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SECONDARY FLEXOR TENDON RECONSTRUCTION
SECONDARY TENDON SURGERY
 Law of diminishing returns: The potential gain from each operation will become less
and less.
 Pre-op assessment involves assessment of the whole hand, ie, skin, blood and nerve
supply, bones and joints, flexors and extensors.

 Particular note must be made of previous or associated injuries, scars, poor vascularity
or sensation, malunion or non union of #s and contractures. If there are any problems
with these structures, they must be dealt with prior to undertaking secondary tendon
surgery.
 Extensors must be corrected before tackling flexors.
Late Direct repair
 a tendon repair performed >3 weeks after injury
 If the finger is mobile, then attempts to repair the tendon as in the acute case may be
reasonable
 contraction of the musculotendonous unit makes it difficult to pull the tendon out to its
proper length. Scar tissue develops within the flexor sheath, decreasing the space
available for the tendons.
 Late direct repair is most commonly performed in the thumb because some loss of
tendon excursion and interphalangeal joint motion is well tolerated
 Several anatomic features unique to the thumb which make it more amenable to late
direct repair, even up to 3 months after injury.
1. The thumb has no lumbrical
2. its flexor sheath has only three pulley
3. there is only one flexor tendon within the sheath rather than two
 If tendon retraction is significant, one option is lengthening the tendon, performed
at the musculotendonous junction so that the lengthening site is proximal to the
carpal canal
 A single tendon cut gives about 5mm in extra tendon length distally. If one repeats this
cut again, about 1-2 centimetres from the first cut but still within the muscle, the
second cut will give another 2-3mm of lengthening.
 When a profundus tendon is pulled-off distally or if cut in Zone 1 and drops back
through the A4 pulley then presents late, it may be too swollen to pass through the
pulley. Because the distal part of the profundus is double-barrelled, secondary surgery
can be avoided by halving the distal part of the tendon. The remaining half of the
tendon is passed easily through the A4 pulley to reattach it distally. This is a
reasonable thing to do as half a profundus tendon is thicker than a palmaris tendon
graft harvested from the same hand. Halving of the tendon is normally only necessary
as far proximally as the proximal interphalangeal joint but can be taken all the way
back into the palm if necessary to allow a swollen profundus tendon to be past through
the A2 pulley and superficialis decussation as well as through the A4 pulley.
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Tendon Reconstruction
 If direct repair not possible, options are tendon graft or staged tendon reconstruction.
Choice depends on extent and magnitude of scar formation within the digital canal and
the condition of the pulley system.
 The true state of the sheath cannot be determined until the time of surgery, so if a onestage procedure is embarked upon, one must be prepared to go on to a two-stage.
 Physio to improve scar, ROM, etc should always be done prior to surgery.
 Patients considered for tendon grafting must be well motivated and compliant.
 Procedures that may be done at the same time as one stage tendon graft include
vascular or nerve grafts and pulley reconstruction.
Classification (Boyes, 1989)
Grade 1
Good. Minimal scar with mobile joints and no trophic changes.
 appropriate for one-stage tendon grafting.
Grade 2
Cicatrix: Heavy skin scarring d/t injury, previous surgery or infection.
Grade 3
Joint damage: Joint injury with  ROM.
Grade 4
Nerve damage: Injury to digital nerve resulting in trophic changes.
Grade 5
Multiple damage: Multiple fingers involved with a combination of the
above problems.
 Grades 2-5 should not be considered for one-stage tendon grafting procedure.
ONE STAGE TENDON GRAFTING
Indications
1. Finger factors: hand is in good overall condition. There is no extensive scarring.
Passive movements are full or nearly full. The circulation is satisfactory. At least one
digital nerve in the affected digit is intact.
2. Patient factors: patient is cooperative
Principles of grafting (Tubiana)
1. only one graft should be placed in any one finger
2. an intact superficialis tendon is never sacrificed
3. the graft should be of small caliber, and that its ends should be fixed away
from the tendon sheath.
Operative technique
 Full exposure of sheath via a Brunner, midaxial or previous incisions. Sheath cleaned
up and any scar removed. Normal pulleys are left.
