two‐stage grafting of flexor tendons: results after mobilisation by controlled early active...

TWO-STAGE GRAFTING OF FLEXOR TENDONS: RESULTS AFTER MOBILISATION BYCONTROLLED EARLY ACTIVE MOVEMENT

Paul Smith,3 Martin Jones3 and Addie Grobbelaar3

From the Hand Surgery Unit, the Restoration of Appearance and Function Trust (R.A.F.T.) Institute For Plastic Surgery Research,Mount Vernon Hospital, Northwood, Middlesex, UK

Scand J Plast Reconstr Surg Hand Surg 2004; 38: 220–227

Abstract. We present the results of two-stage flexor tendon grafting to the hand followed by early activemobilisation. Twenty-six digits from 22 patients were assessed over a 10-year period between 1991 and 2001.Using the LaSalle and Strickland assessment for surgical outcome, we found that 20 digits (77%) achievedexcellent or good results. Two ruptured (8%) and one developed adhesions (4%). We think that our results areachieved through meticulous attention to surgical technique with the use of mid-lateral incisions for surgicalaccess, strong bony fixation of the graft that allows a good interface between tendon and distal phalanx, and aclosely supervised early active mobilisation regimen after the repair.

Key words:tendon, graft, active, mobilisation.

Correspondence to: P.J. Smith, Hand Surgery Unit, Mount Vernon Hospital Northwood, Middlesex HA6 2RN,UK. (Tel: 01923 844412. Fax: 01923 844408)

Accepted 5 March 2003

Lexer did the first free tendon grafts in 1912, andmodest recovery was reported after tendon graftingunder less than optimal conditions (12). Potenzareported the scientific basis for the theory of extrinsichealing of tendons (24), so flexor tendon grafts weretreated by immobilisation for some weeks postopera-tively as this was thought to allow the necessaryrevascularisation of the tendon graft from the surround-ing structures. It also allowed uncontrolled formationof adhesions, which limited active movement. Theability to do tendon grafts successfully was limited to afew hand surgeons, but grafting remained the mainstayof treatment for tendon injuries in no-man’s land, as theresults of primary repair were so poor.

The outcome of primary repair of a flexor tendonwas revolutionised with increased anatomical knowl-edge, finer instrumentation, and the introduction ofearly movement involving active extension againstdynamic flexor bands but misleadingly called con-trolled passive movement (15). Small et al. in 1989were the first to our knowledge to record the results of alarge series of patients in whom primary flexor tendonrepairs were moved early and actively (28). Thesuccess of this technique for primary repair of flexortendons has been confirmed by others (5, 7). Accep-tance of these techniques coincided with experimental

work, which indicated the intrinsic healing propertiesof tendons (3, 17, 18, 20) and the existence of asynovial pathway of nutrition (6, 16–18, 21). Thiswork had repercussions in the use of tendon grafting— particularly two stage tendon grafts. This techniquewas developed by Hunter in 1965 and involved a two-stage procedure using a silicone-Dacron reinforcedgliding prosthesis before the tendon was grafted, whileattempting to develop an active gliding prosthesis (11).In the absence of an intact sheath a Silastic tendon rodwas used to produce a pseudo-sheath with a mesothe-lial lining (10). Tendon grafts in pseudo-sheaths aremetabolically active and maintain their viability bydiffusion of tissue fluid (19).

The donor site has also been studied. Tendon graftsof intrasynovial origin might become incorporatedwithout the formation of adhesions or the developmentof avascular necrosis (8). Such research indicated thatadhesions were unnecessary for the viability of tendongrafts and freed the way for immediate postoperativemovement.

Tonkin et al. in 1988 were the first to show thatflexor tendon grafting can be managed postoperativelywith the Kleinert technique (controlled passive motion)with reduced rates of rupture and tenolysis of the graftthan in an immobilised group (29). An active mobilisa-

2004 Taylor & Francis.ISSN 0284–4311DOI 10.1080/02844310410024566 Scand J Plast Reconstr Surg Hand Surg 38

ORIGINAL ARTICLE

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tion technique has been reported after tendon grafting(13).

