inserted into the distal phalanx, after adjusting the proper tension, using a pull-out wire technique. Two other horizontal mattress sutures are placed between the graft and the distal profundus stump. A separate suture is placed through the distal end of the nail to be used for

B

Figure 1. First stage. (A) The scars and the flexor tendons were excised. The pulleys are preserved. (B) The profundus and superficialis proximal stumps have been sutured. The silicone implant was inserted through the preserved pulleys.

The Journal of Hand Surgery / Vol. 22A No. 2 March 1997

A

........

325

B

Figure 2. Second stage. (A) The site of tenorrhaphy is exposed in the palm and the free end of the superficialis tendon is sutured to the proximal end of the silicone implant. (B) The superficialis tendon is delivered to the distal wound by gentle distal traction on the implant.

dynamic traction. The wound is closed, and a dorsal splint is applied to hold the wrist in about 40 ~ flexion and the fingers in intrinsic-plus position. At 5 to 7 days after surgery, patients are started on a controlled mobilization program using the methods of Lister et al.16 and/or Duran et al. 17 Active ROM exercises are started at 3 weeks, and unprotected digital motion is allowed at 6 weeks.

Results The postoperative follow-up period ranged from l to 9 years following the second stage (average, 44 months). The measurements of active ROM of the involved finger were taken in the fist position. The results were evaluated using the grading system recommended by Schneider 18 and LaSalle and Strickland. 19 The following formula was used to evaluate the return of active motion as a percentage of preoperative passive motion: postoperative active PIP + DIP flexion - ext. loss x 100 preoperative passive PIP + DIP flexion - ext. loss The return of 7 5 % - 1 0 0 % of active motion was rated as excellent, of 5 0 % - 7 4 % as good, of 2 5 % 49% as fair, and of 0 % - 2 4 % as poor. Based on these criteria, 8 patients' results in this series were rated as excellent, 13 as good, 5 as fair, and 7 as poor. Another measurement system used in this group of patients was that of Strickland and Glogovac, 20 which was recommended for evaluating digital function following acute flexor tendon repair. This method measures the active degree of flexion of PIP plus distal interphalangeal (DIP) joints minus any extension lag. Seven patients were rated as excellent

(more than 150~ 14 as good (125~176 5 fair (90~176 and 7 as poor (< 90~ The results by zone of injury are listed in Table 1. The effect of preoperative status of the finger, according to the modified Boyes grading system, on the outcome is listed in Table 2. Tenolysis was carried out in three patients with zone II reconstruction. One patient's hand improved from the poor category to good, another patient's improved from poor to fair, and for the third patient, there was not any significant improvement. There were no perioperative infections in this series, and there were no ruptures of the grafts. Persistent flexion contractures of the PIP or DIP joints or both were present in 29 patients and ranged from 8 ~ to 55 ~. The initial postoperative flexion deformities were generally worse, but most of them improved with a program of hand therapy, including dynamic splinting. Age was a significant factor in this group of patients. Patients who were 25 years old or younger had better functional results than the older age group. Average total active ROM of the PIP and the DIP joints was 140 ~ in the younger age group compared to 125 ~ in the older group.

Table 1. Results According to Zone of Injury Zone

No. Patients

Excellent

Good

Fair

Poor

I

4

1

3

0

0

II III IV

21 5 3

4 2 1

7 2 1

5 0 0

5 1 1

g

.

.

.

.

.

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Naam/ FDS Pedicled Tendon Graft

Table 2. Results as Related to Preoperative Boyes Grading System Modified Boyes Grade I

11 III IV V

No. Patients - -

12 4 7 10

No. Excellent and Good Results - -

8 3 5 5

Hand therapy was found to play a role in improving the results. Of the 6 patients who were noncompliant or who could not be evaluated regularly because they lived far away, only 2 had good or excellent results, compared to 19 good or excellent results in the remaining 27 patients. There was no significant change in the active ROM of the digits beyond 6 months after stage 2. The patients who were followed for several years did not exhibit any significant deterioration of the active ROM over time.

