- Email: [email protected]
Zone I Extensor Reconstruction With Tendon Salvaged From Another Finger
SURGICAL TECHNIQUE
Zone I Extensor Reconstruction With Tendon Salvaged From Another Finger Tolga Türker, MD, Nicole Capdarest-Arest, MA, Dennis T. Schmahl
Surgical Technique
Laceration, crush, and avulsion injuries are common acute extensor tendon injuries. Simple lacerations may often be repaired in the emergency room, but crush or avulsion injuries may involve tendon loss and gaps in the extensor tendons. Reconstruction can be difficult. The purpose of this article is to present a salvage technique for reconstruction of large extensor tendon gaps in extensor zone I in patients with severe injuries to multiple fingers. This technique, in which a tendon is transplanted from an unsalvageable finger to another with a terminal tendon gap in the same patient, may be a reasonable remedy for reconstruction of tendon loss or gaps and may offer advantages over other traditional reconstructive techniques in certain cases. (J Hand Surg Am. 2014;39(5):976e980. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Key words Extensor tendon, reconstruction, technique, terminal tendon, transplantation, zone I.
L
ACERATION, CRUSH, AND AVULSION
injuries are common extensor tendon injuries presenting for acute care. Simple lacerations may often be repaired in the emergency room, but crush or avulsion injuries that may involve tendon loss or gaps in the extensor tendons need more attention. Reconstruction can be difficult. In such cases, tendon grafting or tendon transfer techniques may be employed for reconstruction of complex lacerations or tendon gaps.1 In reconstructing mutilating injuries to the hand, use of bone, artery, vein, nerve, tendon, and skin from unrepairable fingers for another finger that can more likely be reconstructed is possible. In some injuries where there is an extensor tendon gap, small local rotational extensor tendon flaps or tendon grafts may be used to overcome the gap.2e4 In addition to From the Division of Reconstructive and Plastic Surgery, Department of Surgery, University of Arizona; the Arizona Health Sciences Library, University of Arizona; and St. Mary’s Hospital, Tucson, AZ. Received for publication October 23, 2013; accepted in revised form January 19, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Tolga Türker, MD, Division of Reconstructive and Plastic Surgery, Department of Surgery, University of Arizona, 1501 N. Campbell Avenue, Room 5334, Tucson, AZ 85716; e-mail: [email protected]. 0363-5023/14/3905-0026$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.01.029
976
r
Ó 2014 ASSH
r
Published by Elsevier, Inc. All rights reserved.
these options, we present an extensor tendon salvage technique from another finger for terminal tendon reconstruction in severely injured fingers. INDICATIONS AND CONTRAINDICATIONS Patient selection and indications Patients with injuries in 2 or more fingers may be candidates for this technique. The injuries should involve (1) a finger with a terminal tendon defect (this will be the recipient finger), and (2) another finger that can be used as a donor for the terminal tendon because of notable distal interphalangeal joint (DIPJ) destruction that needs fusion or because of simultaneous DIPJ-level amputation that cannot be reattached. Contraindications This technique should not be performed in infected fingers, if the extensor tendon is lacking skin coverage, if there is injury to only 1 finger, or if injuries to another finger are individually salvageable. SURGICAL ANATOMY AND TECHNIQUE Step 1: tendon harvest For acute reconstructions, if there is a dorsal laceration, this laceration can be used for the surgical approach. Otherwise, a dorsal longitudinal incision is
ZONE I EXTENSOR TENDON RECONSTRUCTION
977
made to the donor finger. The terminal tendon of the donor finger is completely removed from its distal and proximal attachments at both the radial and ulnar lateral bands, leaving the central slip intact (Fig. 1). Surgery for the donor finger is then completed by either fusing the DIPJ or revising the distal amputation.
and occupational therapy (OT) is initiated. If there is tenderness, OT should be postponed and the patient should be reevaluated in 2 weeks. The comprehensive OT regimen includes 4 main components. First is therapeutic application of an outrigger orthosis with the metacarpophalangeal (MP) joint free, the proximal interphalangeal (PIP) joint stabilized to avoid hyperextension, and the DIPJ with dynamic extension assist to 5 hyperextension with a volar block at 30 DIPJ flexion (Fig. 3). If extensor lag is not greater than 10 , the volar block is increased to 40 during the second week of OT. The DIPJ dynamic extension assist is at 90 to the distal phalanx. Second, a static 5 DIPJ extension splint is worn at night for 10 weeks. Third, early protected range of motion (ROM) exercises are performed hourly while in the brace for 4 weeks. After 4 weeks, regular ROM exercises are continued hourly during waking hours with maintenance of static extension at night. Passive ROM is performed as needed to the wrist and MP and PIP joints, and lumbrical strengthening exercises are issued if needed. Fourth, scar and edema management are performed, and desensitization therapy is employed to decrease tenderness on the incision line. In addition, continuous (100%) ultrasound at 3 MHz and 1.0 W/cm2 is used for approximately 8 weeks or until desired ROM and function are achieved.
