late reconstruction of flexor tendons...single stage flexor tendon grafting • direct early repair...

Late Reconstruction of Flexor Tendons

Overview

• Tenolysis • Acute Free Tendon Graft • Single Stage Flexor Tendon Grafting with FDP

disrupted, FDS intact • Two Staged Flexor Tendon Reconstruction • Thumb Flexor Tendon Reconstruction • Secondary Reconstruction in Zones 3,4,5 • Flexor Tendon Reconstruction in Children • Complications of Flexor Tendon Reconstruction

Flexor Tendon Reconstruction

• Satisfactory function difficult • Treatment of choice in the past

– Typically waited > 3 weeks !

• Now secondary repair less common

Aspects of Reconstruction

• Tenolysis • Staged Reconstruction • Tendon Transfers • Pulley Reconstruction

Aspects of Reconstruction

• Fall-Back – Arthrodesis – Amputation – No Operation

May be more Prudent

The Key

• Patient Selection – Rigorous post-op physical therapy – Possibly no improvement

• Possibly worse function

– Expense – Age – Functional status

Management Ladder

• Initial consideration: adhesions? • Capsulodesis? • Tendon/ pulley integrity? • Tendon Transfer • Primary graft • Pulley reconstruction

More Procedures = More Scars

• Factors influencing outcome of multi-stage procedure

• Age – Young (except vy young) do better – Motivation – Strength – Postop care

Other Factors

• Mechanism – Clean laceration vs crushing injury – # of ass. Injuries decreases final function

• Level – Outside sheath do better than inside

• Innate healing response

Tenolysis

• Adhesions Occur anywhere the epitenon is violated !– Failed 1* repair – Crush injuries – Fractures – infections

Indications for Tenolysis

• Plateau in progress with physical therapy

• Significant difference between active and passive ROM

Post Op Tenolysis

• Maximal function demands immediate mobilization

• Any concommitant procedure requiring imobilization will decrease end result – Common

• Capsulotomy • Pulley reconstruction • Nerve repair

Tenolysis

• Timing – < 3 months

• Soft wound • Nutrition via diffusion

– <9 months • Contracture

– Most active function achieved by 22 weeks

Tenolysis

• Steroids – As much evidence shows benefit as not – Some show increase scarring

• Birnie and Idler – <11 y.o. à minimal gains – Older children benefitted up to one year after

original procedure

Technique

• Neuroleptanesthesia – Pt cooperation

• Post op – AROM started within days – CPM if combined with contracture release

Single Stage Flexor Tendon Grafting

• Direct early repair is usually treatment of choice

• Some instances when free tendon grafting is the treatment of choice – 1) segmental tendon loss – 2) delay in definitive repair (3-4 weeks) ends are

degenerative, scar fills sheath – 3)dalayed presentation of some FDP avulsion

Single Stage Acute Free Tendon Grafting

• Principals – 1) Injured tendon is excised – 2) distal anastamosis to FDP insertion – 3)proximal anastamosis in palm or forearm – 4)preffered in digits with FDP + FDS injury – 5) never sacrifice intact FDS – 6) one graft / finger

Distal Anastamosis

• Created first – Easier to adjust tension on the proximal ‘mosis

Proximal Juncture

• Goal – Early: withstand early muscle pull – Resist gap formation

• Weave – Most people prefer if outside sheath

Technique

• Zig-zag • Minimal resection of injured tendon

sheath • 1cm distal FDP stump ideal • Sharp excision FDP à lumbrical • In palm if FDP of poor quality can

anastamose to FDS

Technique Cont’d• In cases where FDP + FDS stump are

injured à FDS stump transected and can retract

• If FDS is resected à 1 cm stump provides favorable dorsal border – FDS (-) finger à hyperextension at PIPJ

• Graft obtained • Atraumatic graft handlling/ passing

Technique:Distal Juncture

• Prolene criss-crossed thru end of graft (Bunnell)