 FDS tendon removed except for the chiasma of Camper and the short vinculum which
will help to prevent a recurvatum deformity (distal 1 cm of FDS maintained). FDP
removed all the way back so that the proximal anastomosis can be done in the forearm
or in the palm.
 Distal 1 cm stump, if present kept. Scarred or shortened lumbricals are removed next
to prevent a “lumbrical-plus” finger. If the PIPJ tends towards hyperextension, then a
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FDS tenodesis can be done. Joint contractures may require capsulotomy or volar
plate/collateral ligament release.
 Graft is fixed, distally first - use of a drill hole at the base of the distal phalanx is not
appropriate in children with open epiphyses; in such cases, direct tendon suture to the
stump of the profundus is preferable.
 Pulvertaft tendon weave is excellent for the proximal juncture (usually in the palm)
and allows careful adjustment of the tension of the graft
 Most surgeons agree that the tension placed on a tendon graft should result in a resting
posture of the grafted digit that is slightly more flexed than it would be under normal
circumstances. This is best achieved by placing the wrist in neutral and observing the
posture of adjacent digits. In general, the posture of the grafted digit should be
approximately the same as the adjacent ulnar digit, and in the fifth finger, a position of
flexion somewhat greater than that of the fifth finger on the opposite hand would be
appropriate.
FDP Cut, FDS Intact
 late treatment of FDP division or rupture with an intact superficialis tendon is
controversial.
 If the patient has full, strong function of the superficialis, the functional impairment to
the involved digit may not be great. Because a tendon graft brings with it the risk
for compromising existing function, many surgeons have devised a conservative
approach in this situation, with no treatment, tenodesis, or arthrodesis being preferred
to free grafting
 Pulvertaft – ‘should not be advised unless the patient is determined to seek perfection
and the surgeon is confident of his ability’
 reserved for those few patients who have functional needs or a strong desire for the
restoration of profundus function
 should be performed only after a thorough and honest discussion with the patient
about the details of the procedure and its possible complications.
 More likely to reconstruct in the little finger particularly when the superficialis tendon
is found to be weak, because in such patients the improvement of grip provided by the
restoration of profundus function makes the procedure worthwhile.
 Method
o Use small, thin graft (ie plantaris)
o graft should be gently passed through the decussation of the superficialis
in an effort to restore its normal anatomic position.
o In such cases, when the chiasm has been closed and it is not possible to
pass the graft between the superficialis slips, it may be passed around them
TWO STAGE TENDON GRAFTING
.
 Two-stage operation is a salvage procedure indicated when the initial injury is too
severe to allow primary repair or single stage grafting. Factors to consider are:
1) the severity of the initial injury (crush, associated #s, nv injury, skin loss)
2) scarring of the tendon bed, scarred FDP bed with intact FDS.
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3) loss of retinacular pulley system
4) inadequate skin cover which requires a flap
5) joint contracture which requires release
6) permanent retraction of the tendon ends
7) bone fractures requiring internal fixation
 Patients with poor sensation or severe vascular impairment are poor candidates
 Where contractures are fixed d/t joint irregularities, where multiple ops have been
done, where sensation is poor (lack of protective sensation) or if the digit has poor
vascularity, salvage may not be possible and arthrodesis or amputation should be
considered.
Insertion of Silicone Rods (Hunter, 1983)
 Implantation of the silastic rod is to cause induction of a pseudosheath.
 Usually the decision to insert a rod is made after unsuccessful tenolysis. The sheath is
cleared and any pulley reconstruction needed done.
 FDS chiasma of Camper is best left because via the vincula prevents recurvatum
deformity of the PIPJ. FDP excised except for the distal 1 cm.
 The largest size silicone rod is chosen that will fit the sheath - usually 4 mm - and
threaded through to lie in the forearm. Lister, to avoid instruments passing through the
carpal tunnel, attaches the proximal end of the rod to the cut end of FDS in the palm
and then pulls the rod through attached to FDS, after which FDS is excised.