Discussion The combined Paneva-Holevich and Hunter technique for reconstructing severely damaged flexor tendons has the advantage of using local tendon as a graft and allowing early active movements of the fingers without the risk of rupture of the proximal juncture. Recently, there has been a considerable body of research supporting improved function in animal models after tendon grafts using intrasynovial tendons such as the FDS as compared to extrasynovial tendons such as the palmaris longus or plantaris. 21-25 Gelberman et al. e3-25 studied the morphologic and functional characteristics of intrasynovial versus extrasynovial tendon grafts in dogs. They found that the intrasynovial tendon grafts healed with minimal adhesions with normal cellularity and collagen organization, which provided a smooth, adhesion-free gliding surface, while the extrasynovial grafts healed with ingrowth of peripheral adhesions that became larger and more dense over time. They concluded that intrasynovial tendon grafts had significantly improved morphologic and functional characteristics compared with the extrasynovial tendon grafts. This may explain the improved results in this series. Paneva-Holevich has recommended starting active motion of the involved finger in the first postoperative week, and she reported no increase in the incidence of rupture of the distal insertion with the very

early active motion, l0 In our series, a controlled mobilization program was used for the first 3 weeks under the close supervision of the treating physician and a hand therapist. The comparable results that we obtained may suggest that a well-executed, controlled mobilization program is perhaps as effective as very early active motion. Another possible benefit is reduction of the potential of graft rupture; however, we are encouraged to try to start active motion earlier than 3 weeks. In our series, two different methods of assessment of digital function were used. The postoperative grading system recommended by Schneider is and LaSalle and Strickland 19 mainly compares the postoperative digital active ROM with the preoperative passive ROM. Thus, it has a tendency to make a rather unimpressive result look fairly good. For example, if the passive potential is only 30 ~ and it is achieved postoperatively, then this would be considered an excellent result, even though the total motion might have improved only 30 ~ and the actual impact on the patient might be rather minimal. Therefore, the total active ROM system was used to better evaluate the actual achieved range of motion of the digit. We found the results of the assessment using the two methods to be almost identical. This may be explained by the fact that in this group of patients, the second stage was not performed until an excellent preoperative passive ROM was achieved. The relatively larger size of the FDS tendon as compared with the thin palmaris longus or plantaris tendon grafts did not impose any difficulty in threading it through the new sheath and the pulley system. It may be of advantage to use the largest possible silicone implant during the first stage. It is also important to perform any joint release, digital nerve repair, or pulley reconstruction in the first stage and limit the second stage to the tendon grafting. 12a8,19,26 Pulley preservation and reconstruction is of pivotal importance for a good outcome. Every effort should be made to preserve or reconstruct at least the A-2 and the A-4 pulleys. Several authors recommended preservation or reconstruction of at least three or more pulleys.3a2,18 The pulley system is not only important to prevent bowstringing and improve the effective excursion of the tendon but also to decrease the degree of flexion contractures. Wehbe et al. 12 identified a clear association between the number of intact pulleys and the final flexion contractures. We noted in our group of patients that the amount of preoperative flexion contractures prior to the second stage persisted or even became worse later on.

The Journal of Hand Surgery / Vol. 22A No. 2 March 1997 This c o n f i r m s the i m p o r t a n c e o f c o r r e c t i n g any flexion c o n t r a c t u r e s either b y s p l i n t i n g o r s u r g e r y p r i o r to the s e c o n d stage.