• Tendon braider used to place graft thru distal stump

• Sutures are placed around or thru P3 and thru nailbed

• FDP jnctn reinforced • If stump is short, simply split

Technique:Distal Juncture

• Other Distal Techniques – Can bring thru the pulp – Classic Bunnell tendon to bone attachment – Can also place transversely oriented drill holes

Proximal Juncture Technique

• If in palm à make distal to lumbrical • Lumbrical left alone unless involved in scar

– Significant scarring is criteria for two staged procedure

• Graft is braided thru a fish-mouth distal split • Estimate tension in an awake pt

– At rest each digit is more flexed than radial border digit

Post Operative Treatment

• Past: 3 weeks of immobilization – Splint: WRIST: 35* flexion – MCPJ : 60* flexion – IPJ : full extension – Spint worn for three weeks – AROM at 3 weeks – 2 more weeks in splint when not exercising – Pullout removed at 6 weeks


• With 1* repair early motion beneficial – Has been extrapolated to the post op course of

2* repair


• Typical Early Motion Protocol – Post-op splint = static dorsal block – Splint: wrist in nuetral – MCPJ @ 45* flexion – IPJ in nuetral – Splint worn for 6 weeks – PROM 2-3 days post-op – 2 weeks: gentle place and hold – Active short-arc

Post Operative Treatment – Cont’d

• Blocked flexion exercises – Puts increased tension on anastamosis – Initiated at 4 weeks – Against resistance at 6 weeks !!

!

Long Term Graft Integrity

• If explored at 6 months – Histologic replica of the original

• Is it the original graft or a new creation built on a scaffold of collagen ?

• Lindsay and McDougal – Initial nutrition thru synovium – Later nourished via adhesions

Single Stage Flexor Tendon Grafting with FDP disrupted, FDS intact

• Primary Indication: repair has been delayed > 3-4 weeks

• Occasionally short vinculum remains intact and can do 1* repair


• Potentially Dangerous – Most function intact when FDS intact – Minimal gain if DIPJ does not hyperextend – Significant chance of injury to FDS


• “It should not be advised unless the Pt is determined to seek perfection and the surgeon is confident of his ability to offer a reasonable expectation without the risk of doing harm”

• -Pulertaft

Single Stage Flexor Tendon Grafting with FDP disrupted,

FDS intact• Technique is similar • Attempt to pass graft thru FDS decusation • Can detach one FDS limb • Never fully detach intact FDS • If difficult and FDS injuredàconsider

staging • Can also consider passing around the FDS

Single Stage Flexor Tendon Grafting with FDP disrupted,

FDS intact

• Post Operatively • 1’st week :

– short arc active flexion/ extension – Gentle place and hold – Straight fist flexion

Two Staged Flexor Tendon Reconstruction

• Principal: – active or passive tendon implant followed by a

replant graft

• Pts more suited for 2 stage: – Severe crush with Fx or skin damage – Failed first procedure with scarred bed – Damage to pulley – Both digital nerves injured – Contracted joints

Two Staged Flexor Tendon Reconstruction

• Patient Selection – Understand that in some you are starting with a

bad finger – Can you justify subjecting finger to 2+

procedures? – Arthrodesis? – Amputation?

Historical Aspects of Staged Reconstruction

• ’65 Hunter published personal experience • ’71 Hunter + Salisbury published 10 yr

experience • Their tec. Involved excision of tendon

and rebuilding of pulley system around silicone graft


• Attached implant dstally • Left proximal end in forearm unattached • Post-op à PROM • Found that in a previously scarred bed the

graft would create a smooth well organized pseudosheath

• 2’nd stage performed at 3 months


• ’69 Paneva- Holevich alternative staged technique – 1’st stage : proximal cut FDS sutured to proximal

cut FDP • Can place a silicone rod if neccessary

– 2’nd stage : FDS cut as far proximal as possible and this is sutured to the distal phalanx