In this study we report the results of a regimen ofearly active motion (active flexion) after two-stageflexor tendon reconstruction in Zone II of 26 fingers in22 patients.

PATIENTS AND METHODS

Patients

Over a period of 10 years (1991–2001) 22 patients (26

fingers) were treated with a two-stage tendon recon-struction and a regimen of early active movement.These include 16 adult men, five adult women, and onegirl 9 years of age. The mean age was 33 years (range9–56). Seven little, six middle, four ring, four index,and five thumbs were involved. All patients werefollowed-up for a minimum of one year after thesecond stage to provide adequate information aboutrates of rupture and range of movement. All patientswere assessed preoperatively according to the Boyesclassification (1955) to evaluate the preoperativeseverity of damage in each finger (Table I) (4). An

Table I.Boyes classification applied to patients within the study

Boyes grade Type of injury Number of fingers

1 Good, minimal scar, mobile joints 02 Extensive scar involving tendons and tendon sheath 53 Joint damage with restricted motion 24 Nerve damage with trophic change 85 Multiple digital damage with combination of 1–4 11Total 26

Table II. Details of patients

CaseNo.

Age/Sex(years)

Boyesgrade

Fingerinvolved

No. ofproceduresprior toreferral

Procedures beforereferral

No. of pulleysreconstructed Outcome

1 26 M 4 Little 2 PTR/Teno 1 Excellent2 34 M 4 Little 3 1st/2nd/Teno 2 Fair3 24 F 2 Thumb 2 PTR/TT 1 Excellent4 19 M 4 Middle 3 PTR/DPR 2 Excellent

4 Ring 3 PTR/DPR 1 Excellent5 21 M 5 Ring 6 PTR/Teno/1st/2nd/Teno 2 Failed/amputation6 25 M 4 Ring 4 PTR/Teno/1st/2nd/Teno 1 Good7 29 M 4 Ring 2 PTR/Teno–Rupture 2 Failed8 32 M 2 Thumb 3 Skin/ DPR/Teno 0 Good9 21 M 5 Ring 3 PTR/DPR/Teno 2 Good

10 30 M 5 Thumb 2 PTR/DPR 2 Excellent11 28 M 5 Middle 3 PTR/DPR/Teno 1 Good12 27 F 3 Middle 2 PTR/DPR 2 Excellent13 31 M 5 Index 3 Skin/ DPR/Teno 0 Excellent14 15 M 2 Little 2 PTR/Teno 0 Excellent15 21 F 3 Little 2 PTR/DPR 2 Good16 46 F 4 Little 3 PTR/DPR/Teno 2 Excellent17 22 F 2 Little 2 PTR/Teno 0 Excellent18 9 F 4 Thumb 1 PTR (Replant) 2 Excellent19 24 M 5 Index 2 PTR/DPR 1 Excellent20 57 M 5 Little 4 Skin/ DPR/TT/Teno 2 Good21 40 M 2 Ring 2 PTR/DPR 1 Excellent22 30 M 5 Index 3 Replant/PTR/Teno/JCR 2 Good

Middle 3 Replant/PTR/Teno/JCR 1 FairRing 3 Replant/PTR/Teno/JCR 1 FairLittle 3 Replant/PTR/Teno/JCR 2 Fair

Skin = skin repair only; PTR = primary tendon repair; DPR = delayed primary tendon repair; TT = tissue transfer;Teno = tenolysis; 1st = first stage of graft; 2nd = second stage of graft; and JCR = release of joint contracture.

Scand J Plast Reconstr Surg Hand Surg 38

Mobilisation of tendon grafts 221

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appreciable number of our patients fell into the‘salvage’ category, with 19 fingers being Boyes grade4 or 5 involving extensive scarring, joint contractures,nerve injury, and multiple digital involvement.

Previous operations

All patients had had more than one previous attempt atreconstruction (Table II) with a range of previousoperations between two to five (mean 3.2). Previousinterventions included skin repair only where divisionof the tendon had been missed at the referring hospital,primary tendon repair, delayed primary repair, teno-lysis, failed tendon grafts, joint capsule release,replantation, and even free flap cover to the palm afteravulsion of all the palmar skin (Table II). In most casespulley reconstruction was required using the extensorretinaculum (22 out of 26 fingers).