References 1. Paneva-Holevich E. Two-stage plasty in flexor tendon injuries of fingers within the digital synovial sheath. Acta Chir Plast 1965;7:112-124. 2. Paneva-Holevich E. Two-stage tenoplasty in injury of the flexor tendons of the hand. J Bone Joint Surg t969;51A: 21-32. 3. Hunter JM, Salisbury RE. Flexor tendon reconstruction in severely damaged hands: a two-stage procedure using a silicone-Dacron reinforced gliding prosthesis prior to tendon grafting. J Bone Joint Surg 1971 ;53A:829-858. 4. Kessler FB. Use of a pedicled tendon transfer with a silicone rod in complicated secondary flexor tendon repairs. J Plast Reconstr Surg 1972;49:439--443. 5. Chong JK, Cramer LM, Culf NK. Combined two-stage tenoplasty with silicone rods for multiple flexor tendon injuries in "no-man's land" J Trauma 1972;12:104-121. 6. Alms A. Pedicle tendon graft for flexor tendon injuries of the fingers. J Bone Joint Surg 1973;55B:881-882. 7. Winspur I, Dennis PB, Boswick JA. Staged reconstruction of flexor tendons with a silicone rod and a "pedicled" sublimis transfer. Plast Reconstr Surg. 1978;61:756-761. 8. Brug E, Stedtfeld HW. Experience with a two-stage pedicled flexor tendon graft. Hand 1979; 11:198-205. 9. Chuinard RG, Dabezies EJ, Mathews RE. Two stage superficialis reconstruction in severely damaged fingers. J Hand Surg 1980;5:135-143. 10. Paneva-Holevich E. Two-stage tenoplasty: result. In: Hunter JM, Schneider LH, Mackin E J, eds. Tendon surgery in the hand. St. Louis: CV Mosby, 1987:272-281. 11. Amadio PC, Wood MB, Cooney WP III, Board SD. Staged flexor tendon reconstruction in the fingers and hand. J Hand Surg 1988; 13A:559-562. 12. Wehbe MA, Hunter JM, Schneider LH, Goodwyn BL. Two-stage flexor-tendon reconstruction: ten-year experience. J Bone Joint Surg 1986;68A:752-763. 13. Boyes JH: Flexor tendon grafts in the fingers and thumb: an evaluation of end results. J Bone Joint Surg 1950;32A: 489-499.

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14. Boyes JH, Stark HH. Flexor tendon grafts in the fingers and thumb: a study of factors influencing results in 1000 cases. J Bone Joint Surg 1971;53A:1332-1342. 15. Bruner JM. The zig-zag volar-digital incision for flexor tendon surgery. J Plast Reconstr Surg 1967;40:571-574. 16. Lister GD, Kleinert HE, Kutz JE, Atasoy E. Primary flexor tendon repair followed by immediate controlled mobilization. J Hand Surg 1977;2:441-51. 17. Duran RJ, Houser RG, Stover MG. Management of flexor tendon lacerations in zone 2 using controlled passive motion postoperatively. In: Hunter JM, Schneider LH, Mackin E, Bell J, eds. Rehabilitation of the hand. St. Louis: CV Mosby, 1978:219-224. 18. Schneider LH. Staged flexor tendon reconstruction using the method of Hunter. Clin Orthop 1982;171:164-171. 19. LaSalle WB, Strickland JW. An evaluation of the twostage flexor tendon reconstruction technique. J Hand Surg 1983;8:263-267. 20. Strickland JW, Glogovac SV. Digital function following flexor tendon repair in zone II: a comparison of immobilization and controlled passive motion techniques. J Hand Surg 1980;5:537-543. 21. Lundborg G. Experimental flexor tendon healing without adhesion formation: a new concept of tendon nutrition and intrinsic healing mechanisms. A preliminary report. Hand 1976;8:235-238. 22. Lundborg G, Rank E Experimental intrinsic healing of flexor tendons based upon synovial fluid nutrition. J Hand Surg 1978;3:21-31. 23. Gelberman RH, Seiler JG III, Rosenberg AE, Heyman P, Amiel D. Intercalary flexor tendon grafts: a morphological study of intrasynovial and extrasynovial donor tendons. Scandinavian J Plast Reconstr Surg Hand Surg 1992;26: 257-264. 24. Gelberman RH, Vande Berg JS, Lundborg GN, Akeson WH. Flexor tendon healing and restoration of the gliding surface: an ultrastructural study in dogs. J Bone Joint Surg 1983;65A:70-80. 25. Seiler JG III, Gelberman RH, Williams CS et al. Autogenous flexor tendon grafts: a biomechanical and morphological study in dogs. J Bone Joint Surg 1993;75A: 1004-1014. 26. Schneider LH. Staged tendon reconstruction. Hand Clin 1985;1:109-120.