• Peacock and Hueston – Described using a homograft consisting of the

entire flexor system, tendon and supportive structures

– Obtaining grafts was difficult


• ’74 Chacka – Used autologous composite grafts from the toe – Modest results only


• Recently – Many permanent active tendon implants have

been attempted – No reliable with either the proximal or distal

anastamosis

Technique of TWO Stage Flexor Tendon Reconstruction

• Zig-zag or mid-lateral • All pulley material is preserved • Flexors excised

– 1 cm FDP stump – 1 cm FDS stump – Set aside tendon for possible pulley repair

• If lumbrical scarred à excise


• Check for static joint deformities – ? Volar plate incision – ?col. Lig. incision

• FDS excised at 2’nd incision prox. To flexor retinaculum

• Silicone implant sized and placed • Asses pulley system


• Handling the implant – Smooth forcep – talc

• Suture distal graft • Test for smooth gliding

– Buckle à dilate pulley


• Post-OP regimen – Splint : wrist 35* flexion mcpj 60* IPJ extension PROM POD 2 Wait 3 months

Technique of TWO Stage Flexor Tendon Reconstruction (stage II)

• Use previous incision • Expose distal attachment • Expose proximal graft • Select motor

– S,R,M F’s àprofundus mass – IF à FDP of IF


• Select Graft – Palmà tip : palmaris – Forearm à tip : plantaris or toe extensor – Select Graft

• Graft sutured to implant, pulled thru • Distal followed by proximal

anastamosis


• One Motor Used : end weave • Profundus mass used: inter-weave • Post-op Splint

– Wrist : nuetral – MCPJ : 45* flexion – IPJ : neutral

Inter-Weave


• Post-OP Care • Immediate

– Protected PROM

• Two weeks – Short arc active extension/ flexion – Place and hold

• 4-6 weeks – Add resistance

• >6 weeks – +/- dynamic splinting

Tissue Response to Silicone Implant

• Dogs in 60’s – early : Nutrition provided thru diffusion – Later : nutrition thru mobile, vascular adhesions

• Electron Microscopic Studies – Psuedosheath and synovium similar

• ’76 Rayner – Pseudosheath = fibroblastic (not mesothelial in origin) – + fluid secreted – Lesson: wait for adhesions (mobile) to form before 2’nd

stage

Tissue Response to Silicone Implant

• Later histologic studies: mainly connective tissue (F.B. reaction)

• Unknown exact nature of sheath • Unknown origin but reliable results

Thumb Flexor Tendon Reconstruction

• Flexor system is less complicated • one less joint • 30* will give excellent result • Primary repair can be done within 6

weeks • Indication for Reconstruction:

– Good ROM but unable to do 1* repair


• Options for Reconstruction – Free tendon graft – FDS transfer – Staged reconstruction – Nothing (especially if MCPJ and CMCJ are nl.) – Arthrodesis (require string pinch)


!

• Thumb Free Tendon Graft – Same indications as for fingers – Can use FPL or FDS as motor – If > 1 cm tendon loss à IPJ deformity


• Technique (similar to fingers)

– Zig-zag : distal phalanx àMCPJ – divide tendon – Preserve pulley – Curvilinear distal forearm incision – FPL musculotendinous jnctn – Excise tendon – Obtain graft – Distal jnctn with pullout – Tension adjusted

• Wrist in neutral • Thumb palmar abducted in front of IF MC • IPJ at 30*


• Post-Op Splint – Wrist neutral – 30* abduction at CMCJ – MCPJ and IPJ 30* flexion


• Post - Op Protocol • 1’st week

– Full passive flexion, fully extend to limit of splint

• 2-6 weeks – Active flex/ ext out of split

• >6 weeks – Pull-out removed – Start blocking techniques


• FDS Transfer – Alternative to grafting – Consider if FPL m. not functional – FDS of RF transferred


• Technique of FDS Transfer – Zig-zag over thumb – Curved distal forearm – Transverse at base of RF – FDS divided 2 cm proximal to PIPJ – Pull into forearm wound – Passed antegrade into thumb flexor system


!