Step 2: tendon reconstruction For the recipient finger that has tendon loss or gap, for acute reconstructions, if there is a dorsal laceration, this can be used for surgical access. Otherwise, for late reconstruction, a dorsal longitudinal incision is made to the finger. In this second scenario, scar tissue formation in the area of the terminal tendon is removed. In all cases, 2 clean-cut incisions are performed on the ulnar and radial lateral bands of the extensor tendon at the level of the central slip. Another clean-cut incision is performed at the site of the distal portion of the extensor tendon, leaving a 2-mm attachment intact. If there is no attachment remaining, the tendon may be directly sutured to the bone. Subsequently, the harvested tendon from the donor finger is first attached at the level of the lateral bands, both ulnar and radial. The DIPJ is kept at 5 from full extension and a 0.9-mm K-wire is used for temporary joint fixation. Then, the excessive portion of the donor distal terminal tendon is cut and leveled with the distal stump of the recipient terminal tendon. The stump and the transplanted tendon are positioned end-to-end and reattached using simple interrupted sutures with 4-0 absorbable, synthetic, braided suture (Fig. 2). Hemostasis is then performed and the skin is closed with 5-0 nylon. A finger splint is applied for 8 weeks.
COMPLICATIONS Possible complications include extensor lag, tendon adhesions, infection, and extensor tendon rupture. CASE ILLUSTRATIONS Case 1 A 57-year-old male patient sustained a table saw injury to the left index and middle fingers. The index finger had lacerations through the DIPJ causing joint destruction, with complete cut of the flexor tendon,
POSTOPERATIVE MANAGEMENT If there is no tenderness at the distal attachment of the tendon, the K-wire is removed 8 weeks after surgery J Hand Surg Am.
r
Vol. 39, May 2014
Surgical Technique
FIGURE 1: Left index finger dorsal view. A Longitudinal incision made to access the terminal tendon. B Dorsal view of harvested terminal tendon.
978
ZONE I EXTENSOR TENDON RECONSTRUCTION
Surgical Technique
FIGURE 2: Left middle finger dorsal view. A The scar tissue is completely removed and proximal and distal parts of recipient area are prepared for tendon placement. B The harvested terminal tendon is transplanted to the extensor tendon void. The DIPJ is temporarily fixed with a K-wire.
FIGURE 3: Lateral view of left middle finger with custom outrigger orthosis.
ulnar digital nerve, and ulnar digital artery. The middle finger had near amputation at the midphalanx level (Fig. 4). Owing to the severity of the injury in the index finger joint, we performed a DIPJ arthrodesis and an ulnar digital nerve repair for the index finger. The middle phalanx of the middle finger was shortened approximately 3 mm at the injury level and then fixed. The injury zone of the flexor digitorum profundus was debrided and then repaired 5 mm short of its original length. Both radial and ulnar digital nerves and arteries were repaired. There was approximately a 1.5-cm extensor tendon defect J Hand Surg Am.
FIGURE 4: Volar view of the left hand showing near amputation of the middle finger. The laceration to the index finger starts dorsally and continues radially around the finger and is not visible here.
remaining, and we attempted to repair this defect using lateral band rotational flaps. Flexor tendon rehabilitation was started 7 days postsurgery. In the middle finger, the patient achieved 90 flexion of the MP and PIP joints and 60 flexion of the DIPJ, and r
Vol. 39, May 2014
979
FIGURE 5: Radial lateral view of the left middle finger 10 weeks after extensor tendon salvage and reconstruction. A Flexion of the middle finger. B Extension of the middle finger.
