|Year : 2021 | Volume
| Issue : 8 | Page : 1174-1180
Mid-term Results of Two-Stage Tendon Reconstruction of Zone II Flexor Tendon Injuries
M Karakaplan1, O Kilinc1, MF Ceylan1, K Ertem1, O Aslanturk2
1 Department of Orthopedic and Trauma Surgery, Inonu University Medicine Faculty, Malatya, Turkey
2 Department of Orthopedic and Trauma Surgery, Malatya Educational Research Hospital, Malatya, Turkey
|Date of Submission||11-May-2020|
|Date of Acceptance||03-Oct-2020|
|Date of Web Publication||14-Aug-2021|
Dr. O Aslanturk
Department of Orthopedic and Trauma Surgery, Malatya Educational Research Hospital, Özalper Mah. Turgut Özal Bulvarı No: 4 44330, Malatya
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Secondary repair of flexor tendon injuries remains a challenging procedure for hand surgeons. Usually, secondary reconstruction should be performed by a staged approach. Two-stage surgical reconstruction of the flexor tendons by the Hunter technique is the salvage option in case of a severely damaged fibro-osseous canal or neglected flexor tendon injury. Aims: We report the results of staged flexor tendon reconstruction in 10 patients (10 fingers) with neglected or failed primary repair of flexor tendon injuries in zone II. Materials and Methods: Between 2012-2016, patients who underwent two-stage tendon reconstruction due to flexor digitorum profundus (FDP) sectioning or tearing in zone II with destruction of flexor pulleys and extensive scarring in the flexor tendon bed were included in the study. Results: Ten patients included to study with a mean follow-up of 34 months (range 12–70 months) and the results were assessed by clinical examination and questionnaire. According to the Strickland score, one (20%) of the results were excellent, five (50%) were good, two (20%) were fair and two (20%) were poor. After the second stage, good to excellent results were achieved in 60% of patients, one patient needed graft tenolysis. These results were similar to the subjective scores given by the patients, four of whom complained of functional problems in daily life at follow-up. There was no complication after the first stage. But after the second stage, there was one bowstringing and one adhesion that require tenolysis. Conclusions: Hunter technique is still the reference procedure for the reconstruction of flexor tendons. The results of our study showed that two-stage tendon reconstruction which is applied in patients with tendon sheath disruption as a result of acute or delayed tendon injuries which are not possible for primary repair is reliable and satisfactory.
Keywords: Flexor tendon, hunter prosthesis, two-staged reconstruction, zone II
|How to cite this article:|
Karakaplan M, Kilinc O, Ceylan M F, Ertem K, Aslanturk O. Mid-term Results of Two-Stage Tendon Reconstruction of Zone II Flexor Tendon Injuries. Niger J Clin Pract 2021;24:1174-80
|How to cite this URL:|
Karakaplan M, Kilinc O, Ceylan M F, Ertem K, Aslanturk O. Mid-term Results of Two-Stage Tendon Reconstruction of Zone II Flexor Tendon Injuries. Niger J Clin Pract [serial online] 2021 [cited 2022 Aug 19];24:1174-80. Available from: https://www.njcponline.com/text.asp?2021/24/8/1174/323850
| Introduction|| |
The best treatment of flexor tendon injuries should be primary repair. In spite of the improvement in flexor tendon reconstructive techniques, this is not always possible in serious hand trauma and it is difficult to reach good outcomes in primary flexor tendon repair. This inconsistent result of flexor tendon repair has made surgeons to consider the possibility of reconstruction with tendon implants as an alternative method to salvage finger functions.
Until the 1960s, tendon lacerations in zone II, or “no man's land,” were treated with removal of the tendon with grafting of new tendons. The technique of Bunnel's single-stage free tendon grafting was later refined by a number of master hand surgeons, including Pulvertaft, Graham, Littler, Boyes, and Stark. In 1963, Bassett and Carroll subsequently first described this type of two-stage flexor tendon reconstruction using a silicone implant. In 1965, Hunter first published his experience with tendon implants for tendon reconstruction. Hunter further refined this process in the early 1970s, resulting in the naming of the Hunter silicone rod and staged tendon reconstruction techniques currently used. Hunter's classic two-staged flexor tendon reconstruction includes the use of a flexible silicone gliding implant placed at the first-stage before extrinsic free donor tendon graft that is placed at the second stage. Potential sources for the donor graft include respectively palmaris longus, plantaris, extensor digiti minimi, extensor indicis proprius, or the extensor digitorum longus to the second toe.
Two-stage reconstruction of tendon is a valuable option for some patients, including patients who suffer severe trauma, those with extensive destruction of flexor pulleys, those with crushing injuries with extensive soft tissue damage or underlying fractures, and patients with extensive scarring of the flexor tendon bed. Adequate passive range of digital motion and pliable skin is essential for the patients as candidates of the staged reconstruction.