• Pitfalls of FDS Transfer to Thumb – Intertendinous connections in palm – Tension adjustment is more difficult

Staged Reconstruction in the Thumb

• Criteria – Imperative thumb flexion – Prior failed surgery – Severely scarred bed – Destruction of pulley system

• Tendon – Can use: 1) free graft 2) FDS

Secondary Reconstruction in Zones 3,4,5

• Primary and Secondary repair has more favorable results

• Principals – Large longitudinal incisions – Resultant dysfunction usually a result of

concomitant injuries – Well-healed soft wounds prior to 2’nd stage – if no proximal migration à 1* repair


• Interposition Graft – Common to have a 2-3 cm tendon gap – Graft = intact FDS or palmaris – 1)Criss-cross proximal tendon – 2)thread graft over suture – 3)criss-cross distal tendon – Tension critical – Neuroleptanesthesia – +/- pulley incision


!

• FDS Transfer – adjacent intact FDS tendon – Pass deep to N-V bundle


• End To Side FDP Juncture – Distal FDP à side of an adjacent FDP – Inter-weave – Most useful in forearm – Limited in Zone III by A1 pulley


• Splint (dorsal, to fingertips) – Wrist : neutral – MCPJ :40* flexion – IPJ : neutral

• Early – Controlled AROM

• 2 weeks – AROM

• 4 weeks – DC splint – Blocking techniques – Resisted exercises started

Obtaining Tendon Grafts

• palm à finger – palmaris

• forearm à finger – plantaris – Long extensors of 3 middle toes – EIP – EDM

Palmaris Tendon

• Pro – Same field

• Con – 15-25% absent – Length

• Technique – Wrist incision – Transect tendon – Mobilize under direct vision x 6 cm – Circular tendon stripper – Usually can do with one incision – 2’nd incision if meet resistance

Plantaris as a Graft

• Pro: – longer

• Con: – 7-20% absent – Girth – Attachments

• Technique – 5 cm vertical incision Anterior Medial of Achilles – Blunt dissection under direct vision – Tendon stripper – Knee extended – Divide when plantaris m. fills stripper – Compartent syndrome reported

Long Toe Extensors• Can use 2-4 toe extensors • Pro

– Good diameter – Up to 3 grafts – Almost always present

• Con – May fuse distal to ankle

• Technique – Transverse incision over MTPJ – Isolate and divide extensor – Tendon stripper – Stop if encounter resistance – Additional incisions – Pull tendon into 2’nd wound – Early transection of graft – Can potentially obtain graft into leg

Extensor Proprius Tendons

• Each can potentially give 1 palmà tip graft • EIP

– Lies ulnar to EDC – Transverse incision over MCPJ – Transect 1 cm proximal to hood – 2’nd incision over musculo-tendinous junction

• EDM – Harvest similar to EIP – Usually has 2 tendon slips – Only harvest the ulnar 1/2

Toe Flexors

• Studies have shown fewer adhesions verse extra-synovial grafts

• Long flexors of the 2-5’th toes minimal morbidity

• Technique – Transverse incision at base of toe – 6 cm incision over NWB mid foot – Dissect individual tendon from coalescence – Mid-foot à toe = palm à tip – Multiple grafts possible

Recontruction of the Pulley System

• Barton showed that at minimaum A2, A4 • With complete destruction: minimal

reconstruction distal to MCPJ and PIPJ • One Stage Tendon Grafting

– All uninjured tendon is retained – Earlier work suggested wide debridement except critical

bands

• Pulley Reconstruction – Criteria for 2 stage procedure

Pulley Reconstruction Using Free Tendon Graft

• During 2 stage procedure excess tendon for grafting

• 1)encircle P1 and P2 – Pro : strong – Con : bulky

• 2)Tendon is woven into remnant pulley • 3)osteotomy • 4)FDS tail

Pulley Reconstruction Using Extensor Retinaculum

• Segment of retinaculum passed around phalanx

• Pro: – Undersurface glides well – Strong enough for early motion

• Con: – Difficult – Second incision


• Karev described using the Volar Plate • Creates slits in the volar plate • Pro: almost as strong as annular band • Con: abnormal joint motion


• Artificial materials – Gor-tex – Dacron – Silicone – Xenograft – Fascia lata – Nylon – Porcine collagen – Peritoneum !