 The rod is sutured distally to the stump of FDP.
 With the fingers in extension (flat on the table), 1-2 cm of rod should lie proximal to
the wrist crease. The finger is passively flexed to check the excursion is adequate
(should be 3-4 cm) and that it is not impaired and does not buckle. If necessary, the
pulleys or sheath can be reconstructed now.
Post-op care
 Early mobilisation ensures that joint mobility is maintained.
 Buddy strapping is useful.
 Physio to maintain the passive range and to  oedema as well as scar Mx is done.
Complications
1. Synovitis: 15-20%. Often d/t excess mobilisation. Signs of inflammation. Rx: rest.
2. Infection: (rare). Rx: implant removal, debridement, irrigation, rest, A/B.
3. Extrusion: Rx as above: immobilisation and antibiotics.
4. Migration after distal end has come loose: Proceed to 2nd stage.
5. Contracture (as for breast prostheses)  1 case.
Synovitis and extrusion can be treated by immobilisation and antibiotics in an attempt to
salvage the reconstruction (Lister).
Second stage
Timing
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 According to Lister timing of the 2nd stage is determined by the state of the digit not by
the calendar (usually 3 months). The skin must be soft, joints mobile with a good
passive range. Mobility should be stable over the period of a month. Often the longer
the better.
 palmaris longus usually is not of sufficient length to serve as a tendon graft for
the forearm to digital tip technique of staged flexor tendon reconstruction. When
present, the plantaris tendon makes a better graft for this procedure because of its
small size and long length. If absent, use EDL.
Method
 The finger is opened and the integrity of the rod noted. The rod is then replaced with
donor tendon (graft attached to distal end of rod and rod then withdrawn). Distal
attachment is done first.
 Tendon repair is usually done in the distal forearm bypassing scarring in the palm.
The proximal anastomosis is then done, usually as a Pulvertuft weave.
 Tension must be such that the operated finger(s) are slightly tighter than the natural
cascade (the repair tends to stretch). Extension must be checked to see that full
extension can be attained and that the proximal tenorrhaphy does not impinge on any
structures. Also check the tenodesis effect. Splintage is as for primary tendon repair,
ie controlled mobilisation with elastic bands.
Modification:
 At the 1st stage the FDP and FDS proximal stumps are sutured end to end to each other
(a silicone rod can also be inserted) and at the second stage, the FDS, “pedicled” on
the FDP is passed down the sheath for distal attachment.
Children:
 Less compliant, therefore many advocate not grafting children < 5 yrs old as
results tend to be poorer.
 It may be best to keep the joints supple and to delay grafting until the child can
comply with rehab (ie, > 5 yrs of age).
 The graft grows with the host so flexion contracture should not develop.
Donor tendon
 Considerations are availability and length.
 The tendon must be thick enough to withstand the forces on it, but thin enough to
become re-vascularised.
 Its loss must not cause a significant loss of function.
 Grafts harvested from intra-synovial locations have recently been shown to do better
than those from extra-synovial positions: quicker healing, fewer adhesions, etc.
 Any of the 6 below can be used for tip to palm grafts but the first 3 and possibly the
fourth are too short for longer grafts from the wrist.
1. Palmaris:
 (+ 13 cm). Present in 85% of patients and when absent, bilateral in 60%
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 When present, occasionally the muscle belly is distal and the tendon proximal or
the tendon duplicated or triplicated. To determine if present approximate the Th
and L and gently flex the wrist. Harvest is by 2 transverse incisions, one distally
at the wrist crease and one proximally at the musculo-tendinous junction.
 Lengthen 5cm if take with palmar aponeurosis
2. EDL of 2nd, 3rd and 4th toes:
 5th toe usually only supplied by EDL and not EDB and therefore EDL to 5th toe
should not be harvested or if it is, tenodesed to EDB to 4th toe
 Multiple interconnection exist in the dorsum of the foot and their separation
results in raw areas.
 Transverse incision over the MTPJ (note EDB lies lateral to EDL). Serial
transverse incisions are made over the dorsum of the foot about 3 inches apart,
the most proximal just above the extensor retinaculum. Can split one tendon into
2 longitudinally.