Operative procedure

Stage 1. No incision was curved to cross thetendon route. The whole length of the digital sheathwas exposed through a mid-lateral incision to allowtotal inspection. We used a standard surgical tech-nique in all patients that involved the removal of allscar tissue and damaged tendons and the insertion ofa medical grade Silicone rod between 4 and 6 mm indiameter (Fig. 1a). Hunter’s rods were used initially

but later abandoned and not included within thisseries as they were too rigid and in some casescaused sterile synovitis. The distal end of the rod wasbevelled and inserted beneath the profundus stump. A3/0 polypropylene (Prolene) anchor suture preventedproximal migration of the rod. The length of the rodwas from the distal interphalangeal joint to theproximal end of the A1 pulley so that when fullyflexed it did not impinge on the carpal tunnel. Finallythe motor tendon, preferably sublimus, was sutured tothe A1 pulley allowing subsequent easy identification,maintenance of length, and isometric contraction.When the rod had been inserted the pulleys wereagain inspected. Any disruption of the A2 and A4pulleys was corrected surgically with a reconstructionusing extensor retinaculum (Fig. 1b, c).

Stage II. This was done through the previouspalmar incision to locate the motor tendon and theprevious incision over the distal phalanx to locate theprofundus stump, which was removed. To allow atendon graft bony interface, the base of the distalphalanx was drilled with a rotating burr to aid thetendon insertion through the bone and held with aBunnel type pullout suture using 3/0 polypropyleneover a foam-cushioned button on the nail (Fig. 2a). Apalmaris longus graft was harvested through a seriesof transverse incisions with the aid of an Aufricht

Fig. 1. (a) Correct position of the proximal end of theSilicone rod in the palm — not pushing against the carpaltunnel when the finger is in full flexion. We now use medicalgrade Silicone rods rather than Hunter rods, which are toorigid and are commonly associated with frequent sterilesynovitis. (b) Harvesting of extensor retinaculum for pulleyreconstruction. (c) Fashioning of the extensor mechanismaround the graft for reconstruction of the A2 pulley.


222 P. Smith et al.

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retractor. The proximal end of the palmaris graft wasattached to the motor tendon using three passes of aPulvertaft weave (Fig. 2b). We found that simplehorizontal mattress sutures were prone to split thegraft and motor tendon and these were thereforeabandoned in favour of crisscross gripping sutures.Tension was adjusted so that with the wrist in naturalextension over a bowl, the finger was allowed toexceed its natural flexion cascade by 1 cm before thefirst crisscross suture was placed. The repair site wasthen repositioned within the wound and a tenodesistest done to assess the accuracy of the tension. Thiswas adjusted if necessary or completed with twofurther passes if correct. On release of the tourniquet

meticulous haemostasis was practised and the woundsutured. A gently flexed dorsal slab was applied togive a natural digital cascade that aided mobilisation.The digits were wrapped up until the patient hadrecovered from the anaesthetic and then reduceddown to the metacarpophalangeal joints to allow theimmediate start of supervised mobilisation exercises.

Mobilisation

All patients were managed with a protective splint andearly active flexion and extension (Table III). Thismethod of active mobilisation is identical to that usedfor our primary tendon repairs with 20 passive and 5active movements an hour throughout the working day.

Fig. 2. (a) Bony fixation of the distal end of the tendon graft with a Bunnel pullout type 3/0 polypropylene (Prolene) suture.(b) Pulvertaft weave of the motor to the proximal end of the tendon graft with three passes each secured with a crisscrosssuture.

Table III. Postoperative mobilisation regimen

0–4 weeks postoperatively:Splintage—

Backslab immobilising the wrist joint in 20° flexionMetacarpophalangeal joints held in 20° flexionInterphalangeal joints extended

0–4 weeks postoperatively:Exercises—

Active extension (10/hour)Passive flexion (10–20/hour)Active flexion (5/hour increasing to 10/hour if necessary throughout the duration of the day)No passive extension of active flexion against resistance of fingers for 8 weeks

4 weeks postoperatively:Splint removed for exercisingWorn for protection for the next 4 weeksWrist flexion and extension started carefullyActive extension of metacarpophalangeal joints to neutralNo passive extension for further 4 weeks

8 weeks postoperatively:Increase careful use of handStart graded strengthening activities and exercises but no full resistance until 12 weeksNo heavy activities for a further 4 weeksPassively splint and stretch into extension if necessary



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Assessment

The patients were all assessed preoperatively by thehand therapists and seen on the day of operation, thenext day, then twice weekly thereafter.