• Limited experience 2* abundant 1* graft material


• Technique • At proximal phalanx graft is placed deep to N-V

bundle and intrinsic system • Minimum of 2 wraps • 4 wraps better • At A4 2 wraps enough • 6-8 cm of graft for 1 wrap • Enter pulley system at cruciate pulley

– But blood supply to vincula enter here

• Post-op – External protective pulley ring x 2 weeks

Flexor Tendon Reconstruction in Children

• Primary repair better • Small structures à do not hold

sutures well • Post op rehab difficult • Conservative approach

– Delay graft until 7 y.o.

Technique of Flexor Tendon Reconstruction in Children

• Same as for adults except: – Do not place graft into P3 – Distally suture to FDP stump – If no stump; suture with non-absorbable thru drill holes

distal to epiphysis – Preferred graft:

• Palmaris • FDS of injured finger • Plantaris too thin

– Injured finger remains smaller

Complications of Flexor Tendon Reconstruction

• Adhesions – Most common complication – Occurs at anastamosis or anywhere epitendinous layer

disrupted – To reduce:

• Handling • Post op therapy

– Tenolysis • Salvage • Only done after plateau reached • Timing

Complications

• Mechanical Failure of Implant – rare

• Graft Rupture – Distal > proximal – 1* repair if recognized early – Salvage procedure: suture to P2

• Pulley disruption – Diagnosis: decrease in ROM with bowstringing – Rare – Continue PROM while plan repair

Complications – Cont’d• Quadregia • Decreased flexion of an adjacent nl finger 2* limitations on

FDP due to common musculotendinous origin • Flexion deformity • Occurs:

– Adhesions – FDP advancement too great – Short tendon graft – P3 ampand flexor sutured over tip of P2 – Amp and FDP adheres to proximal phalanx

• Treatment – Depends on cause

Tenolyse Lengthen Divide

Complications –Cont’d• Hyperextension of PIPJ

– Absence of FDS may cause – Difficult initiation of flexion – Can do tenodesis with 1 slip of the FDS

Complications –Cont’d• Lumbrical –Plus Finger

– If graft is too long – Excessive traction on lumbrical with flexion – Paradoxical IPJ extension – High risk if advocate wrapping lumbrical

around proximal anastamosis

Complications –Cont’d• Synovitis

– Present in 8-20% at Stage II – Increased crepitus, swelling, heat, thickened sheath – Culture negative – Expect increased adhesion formation – ? cause

• distal implant jnctn breakdown • Buckling of implant • talc

– Treatment • Decrease exercse program • Move up Stage II

Complications –Cont’d• Infection

– Disaster – Implant removal – Abx – Repeat stage one in 3-6 mo

Complications –Cont’d• Late Flexion Deformity

– Poor nutrition – Wound contracture – Splinting problems

• Treatment • Early

– Splint digits in extension between exercises and at night – Gentle stretching

• Attempt x 1 year

• Late • Capsular release • tenolysis

Complications –Cont’d• FDS Finger

– 1) DIPJ inadequate 2* intra-art damage or extensor damage

– 2)inadequate pulley –> Bowstring -> decrease excursion

– 3)rupture of distal insertion

Complications –Cont’d• Treatment of FDS finger • 1)

– Insert graft into P2 – Arthrodesis if joint unstable

• 2+3) – Same as 1) + pulley reconstruction

late reconstruction of flexor tendons...single stage flexor tendon grafting • direct early repair...

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