3. Plantaris
 Present in 80-93% (presence unrelated to that of PL). If absent on one side, 1 in
3 chance of finding it on the other.
 Good length (+ 30 cm). Harvested by a longitudinal incision just anterior to
tendo Achilles. Tendon strippers (blunt then sharp) aid in its harvest and can
avoid a proximal incision. Can be split into 2-3 strips or tails
4. EDM: Usually duplicated, rarely more, occasionally single. Pre-op confirmation of
presence only in thin patients. Distal incision transverse and 2 cm proximal to MCPJ
of L. Proximal incision 2 cm proximal to ulnar styloid. Paratenon usually excise,
although some leave it.
5. EIPJ: Note lies on the ulnar side of EDC to I.
6. FDS
 most only use it if it has also been injured in the same finger.
 More useful as a tendon transfer for FPL reconstruction
7. Undamaged tendon in an amputated digit
Methods of Pulley Reconstruction
 pulley should be tight enough to prevent any tendon bowstringing and loose enough to
allow unimpeded tendon gliding.

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(A) The Kleinert/Weilby technique weaves a tendon through the “always-present
fibrous rim” of the pulley being constructed.
(B) The triple loop forms a wide pulley reconstruction by individually passing three
tendon grafts around the phalanx. When a loop technique is used to reconstruct
the A2 or A3 pulleys, the loops must be passed volar to the extensor mechanism
(between the extensor tendon/lateral bands and the proximal phalanx), whereas
when used to reconstruct the more distal A4 pulley, the loop must be passed
dorsal to the extensor mechanism (conjoint lateral bands, oblique retinacular
bands and triangular ligament).
(C) The Karev technique involves making two transverse incisions in the volar plate
and sliding the tendon through the so called “belt-loop” that is formed
(D) Lister's technique wraps a segment of extensor retinaculum around the phalanx.
(E) The loop and a half technique passes a tendon graft around the phalanx and then
through the substance of one limb of the tendon graft.
Complications
1. Rupture: Can occur during any stage of the 1st 8 weeks, especially in those patients
who are progressing well. Usually occurs at the proximal repair site. Treatment is
immediate graft replacement.
2. Adhesion
3. Flexion contracture (41%)
4. Infection (4%)
5. Synovitis (8%)
6. Recurvatum deformity: Hyperextension deformity of the PIPJ d/t excision of the
FDS. Avoided by retaining the V2 vinculum (vinculum brevis to FDS). Once it has
occurred, capsulodesis or construction of a spiral retaining ligament may be needed.
7. Bow-stringing
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8. Lumbrical plus: D/t incorrect tension in the graft: too loose - As FDP tightens (gentle
flexion) the finger starts to flex. With further tightening, the FDP then pulls on the
lumbricals rather than the insertion of the tendon into the DP. As the lumbricals
tighten, the IPJs paradoxically extend. If function in the graft is otherwise good, the
condition is cured by division of the lumbricals under LA.
9. Quadriga syndrome: D/t incorrect tension in the graft: too tight - Because the graft is
too tight, the grafted finger reaches the palm before the others thus preventing further
flexion in those digits which thus seem weak. In addition, extension will be limited.
Cx usually treated by prompt re-exploration.
EXPLORATION AND TENOLYSIS
 Exploration and tenolysis indicated if problems.
 Strickland states that tenolysis is indicated when the passive range exceeds the active
and all joint contractures have been overcome. This is rarely the case as often the
contracture is the problem.
 Careful patient selection is important. Bear in mind the patient’s age, job, desires,
mental state, compliance; the original injury and the current state of the finger:
vascularity, sensation, active and passive ROM.
 Tenolysis can worsen the condition.
 Tenolysis may result in cure or, as is often the case, may be the initial exploratory
manoeuvre prior to a more complex procedure (secondary repair, tenolysis, tendon
grafting - primary or staged, pulley reconstruction, salvage procedures: tenodesis or
arthrodesis, amputation).
 The patient must be compliant and co-operative.