18 extensor tendon lag with minimal active extension of the DIPJ at 8 weeks. In addition, there was DIPJ nonunion in the index finger. The patient was then offered DIPJ fusion of the index finger and reconstruction of the middle finger extensor tendon using this tendon salvage technique. To perform the salvage and reconstruction, we performed index finger DIPJ arthrodesis using a variable-pitch headless screw and completely removed the terminal tendon of the donor index finger, leaving the central slip attachment intact as described earlier (Fig. 1). The recipient middle finger terminal tendon area that had healed with marked scar tissue was removed. The DIPJ of the middle finger was then temporarily fixed with a 0.9-mm K-wire and the terminal tendon of the index finger was used to reconstruct the terminal tendon of the middle finger (Fig. 2). The patient was initially fitted with finger splints for both the donor and recipient fingers. However, because both fingers were on the same hand, the patient was unable to comfortably tolerate the 2 splints, so a short-arm splint was applied. Postsurgical OT was initiated for the 8-week protocol. After 2 months of OT, the patient was able to extend the middle finger DIPJ, but there was 30 lag, most likely the result of a long terminal band and/or adhesions from the tendon to bone. Because the patient was still concerned about the extension lag, we offered Fowler tenotomy to improve extension of the DIPJ. After Fowler tenotomy and tenolysis of the extensor tendon, the patient achieved full flexion of the middle finger, 90 MP joint flexion, 100 PIP J Hand Surg Am.
joint active flexion, and 60 active flexion of DIPJ. The patient achieved active extension of the DIPJ with about 10 lag (Fig. 5). Case 2 A 77-year-old male patient was brought to the emergency room after a bicycle accident that caused right-hand index finger subtotal DIPJ amputation and a right-hand middle finger dorsal open wound with complete terminal tendon loss. A revision amputation to the patient’s index finger was performed and the terminal tendon was harvested for use in repairing the middle finger. Using this harvested tendon, the terminal tendon loss of the middle finger was reconstructed. We used a 0.9-mm K-wire to temporarily fix the DIPJ of the middle finger (Fig. 6). The middle finger dorsal skin was closed using an advancement flap. The patient was lost to follow-up. PEARLS AND PITFALLS In this article, we present an approach to repair a terminal tendon using unused tendon from another finger on the same patient. Terminal tendon injuries are common injuries, and in some cases such as in mallet finger injuries, they can be simply repaired. However, if there is a defect owing to a traumatic event, reconstruction of the terminal tendon may be challenging. In such cases where multiple fingers are damaged and lacking in function, it may be logical to take an unused part (spare part) from 1 finger (eg, the terminal tendon of a fused index finger) and transplant it to another finger, thereby reconstructing the poorly functioning r
Vol. 39, May 2014
Surgical Technique
ZONE I EXTENSOR TENDON RECONSTRUCTION
980
ZONE I EXTENSOR TENDON RECONSTRUCTION
FIGURE 6: Dorsal view of the right middle finger in Case 2. A Extensor tendon defect in the terminal tendon. B Harvested terminal tendon from the index finger. C The harvested terminal tendon is transplanted to the extensor tendon gap. The DIPJ is temporarily fixed with a K-wire. A dorsal rotation flap is designed to cover the distal dorsal portion of the defect and provides access for the extensor tendon reconstruction.
Surgical Technique
finger with either arthrodesis or amputation and achieving improved function in the recipient finger without making the donor finger worse. For short terminal tendon gaps, lateral band rotational grafting may be 1 of the chosen reconstructive methods for terminal tendon repair.4 In Case 1, for example, tendon rotational grafting was performed but the outcome was suboptimal. If the recipient finger could have been kept in extension, it is possible that the hemilateral band technique performed in the first surgery could have worked if the patient had not had a flexor tendon repair in the same finger. However, because early flexor tendon rehabilitation was started to achieve a better functional outcome, this rehabilitation may have contributed to failure of the hemilateral band technique by stressing the extensor tendon repair. Kochevar et al3 studied using the same extensor tendon as a tendon graft. In addition, Baratz et al2 previously described the rotational “lateral band turndown” procedure for zone II extensor tendon grafting. Rotational grafting is a good repair option for small defects, but in cases with large defects, a free tendon graft may be necessary. If the defect is bigger than one that can be repaired by rotational grafts, free extensor tendon graft is needed, such as with palmaris longus.5,6 Alternative reconstructive options for combined skin and tendon defects in the mangled hand are free composite flap reconstruction from the toes or elsewhere.7,8 Extensor tendon salvage and reconstruction provided a good outcome in Case 1. However, additional surgery (Fowler tenotomy and tenolysis) was needed
J Hand Surg Am.
