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Staged Flexor Tendon Reconstruction

- See:
     - Primary Flexor Tendon Grafting
     - Pulley Reconstruction
     - Prosthetic Grafts

- Discussion:
    - indicated for delayed or neglected flexor tendon injuries, tendon rupture following previous attempted repair, and in some cases is indicated for zone II tendon injuries;
          - probably in most cases, free tendon grafting is indicated for flexor tendon injuries which are dirty or contaminated at the time of injury;
          - palmaris longus or plantaris are satisfactory graft choices;
    - contra-indications:
          - loss of full passive digit ROM;
          - w/ isolated FDP loss but good retention of FDS function, tendon reconstruction risks worsening finger function;
                 - in this case, consider FDP tenodesis or DIP joint fusion;

- Exam:
    - pt must have full passive ROM of digits before free tendon grafting can be performed;
    - in cases of isolated FDP loss, carefully assess function of the FDS tendon (if this is functioning then consider FDP tenodesis);

- Technique: Stage I (debridment / prosthetic graft insertion):
    - exposure:
           - phalangeal incisions: midlateral or Bruner skin incision is made to expose involved tendon;
           - for index finger, proximal incision extends from radial aspect of proximal finger crease to ulnar aspect of middle crease & radial aspect of the distal crease and then to ulnar aspect of finger pad;
           - extension into the palm then follows the palmar creases;
           - neurovascular structures are identified;
           - annular ligaments are identified;
           - save as much as the tendon sheath as possible;
           - while protecting annular ligaments, cruciate ligaments are opened to allow access to tendons;
    - tendon debridement:
           - if the FDP is the damaged tendon, excise the FDP tendon from the palm (at the level of the lumbricals) upto the level of the DIP joint;
                  - preserve the distal 1 cm of the FDP which will be used to help anchor the free tendon graft;
                  - avoid injury to profundus stump insertion, since this protects the volar plate and helps maintain a smooth gliding surface;
           - assess FDS tendon insertion:
                  - if the FDS is damaged, then excise the distal 1-2 cm of its insertion;
                  - if the staged flexor tendon reconstruction of Naam (1997) is to be used, then the proximal stumps of the FDS and FDP are sutured together, for later identification;
                   - Staged flexor tendon reconstruction using pedicled tendon graft from the flexor digitorum superficialis. 
    - assessement of tendon sheath environment:
           - scaring within flexor sheath, excessive pulley system damage, joint contractures, and/or nerve injury mandate two-stage tendon grafting;
           - pulley reconstruction, joint release, or nerve repair should be performed at this point in the case;
                    - ref: Flexor sheath dilatation with a Fogarty catheter.
           - prosthetic grafts are inserted at this point;
                    - use the largest prosthetic graft that is possible;
                    - some use a twisted wire, to help pass the graft thru the sheath;
                    - graft is anchored proximally but left free distally;

- Stage II Reconstruction: (flexor tendon grafting)
    - the second stage of free tendon grafting is completed when all signs of infection and significant scarring are absent;
    - donor graft:
           - palmaris longus;
           - plantaris;
           - Leversedge, et al (2000): results with using intrasynovial donor tendons for flexor tendon reconstruction in 8 patients (10 digits) at a mean 3.8 years
                  for neglected or failed primary repair of zone 2 lacerations and for neglected flexor digitorum profundus avulsions;
                  - flexor digitorum longus to the second toe was used as the donor tendon graft.
                  - average active motion recovery was 64% and 56% for single-stage and multistage reconstructions, respectively, and was 73% overall for single digit reconstructions;
                  - ref: Flexor tendon grafting to the hand: An assessment of the intrasynovial donor tendon—A preliminary single-cohort study.
    - distal incision is made over previous incision stopping at mid phalanx;
           - make a small longitudinal incision in the distal sheath, w/ care not to injure the A4 pulley;
           - locate the Hunter rod at the distal FDP stump;
           - the rod is left anchored in place until, tendon graft has been harvested;
    - proximal incision:
           - proximal incision is reopened and the proximal aspect of the sheath is identified;
    - distal end of prosthetic graft is cut, and prosthetic graft is pulled distally, pulling the tendon graft thru the sheath;
    - anchor the distal end of the tendon graft;
           - the distal end is anchored first so that the proximal anastomosis can be used to judge appropriate tendon tension;
           - the remaining FDP stump is split and sutured to both sides of the graft;
           - use pull through technique to augment the repair;
           - distally graft is held in place with a 3-0 Prolene pull out suture tied over a button placed on the finger nail as in Zone I flexor tendon repairs;
           - remaining stump of FDP is sutured to tendon graft w/ 4-0 non-absorbable sutures;
           - distal incision is closed down to the base of the digit;
    - reconstruction with disrupted FDS tendon
           - if the staged flexor tendon reconstruction of Naam (1997) is used, then the site of proximal FDS / FDP juncture is located (which
                  had been sutured together previously);
                  - FDS of the involved finger is exposed and is divided proximally, hence it is a free tendon graft;
                  - the free (proximal) end of the FDS tendon graft is sutured to the prosthetic graft;
                  - free FDS graft is sutured to the remant FDP stump;
                         - since the proximal portion of the graft has already been sutured together, proper tension needs to be established at this point in the case
                 - ref: Staged Flexor Tendon Reconstruction Using Pedicled Tendon Graft From the Flexor Digitorum Superficialis.
    - reconstruction with intact FDS tendon insertion:
           - flexor tendon grafting through the intact sublimis tendons may cause impingement, hence may consider release of one limb of FDS insertion;
                  - ref: Resection of the flexor digitorum superficialis reduces gliding resistance after zone II flexor digitorum profundus repair in vitro.
    - anchoring the proximal tendon end:
           - the proximal end is anchored after the distal end, so that tensioning the graft is easier;
    - misc:
           - a common complication postoperatively is hyperflexion of the DIP joint;
                 - to avoid this complication, consider inserting a pin across the extended DIP joint for a period of 10-14 days, and in the mean time, have the patient concentrate on PIP motion;

- Post Op Care:
    - dorsal split is applied w/ wrist in 40 deg of flexion and MP flexed to 90 deg, until patient is ready to begin passive ROM

Autogenous flexor-tendon grafts. A biomechanical and morphological study in dogs.

Two-stage flexor-tendon reconstruction. Ten-year experience.

Staged Flexor Tendon Reconstruction Using Pedicled Tendon Graft From the Flexor Digitorum Superficialis.

Flexor Tendon Reconstruction in Severely Damaged Hands: a two staged procedure using a silicone-Darcon reinforced gliding prosthesis prior to tendon grafting.

Primary Flexor Tendon Repair Followed by Immediate Controlled Mobilization

Bridge flexor tendon grafts.

Two-stage flexor tendon reconstruction in zone II using a silicone rod and a pedicled intrasynovial graft.

Staged flexor tendon reconstruction fingertip to palm.

Flexor tendon grafting to the hand: An assessment of the intrasynovial donor tendon—A preliminary single-cohort study.

Staged flexor tendon reconstruction fingertip to palm.

Surgical treatment of the divided flexor digitorum profundus tendon in zone 2, delayed more than 6 weeks, by tendon grafting in 50 cases.

Two-stage Flexor Tendon Reconstruction in Zone II Using Hunter's Technique

Zone 2 Flexor Digitorum Profundus and Superficialis Rupture Treated With Single-stage Tendon Reconstruction Using an Active Hunter Rod Implant