 Fingers must be supple, ie, capable of a full ROM.
 now generally accepted that one may consider tenolysis 3 months or more after repair
or graft, providing the other criteria for the procedure have been satisfied and there
has been no measurable improvement in active motion during the preceding 4–8
weeks.
Method
 Tenolysis best done under local block, not only so that the patient can move the finger
when requested, but also to show the patient the benefits while the finger is
anaesthetised.
 The finger is incised from tip to palm and the whole sheath is exposed. Exposure is
through the cruciates into the sheath and the 2 tendons are separated and adhesions
between the 2 tendons and between the tendons and the sheath are freed. The tendons
must not be gripped with forceps, but rather retracted gently with tapes or a retractor.
The area of repair (the scar) must be inspected. Once tenolysis is complete, traction on
the tendon should demonstrate full motion of the joint. More proximal adhesions
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should be checked for and the patient asked to flex the finger which should be full
prior to completion of the procedure.
Instillation of steroids or the application of silicone sheet over the tendon, although it
is advocated by some is not recommended.
After tenolysis has been done, other problems may be evident: attenuated thin tendon,
pulley disruption, contracture, etc. These may require primary reconstruction, tendon
grafting, insertion of silicone rod or other procedure.
Post tenolysis, the wrist is splinted in extension and unrestricted, active finger flexion
and extension is encouraged. Physio at this stage is vital to maintain the ROM.
Improvement expected in70-80% of patients (Lister, Strickland).
Rupture rates following tenolysis vary from 3-20% (Lister, Strickland).
Flexion contracture
Causes
1. injury to other structures
2. poor patient selection: non compliant, etc
3. adhesions
4. bow-stringing
5. ill-designed splint
6. poorly supervised physio
Determine
a) tendon integrity: is there some movement of the digit or scar. Can the tendon be felt to
move.
b) extension deficit, active and passive ROM
 Usually cannot differentiate contracture d/t tendon adhesions alone and those
combined with joint contracture.
Bow-stringing
 Almost always due to excessive disruption of the pulley system or retinaculum.
 Rupture of an intact pulley very unlikely but is a common injury in rock climbers
 Although flexion is more powerful d/t a greater moment arm around the joint,
excursion is limited and the range of flexion and extension may be ed.
 Detected by palpation of the tendon against resisted flexion.
Adhesions
 The most important factors in the production of adhesions are:
1) tendon suture
2) immobilisation
3) sheath excision
 Early controlled motion seems to negate the effects of sheath excision.
 Surgical glove powder causes irritation of the sheath, but not adhesions.
 Attempts at preventing adhesions have been both surgical and pharmacological.
1. Interposition flaps or grafts of sheath, soft tissue, tendon between repair site and
other tendons or bone have helped to a degree in preventing adhesions.
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2. Silastic sheeting has also been used.
3. -aminoproprionitrile and cis-hydroxyproline have been used, but with problems of
toxicity and impairment of wound healing.
4. Brufen, indomethacin and sodium hyaluronate have shown promise.
5. Cortisone, used topically or systemically, is probably the commonest agent used.
VASCULARISED TENDON TRANSFERS
 EHB on the anterior tibial vessels has been used.
 Problematic because flexor sheath too tight to allow tendon and vascular pedicle,
therefore pulley system needs to be enlarged which may compromise overall function.
 According to McC: experimental.
TENDON ALLOGRAFTS
 Host reaction and adhesion formation often unacceptable, although rejection does not
seem to be a problem
 Tendon, however, associated with a low level of antigenicity: hypocellular and
collagen is species specific. Antigenicity related to cellular elements and ground
substance.
 Many methods have been tried to  antigenicity, including freezing, irradiation,
lyophilization, preservation in formaldehyde, etc.
 Results are generally not as good as for autografts.
 Composite allografts have also been tried: tendons, periosteum, palmar plates and
complete tendon sheath.
TENDON XENOGRAFTS
 Cross species transplantation of collagen induces an antigenic response.
 Mass, morphological integrity and strength are lost.
 Recent research promising.