RESULTS

Twenty-six digits in 22 patients underwent two-stagereconstruction. We felt that the best way to evaluatethese results was to compare preoperative passive IPjoint motion with the postoperative active IP jointmotion. The following formula was used to evaluateour patients according to LaSalle and Strickland (14):

where PIP is proximal interphalangeal joint and DIP isthe distal interphalangeal joint. This is a modificationof a formula derived by Whitaker et al. (35). The ratingsystem and results are shown in Table IV.

The four patients in the fair category all hadpreoperative Boyes classifications (4) in the multipleinjury or salvage category (Boyes grade IV or V).Three fingers involved the hand of one patient who hada four-finger replant with extensive bone and soft tissueinjuries. The other patient had a previous two-stagetendon reconstruction of her little finger with asso-ciated joint contractures. She had a tenolysis recently toimprove the range of movement and on exploration hadsevere capsular contracture but minimal adhesions tothe tendon graft. The two ruptures were both in theBoyes grade V category and both were ring fingers.One patient (case 5, Table II) had had six previousinterventions including replantation and a previoustwo-stage tendon graft, and subsequently requiredamputation. The second patient (case 7, Table II) had

two previous procedures after an extensive circular sawinjury and a wound infection postoperatively andpreferred not to have any further intervention.

DISCUSSION

Over the last 10 years we have developed a standard-ised technique of tendon grafting at Mount VernonHospital. Many aspects of this reflect techniques thatwere highlighted by surgeons who practiced handsurgery in the era when tendons were not repairedprimarily and when all patients were referred forsecondary repair using tendon grafts. We think that

attention to every single aspect of this technique isimportant if one is to have consistently good results.

We prefer mid-lateral incisions for tendon grafting;if possible we avoid traversing the flexor tendons. Atevery site where the dermis has been transgressed andoverlies a tendon there is an appreciable fibroticreaction that leads to adhesions. In exposing thetendons it is important to raise flaps in which none ofthe incisions overlie the tendons if possible. In ourexperience, results using Brunner incisions are far lesssatisfactory. Unfortunately, many primary tendonrepairs these days are done through Brunner incisions,which presents problems when the patient returnsshould they require tenolysis or a tendon graft. Manyauthors have suggested that the conversion of aBrunner incision to a mid-lateral incision does notpresent a problem. This is not the case; marginalnecrosis can be considerable and is progressive witheach successive operation. Although the mid-lateralincision is technically more difficult for the junior

Table IV. Outcome of the Mount Vernon series according to LaSalle and Strickland (14)Data are expressed as number (%).

Thumb Index Middle Ring Little Total

Excellent (75% – 100%)* 3 2 2 2 4 13 (50)Good (50% – 74%)* 1 1 1 2 2 7 (27)Fair (25% – 49%)* 0 0 1 1 2 4 (15)Poor (0% – 24%)* 0 0 0 2 0 2 (8)Total 4 3 4 7 8 26

* = % of preoperative movement.


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surgeon, it is important to promote its use in primarytendon surgery so that should secondary surgery berequired a mid-lateral incision can easily be used.

Staged flexor tendon reconstruction using a siliconerod has become the preferred technique in severelydamaged digits. The technique was first reported byHunter and Salisbury in 1971 (12) and several authorshave since reported results using this technique(1, 14, 26, 32–34, 36).