There are few studies with satisfactory results that have been published in the literature on this subject. Therefore, we aimed to evaluate in our study the mid-term results of two-stage flexor tendon reconstruction performed on ten fingers of 10 patients between 2012 and 2016.
| Materials and Methods|| |
In a period from 2012 to 2016, in this study, there were 10 fingers of 10 consecutive patients who underwent two-stage tendon reconstruction that were evaluated. After the ethical approval by the local ethical authority (no; 2020/341), we identified all patients treated with two-stage tendon reconstruction from a surgical database. Seventeen patients were identified from their medical records who underwent two-stage tendon reconstruction. Patients who underwent two-stage tendon reconstruction due to flexor digitorum profundus (FDP) sectioning or tearing in zone II with destruction of flexor pulleys and extensive scarring in the flexor tendon bed were included in the study. Those with flexor tendon injury on multiple fingers and associated injuries to the thumb, patients who were under the age of 10 at the end-stage clinical assessment were excluded. Information about patients' etiology, age, gender, dominant hand, injured hand, profession, affected finger, number of cut tendons and zones, repair type, date of the event, mean interval between initial injury and first stage, additional injuries and complications in the follow-up period were identified from medical records, operative reports, and outpatient charts. 2020/341 in date of 21/01/2020.
For all patients, the fingertip-distal palmar crease distance and the active and passive range of motion for the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints by means of which placing a standard finger goniometer on the dorsal surface of the join at the latest control were measured. Ten patients who met the inclusion criteria were included in this study. The status of the fingers before starting treatment was evaluated using the Boyes and Stark classification modified by Wehbe et al. [Table 1]. Palm-to-pulp distance of fingers was measured thereby distance from the fingertip to the distal palmar crease at maximal active and passive flexion. In the fingers, the passive and active range of motion (ROM) of each joint was measured. The total active and passive extension deficits (respectively TAED and TPED) and total active and passive flexion (respectively TAF and TPF) were calculated in the fingers. ROM was classified in accordance with Strickland evaluation system, identifying the final range of motion as a percentage of normal motion (175°): [Active PIP + DIP flexion-extension lag × 100] / 175° = % of normal active PIP and DIP motion. The grip strength of both hands was measured using a hydraulic dynamometer (Jamar, Sammons Preston Inc. Bolingbrook, Illinois USA). Three values of the power grip strength of both hands were gained and for each hand and the mean was accepted as the power grip strength. Grip strength of the injured hand was compared with the uninjured hand and expressed as a percentage of it. All patients were asked to complete a questionnaire that asks the problems which they had in their daily and working life. In addition, patients were asked to grade the final result in terms of excellent, good, fair, or poor and, were asked them whether they will consider or not any further operation to achieve a better result [Table 2].
|Table 2: Questionnaire (Subjective grading by patient), results of questionnaire|
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All two-stage tendon reconstruction surgeries were performed with pneumatic tourniquet under axillary block or general anesthesia, as described by Hunter. In the first stage, Brunner zigzag skin incision was made on the related finger. Fibro-osseous canals in zones I and II were then exposed [Figure 1]a, [Figure 1]b. To expose the involved tendon a second incision was made at the wrist level [Figure 1]d. If there was soft tissue scarring within the palm the incision was extended from the finger to the palm [Figure 1]c. If there is any scar tissue in the tendon sheath or damaged flexor tendon, these were excised, while critical flexor pulleys (A2, A4) were maintained as much as possible. Joints were passively mobilized and reconstruction of nerves, bones, joint was done when necessary.
|Figure 1: Image of the hand of a 26-year-old male patient. Loss of active flexion of the little finger was the result of a neglected laceration which injured the profundus tendon but the superficialis tendon intact (a). Bruner incision (b), flexor digitorum profundus rupture with digital canal destruction (c) and reconstruction of pulleys (d)|
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If A2 and A4 pulleys were destroyed or if A2 and A4 pulley having been opened to allowed passage of the silicone rod, the pulley system reconstructed. The one end of the silicone implant that corresponds to the FDP diameter was sutured to the stump of the FDP and the other end of the silicon implant was passed within the digital flexor sheath or reconstructed pulleys to the palm into distal forearm. If distal stump of the FDP was not present, the silicon rod was secured to the distal phalanx. Proximal end of the silicon rod was retrieved at the distal forearm incision and is left free [Figure 1]d. The length of the implant was adjusted so that its free end is proximal to the level of the wrist flexion crease, even when the wrist and finger are in full extension [Figure 1]c, [Figure 1]d. After stage I, patients are commenced to immediate physiotherapy with passive motion of the fingers to prevent contractures and to allow for gliding of the implant.