because of extension lag at the DIPJ. The extensor tendon lag could have been related to 1 or more of the following: (1) terminal tendon adhesions at the level of the middle phalanx, (2) long terminal tendon, and/ or (3) early start of OT, which may have caused elongation of the terminal band. We started OT as soon as tenderness in the proximal and distal attachments of the terminal tendon had subsided. It is important to keep the DIPJ at 5 from full extension using a K-wire and then to apply the transplanted tendon, which must fit the length of the defect precisely. REFERENCES 1. Elliott RA Jr. Injuries to the extensor mechanism of the hand. Orthop Clin North Am. 1970;1(2):335e354. 2. Baratz ME, Schmidt CC, Hughes TB. Extensor tendon injuries. In: Green DP, Hotchkiss RD, Pederson WC, Wolfe SW, eds. Green’s Operative Hand Surgery. 5th ed. Philadelphia, PA: Elsevier/Churchill Livingstone; 2005:200e203, 211e212. 3. Kochevar A, Rayan G, Angel M. Extensor tendon reconstruction for zones II and IV using local tendon flap: a cadaver study. J Hand Surg Am. 2009;34(7):1269e1275. 4. Savvidou C, Thirkannad S. Hemilateral band technique for reconstructing gap defects in the terminal slip of the extensor tendon. Tech Hand Up Extrem Surg. 2011;15(3):177e181. 5. Nichols HM. Repair of extensor-tendon insertions in the fingers. J Bone Joint Surg Am. 1951;33(4):836e841. 6. Gu YP, Zhu SM. A new technique for repair of acute or chronic extensor tendon injuries in zone 1. J Bone Joint Surg Br. 2012;94(5): 668e670. 7. Scheker LR, Langley SJ, Martin DL, Julliard KN. Primary extensor tendon reconstruction in dorsal hand defects requiring free flaps. J Hand Surg Br. 1993;18(5):568e575. 8. Wang L, Fu J, Li M, Han D, Yang L. Repair of hand defects by transfer of free tissue flaps from toes. Arch Orthop Trauma Surg. 2013;133(1):141e146.
r
Vol. 39, May 2014
Zone I Extensor Reconstruction With Tendon Salvaged From Another Finger Tolga Türker, MD, Nicole Capdarest-Arest, MA, Dennis T. Schmahl
Surgical Technique
Laceration, crush, and avulsion injuries are common acute extensor tendon injuries. Simple lacerations may often be repaired in the emergency room, but crush or avulsion injuries may involve tendon loss and gaps in the extensor tendons. Reconstruction can be difficult. The purpose of this article is to present a salvage technique for reconstruction of large extensor tendon gaps in extensor zone I in patients with severe injuries to multiple fingers. This technique, in which a tendon is transplanted from an unsalvageable finger to another with a terminal tendon gap in the same patient, may be a reasonable remedy for reconstruction of tendon loss or gaps and may offer advantages over other traditional reconstructive techniques in certain cases. (J Hand Surg Am. 2014;39(5):976e980. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Key words Extensor tendon, reconstruction, technique, terminal tendon, transplantation, zone I.
L
ACERATION, CRUSH, AND AVULSION
injuries are common extensor tendon injuries presenting for acute care. Simple lacerations may often be repaired in the emergency room, but crush or avulsion injuries that may involve tendon loss or gaps in the extensor tendons need more attention. Reconstruction can be difficult. In such cases, tendon grafting or tendon transfer techniques may be employed for reconstruction of complex lacerations or tendon gaps.1 In reconstructing mutilating injuries to the hand, use of bone, artery, vein, nerve, tendon, and skin from unrepairable fingers for another finger that can more likely be reconstructed is possible. In some injuries where there is an extensor tendon gap, small local rotational extensor tendon flaps or tendon grafts may be used to overcome the gap.2e4 In addition to From the Division of Reconstructive and Plastic Surgery, Department of Surgery, University of Arizona; the Arizona Health Sciences Library, University of Arizona; and St. Mary’s Hospital, Tucson, AZ. Received for publication October 23, 2013; accepted in revised form January 19, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Tolga Türker, MD, Division of Reconstructive and Plastic Surgery, Department of Surgery, University of Arizona, 1501 N. Campbell Avenue, Room 5334, Tucson, AZ 85716; e-mail: [email protected]. 0363-5023/14/3905-0026$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.01.029
976
r
Ó 2014 ASSH
r
Published by Elsevier, Inc. All rights reserved.
