- See:
-
Prosthetic Grafts;
-
Flexor Tendon Sheath Anatomy:
-
Staged Tendon Reconstruction;
- Discussion:
- the A2 and A4 pulleys are essential to prevent flexor tendon bow stringing;
- inadequate pulley reconstruction will lead to bowstringing of the flexor tendon;
- include use of a portion of FDS, free tendon graft, or extensor retinaculum;
- reconstruction is performed to a remnant of the destroyed pulley, thru bone holes, or encircling the phalanx;
- pulleys should not be built at the same time as direct repair, tendon grafting, or
tenolysis because early active motion may stretch annular
pulley reconstruction and because adhesion formation bewteen these structures is likely;
- generally only
staged tendon reconstruction can be performed along with pulley reconstruction;
- Techniques:
- consider using the resected flexor tendon for pulley reconstruction;
- any technique used, must allow for revision of flexor pulley, as pulley may be applied too tightly or too loosely as seen on post op x-rays;
- generally, the reconstructed pulley should be snug;
- on x-ray, if
rods are seen to bowstring, then the pulleys are too loose;
- on x-ray, if
rods are seen to buckle, then the pulleys are too tight;
- generally, a reconstructed A2 and A4 pulley will require two loops of bridging tendon segments for adequate repair;
- one technique involves, anchoring a short segment of resected flexor tendon to one side of either the proximal or distal phalanx (using bone anchors);
- on the opposite side of the digit, one end of a flexor tendon segment is anchored to bone, w/ other end of the tendon segment
brought over the flexor tendon (or prosthetic rod) and secured to a segment of previously anchored tendon segment;
- if the pulley tension needs to be adjusted, the tendon-tendon segment interface can be freed and the pulley tension re-adjusted;
- Post Operative Care:
- external pulley rings may limit tendon bowstringing;
A mechanical study of six digital pulley reconstruction techniques. Part I. Mechanical effectiveness.
CJ Widstrom et al. J. Hand Surgery. Vol 14-A. 1989. p 821-825.
Reconstruction of the flexor pulley. The effect of the tension and source ofthe graft in an in vivo dog model.
JG Seiler MD et al. JBJS. Vol 80-A. No 5. May 1998. p 699.
Use of vein graft as a tendon sheath substitute following tendon repair: an innovative technique in tendon surgery.
Results of primary tendon repair with closure of the tendon sheath.
Flexor tendon repair and rehabilitation in zone II open sheath technique versus closed sheath technique