Early active movement after acute flexor tendoninjury has been popularised during the past 15 years(2, 5, 7, 28). An increased rupture rate, particularlyafter flexor pollicis longus (FPL) repair, seem to be theonly possible drawback but condsiderable benefits interms of final range of movement and extensor lag havebeen reported (2, 5, 7, 28). Tendon grafts, however,have traditionally been immobilised for two to three

weeks (9, 23, 30, 31). Pulvertaft in 1956 first suggestedgentle early movement and reported no difference inthe ultimate range of movement when he comparedearly mobilisation with immobilisation in 149 tendongrafts (25). The three cases of graft rupture in his seriesoccurred in patients who had started gentle movementsone week after operation. Schneider (26) adapted theKleinert regimen (15) for flexor tendon grafts andreported no ruptures. Naam used a pedicled tendongraft from the superficialis and controlled mobilisationafterwards (22). Silfverskio¨ld and May used earlyactive mobilisation of tendon grafts using meshreinforced suturing techniques and had three rupturesin 11 digits (27). The rupture rate in our series was low(2/26, 8%). Others have reported varying rates of 4%(1), 7% (14), 9% (36), and 14% (33). Fixation to boneof the distal end of the graft seems to be an important

Table V.Comparative results of flexor tendon grafts by different groupsData are expressed as number (%) of patients.

First author (year)ReferenceNo.

No. ofpatients Postoperative regimen Excellent Good Fair Poor

Weinstein (1976) 34 32 Kleinert for 3 weeks 0 19 (61) 7 (22) 6 (17)LaSalle (1983) 14 43 Immobilisation for 3 weeks 7 (16) 10 (23) 11 (26) 15 (35)Schneider (1985) 26 52 Kleinert for 3 weeks 19 (36) 0 17 (33) 16 (31)Amadio (1988) 1 117 Immobilisation/Kleinert

regimen for 3 weeks20 (18) 41 (36) 22 (19) 31 (27)

Naam (1997) 22 47 Kleinert for 3 weeks 8 (17) 13 (27) 5 (11) 7 (15)Khan (1997) 13 9 Early active 3 (34) 2 (22) 2 (22) 2 (22)Mount Vernon Present series 25 Early active 13 (50) 7 (27) 4 (15) 2 (8)

Fig. 3. Result after two-stageflexor tendon reconstruction ofthe little finger. Preoperativelythe patient was Boyes grade IV.(a) Full extension. (b) Fullflexion.



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factor in reducing the rate of ruptures, as well as aproximal Pulvertaft weave with three passes. Thesestrong attachments at the bone/tendon interface allowsafe immediate mobilisation.

Adhesions from the tendon sheath to the surface offlexor tendon grafts have traditionally been considereda necessary but undesirable component of the healingof tendon grafts. However, adhesion formation restrictsthe gliding function of tendon grafts and result in poordigital function. The exact mechanism by which thesegrafts survive remains unclear.

The results of other series are shown in Table V.According to the LaSalle and Strickland 1983 criteria(14), our results compare well with these series with77% or 20 digits achieving excellent or good results.This compares favourably with the results in primaryrepair (15). It is, however, difficult to make directcomparisons with the results of other series because ofdifferences in assessment methods, and insufficientdata were available within these series to reclassifythem according to our chosen scoring method.

Tenolysis was indicated in only one patient (4%).The low rate is probably the result of the regimen ofcontrolled early active movement. Tenolysis has oftenbeen reported in other series after three weeks ofimmobilisation or the Kleinert regimen initially.Reported tenolysis rates vary ranging from 46.5%(14), 16% (1), 12.4% (33), 6.7% (12), and 6% (22).Tonkin et al. showed higher rates of rupture andtenolysis in tendon grafts managed with immobilisa-tion compared with the Kleinert regimen (29).

Two-stage flexor tendon repair provides the surgeonwith a reliable method of reconstruction in salvagecases. Controlled active movement postoperativelyseems to reduce the number of cases requiring tenolysisand was not associated with an increased rate of rupturein a group of 26 hands of which 80% were Boyes grade3 or above. The combination of mid-lateral access, agood distal graft to bone interface, and early activemovement resulted in good to excellent results in 77%of cases (Fig. 3), giving results equivalent to those ofprimary tendon repair.

ACKNOWLEDGEMENTS

We thank those who helped with this study, particularlyAnna L. Pratt and Nicola Burr, research Hand Therapists atMount Vernon Hospital.

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two‐stage grafting of flexor tendons: results after mobilisation by controlled early active...

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