these options, we present an extensor tendon salvage technique from another finger for terminal tendon reconstruction in severely injured fingers. INDICATIONS AND CONTRAINDICATIONS Patient selection and indications Patients with injuries in 2 or more fingers may be candidates for this technique. The injuries should involve (1) a finger with a terminal tendon defect (this will be the recipient finger), and (2) another finger that can be used as a donor for the terminal tendon because of notable distal interphalangeal joint (DIPJ) destruction that needs fusion or because of simultaneous DIPJ-level amputation that cannot be reattached. Contraindications This technique should not be performed in infected fingers, if the extensor tendon is lacking skin coverage, if there is injury to only 1 finger, or if injuries to another finger are individually salvageable. SURGICAL ANATOMY AND TECHNIQUE Step 1: tendon harvest For acute reconstructions, if there is a dorsal laceration, this laceration can be used for the surgical approach. Otherwise, a dorsal longitudinal incision is
ZONE I EXTENSOR TENDON RECONSTRUCTION
977
made to the donor finger. The terminal tendon of the donor finger is completely removed from its distal and proximal attachments at both the radial and ulnar lateral bands, leaving the central slip intact (Fig. 1). Surgery for the donor finger is then completed by either fusing the DIPJ or revising the distal amputation.
and occupational therapy (OT) is initiated. If there is tenderness, OT should be postponed and the patient should be reevaluated in 2 weeks. The comprehensive OT regimen includes 4 main components. First is therapeutic application of an outrigger orthosis with the metacarpophalangeal (MP) joint free, the proximal interphalangeal (PIP) joint stabilized to avoid hyperextension, and the DIPJ with dynamic extension assist to 5 hyperextension with a volar block at 30 DIPJ flexion (Fig. 3). If extensor lag is not greater than 10 , the volar block is increased to 40 during the second week of OT. The DIPJ dynamic extension assist is at 90 to the distal phalanx. Second, a static 5 DIPJ extension splint is worn at night for 10 weeks. Third, early protected range of motion (ROM) exercises are performed hourly while in the brace for 4 weeks. After 4 weeks, regular ROM exercises are continued hourly during waking hours with maintenance of static extension at night. Passive ROM is performed as needed to the wrist and MP and PIP joints, and lumbrical strengthening exercises are issued if needed. Fourth, scar and edema management are performed, and desensitization therapy is employed to decrease tenderness on the incision line. In addition, continuous (100%) ultrasound at 3 MHz and 1.0 W/cm2 is used for approximately 8 weeks or until desired ROM and function are achieved.
Step 2: tendon reconstruction For the recipient finger that has tendon loss or gap, for acute reconstructions, if there is a dorsal laceration, this can be used for surgical access. Otherwise, for late reconstruction, a dorsal longitudinal incision is made to the finger. In this second scenario, scar tissue formation in the area of the terminal tendon is removed. In all cases, 2 clean-cut incisions are performed on the ulnar and radial lateral bands of the extensor tendon at the level of the central slip. Another clean-cut incision is performed at the site of the distal portion of the extensor tendon, leaving a 2-mm attachment intact. If there is no attachment remaining, the tendon may be directly sutured to the bone. Subsequently, the harvested tendon from the donor finger is first attached at the level of the lateral bands, both ulnar and radial. The DIPJ is kept at 5 from full extension and a 0.9-mm K-wire is used for temporary joint fixation. Then, the excessive portion of the donor distal terminal tendon is cut and leveled with the distal stump of the recipient terminal tendon. The stump and the transplanted tendon are positioned end-to-end and reattached using simple interrupted sutures with 4-0 absorbable, synthetic, braided suture (Fig. 2). Hemostasis is then performed and the skin is closed with 5-0 nylon. A finger splint is applied for 8 weeks.
COMPLICATIONS Possible complications include extensor lag, tendon adhesions, infection, and extensor tendon rupture. CASE ILLUSTRATIONS Case 1 A 57-year-old male patient sustained a table saw injury to the left index and middle fingers. The index finger had lacerations through the DIPJ causing joint destruction, with complete cut of the flexor tendon,
POSTOPERATIVE MANAGEMENT If there is no tenderness at the distal attachment of the tendon, the K-wire is removed 8 weeks after surgery J Hand Surg Am.
r
Vol. 39, May 2014
Surgical Technique
FIGURE 1: Left index finger dorsal view. A Longitudinal incision made to access the terminal tendon. B Dorsal view of harvested terminal tendon.
978
ZONE I EXTENSOR TENDON RECONSTRUCTION
Surgical Technique
FIGURE 2: Left middle finger dorsal view. A The scar tissue is completely removed and proximal and distal parts of recipient area are prepared for tendon placement. B The harvested terminal tendon is transplanted to the extensor tendon void. The DIPJ is temporarily fixed with a K-wire.
FIGURE 3: Lateral view of left middle finger with custom outrigger orthosis.
ulnar digital nerve, and ulnar digital artery. The middle finger had near amputation at the midphalanx level (Fig. 4). Owing to the severity of the injury in the index finger joint, we performed a DIPJ arthrodesis and an ulnar digital nerve repair for the index finger. The middle phalanx of the middle finger was shortened approximately 3 mm at the injury level and then fixed. The injury zone of the flexor digitorum profundus was debrided and then repaired 5 mm short of its original length. Both radial and ulnar digital nerves and arteries were repaired. There was approximately a 1.5-cm extensor tendon defect J Hand Surg Am.
FIGURE 4: Volar view of the left hand showing near amputation of the middle finger. The laceration to the index finger starts dorsally and continues radially around the finger and is not visible here.
remaining, and we attempted to repair this defect using lateral band rotational flaps. Flexor tendon rehabilitation was started 7 days postsurgery. In the middle finger, the patient achieved 90 flexion of the MP and PIP joints and 60 flexion of the DIPJ, and r
Vol. 39, May 2014
979
FIGURE 5: Radial lateral view of the left middle finger 10 weeks after extensor tendon salvage and reconstruction. A Flexion of the middle finger. B Extension of the middle finger.
18 extensor tendon lag with minimal active extension of the DIPJ at 8 weeks. In addition, there was DIPJ nonunion in the index finger. The patient was then offered DIPJ fusion of the index finger and reconstruction of the middle finger extensor tendon using this tendon salvage technique. To perform the salvage and reconstruction, we performed index finger DIPJ arthrodesis using a variable-pitch headless screw and completely removed the terminal tendon of the donor index finger, leaving the central slip attachment intact as described earlier (Fig. 1). The recipient middle finger terminal tendon area that had healed with marked scar tissue was removed. The DIPJ of the middle finger was then temporarily fixed with a 0.9-mm K-wire and the terminal tendon of the index finger was used to reconstruct the terminal tendon of the middle finger (Fig. 2). The patient was initially fitted with finger splints for both the donor and recipient fingers. However, because both fingers were on the same hand, the patient was unable to comfortably tolerate the 2 splints, so a short-arm splint was applied. Postsurgical OT was initiated for the 8-week protocol. After 2 months of OT, the patient was able to extend the middle finger DIPJ, but there was 30 lag, most likely the result of a long terminal band and/or adhesions from the tendon to bone. Because the patient was still concerned about the extension lag, we offered Fowler tenotomy to improve extension of the DIPJ. After Fowler tenotomy and tenolysis of the extensor tendon, the patient achieved full flexion of the middle finger, 90 MP joint flexion, 100 PIP J Hand Surg Am.
joint active flexion, and 60 active flexion of DIPJ. The patient achieved active extension of the DIPJ with about 10 lag (Fig. 5). Case 2 A 77-year-old male patient was brought to the emergency room after a bicycle accident that caused right-hand index finger subtotal DIPJ amputation and a right-hand middle finger dorsal open wound with complete terminal tendon loss. A revision amputation to the patient’s index finger was performed and the terminal tendon was harvested for use in repairing the middle finger. Using this harvested tendon, the terminal tendon loss of the middle finger was reconstructed. We used a 0.9-mm K-wire to temporarily fix the DIPJ of the middle finger (Fig. 6). The middle finger dorsal skin was closed using an advancement flap. The patient was lost to follow-up. PEARLS AND PITFALLS In this article, we present an approach to repair a terminal tendon using unused tendon from another finger on the same patient. Terminal tendon injuries are common injuries, and in some cases such as in mallet finger injuries, they can be simply repaired. However, if there is a defect owing to a traumatic event, reconstruction of the terminal tendon may be challenging. In such cases where multiple fingers are damaged and lacking in function, it may be logical to take an unused part (spare part) from 1 finger (eg, the terminal tendon of a fused index finger) and transplant it to another finger, thereby reconstructing the poorly functioning r
Vol. 39, May 2014
Surgical Technique
ZONE I EXTENSOR TENDON RECONSTRUCTION
980
ZONE I EXTENSOR TENDON RECONSTRUCTION
FIGURE 6: Dorsal view of the right middle finger in Case 2. A Extensor tendon defect in the terminal tendon. B Harvested terminal tendon from the index finger. C The harvested terminal tendon is transplanted to the extensor tendon gap. The DIPJ is temporarily fixed with a K-wire. A dorsal rotation flap is designed to cover the distal dorsal portion of the defect and provides access for the extensor tendon reconstruction.
Surgical Technique
finger with either arthrodesis or amputation and achieving improved function in the recipient finger without making the donor finger worse. For short terminal tendon gaps, lateral band rotational grafting may be 1 of the chosen reconstructive methods for terminal tendon repair.4 In Case 1, for example, tendon rotational grafting was performed but the outcome was suboptimal. If the recipient finger could have been kept in extension, it is possible that the hemilateral band technique performed in the first surgery could have worked if the patient had not had a flexor tendon repair in the same finger. However, because early flexor tendon rehabilitation was started to achieve a better functional outcome, this rehabilitation may have contributed to failure of the hemilateral band technique by stressing the extensor tendon repair. Kochevar et al3 studied using the same extensor tendon as a tendon graft. In addition, Baratz et al2 previously described the rotational “lateral band turndown” procedure for zone II extensor tendon grafting. Rotational grafting is a good repair option for small defects, but in cases with large defects, a free tendon graft may be necessary. If the defect is bigger than one that can be repaired by rotational grafts, free extensor tendon graft is needed, such as with palmaris longus.5,6 Alternative reconstructive options for combined skin and tendon defects in the mangled hand are free composite flap reconstruction from the toes or elsewhere.7,8 Extensor tendon salvage and reconstruction provided a good outcome in Case 1. However, additional surgery (Fowler tenotomy and tenolysis) was needed
J Hand Surg Am.
because of extension lag at the DIPJ. The extensor tendon lag could have been related to 1 or more of the following: (1) terminal tendon adhesions at the level of the middle phalanx, (2) long terminal tendon, and/ or (3) early start of OT, which may have caused elongation of the terminal band. We started OT as soon as tenderness in the proximal and distal attachments of the terminal tendon had subsided. It is important to keep the DIPJ at 5 from full extension using a K-wire and then to apply the transplanted tendon, which must fit the length of the defect precisely. REFERENCES 1. Elliott RA Jr. Injuries to the extensor mechanism of the hand. Orthop Clin North Am. 1970;1(2):335e354. 2. Baratz ME, Schmidt CC, Hughes TB. Extensor tendon injuries. In: Green DP, Hotchkiss RD, Pederson WC, Wolfe SW, eds. Green’s Operative Hand Surgery. 5th ed. Philadelphia, PA: Elsevier/Churchill Livingstone; 2005:200e203, 211e212. 3. Kochevar A, Rayan G, Angel M. Extensor tendon reconstruction for zones II and IV using local tendon flap: a cadaver study. J Hand Surg Am. 2009;34(7):1269e1275. 4. Savvidou C, Thirkannad S. Hemilateral band technique for reconstructing gap defects in the terminal slip of the extensor tendon. Tech Hand Up Extrem Surg. 2011;15(3):177e181. 5. Nichols HM. Repair of extensor-tendon insertions in the fingers. J Bone Joint Surg Am. 1951;33(4):836e841. 6. Gu YP, Zhu SM. A new technique for repair of acute or chronic extensor tendon injuries in zone 1. J Bone Joint Surg Br. 2012;94(5): 668e670. 7. Scheker LR, Langley SJ, Martin DL, Julliard KN. Primary extensor tendon reconstruction in dorsal hand defects requiring free flaps. J Hand Surg Br. 1993;18(5):568e575. 8. Wang L, Fu J, Li M, Han D, Yang L. Repair of hand defects by transfer of free tissue flaps from toes. Arch Orthop Trauma Surg. 2013;133(1):141e146.
r
Vol. 39, May 2014