At stage II, surgery was generally performed when the patient's finger joint has attained maximal passive motion, but at least three months after stage I. In this procedure, the incision is made only over the distal joint of the finger and in the distal part of the forearm [Figure 2]a,[Figure 2]b,[Figure 2]c,[Figure 2]d,[Figure 2]e,[Figure 2]f. First, to identify the newly formed tendon sheath, the previous incision on the distal end of the finger is opened to access the end of the silicone implant to anchor the tendon graft. The tendon graft was passed from fingertip and through the new tendon bed to the wrist by pulling the proximal end of silicone implant [Figure 2]d. Distal end of graft was sutured to the FDP stump at the fingertip [Figure 2]c. After the distal end of the graft was sutured to the tendon stump, the tension of the system was adjusted before the proximally tenorrhaphy using the Pulvertaft technique. Due to postoperative graft loosening, the graft tension was adjusted to be slightly flexed from the finger on the ulnar side when the wrist was extended, and proximal tenorrhaphy was performed with Pulvertaft technique [Figure 2]e.
|Figure 2: Appearance of hand and little finger during stage two of flexor tendon reconstruction (a). In the absence of the palmaris longus, it was elected to use the extensor indicis proprius of the index finger as the donor graft for the small finger (b). Exposure of the silicone implant over the distal phalanx and attachment of graft to distal tip of the rod (c). Proximal traction of the graft after distal attachment in the distal phalanx and digital wound closure (d). The full composite flexion of the digit is demonstrated in preparation for the proximal weave into selected motor tendon (e and f)|
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Dorsal long arm splint was applied to hold the metacarpophalangeal joints in 70 flexion and the wrist in 40 flexion, the fingers in intrinsic-plus position. Active ROM exercise and unprotected digital motion were started at 6 weeks. By 8 weeks light, resistive exercises were started. Heavy resistive exercises were not done until 12 weeks. postoperatively. In our study, no specific statistical method was used.
| Results|| |
The mean follow-up of the patients from the stage II procedure was 34 months (12 − 70 months). The mean interval between initial injury and first-stage repair was 8 months, (range 4 months to 15 months). The tendon grafting was carried out at a mean of 14 weeks after silicon rod implantation (range, 12 − 20 weeks). Their mean age at the stage II repair was 21 years (range, 4 − 34 years). Ten of patients 10 were 8 males, 2 females. Two patients were laborers, two were office workers and four were students. The occupations of the other two patients could not be grouped because one of these patients was a child (14 years-old) and the other was working in irregular jobs.
Except for one, all patients had suffered injuries of both flexor tendons in zone II with considerable scarring and non-functioning flexor apparatus. One patient had only FDP injury [Figure 1]c. All patients had only single digit involvement: Reconstructed rays and initial injury are as stated in [Table 3].
Five of the cases had at least one failed previous repair surgeries. In three of these five cases that were decided to two-stage tendon reconstruction due to excessive adhesion, K-wire fixation due to bone fracture, and tendons repair previously had been made at the same finger. Initial injury of two of these three patients was subtotal amputation. Other five cases were neglected injuries that were managed late, with the collapse of the fibro-osseous canal and incapacity of the flexor pulley system. One of these five patients had a bilateral digital nerve and unilateral digital artery injury and these structures were repaired. After stage I repair, no skin necrosis, rod buckling, synovitis, hematoma, detachment of the distal juncture with proximal prostheses migration were encountered in this series. After stage II repair, we did not record distal disruption of the graft and tenolysis was performed in one patient. There was bowstringing in one patient [Figure 3]b. To provide the needed length, the palmaris longus tendon was used most commonly for the graft in the eight fingers, followed by extensor indicis proprius [Figure 2]b and plantaris tendon was used in two cases.
|Figure 3: Dorsal (a) and palmar (b) image of a 17-year-old female patient with repair of two-stage tendon reconstruction on the middle finger of the left hand. Dorsal (c) and palmar (d) image of the fingers of the same patient with full active digital flexion|
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The mean total active motion (active PIP + DIP flexion – extension deficit PIP + DIP) achieved was 102° [Figure 3]c and [Figure 3]d. The mean total active flexion (PIP + DIP) was 133°. The mean total active extension deficit (PIP + DIP) was 31°. The mean strength (in Kg f) of power grip was 74% (range 30 − 90%) compared to the unaffected side. The mean pulp to distal flexion crease distance was 1.85 cm (0 − 4 cm). The pulp to distal flexion crease distance was 0 cm in one finger, 0.5 cm in one, 1 − 2 cm in four, and more than 2 cm in four fingers [Table 4].
All the patients with severe initial injuries such as subtotal amputations, associated bone fractures, and concomitant neurovascular compromise were rated in the groups with fair and poor results. When the patients graded on their own end-results, six patients were good, one patient was fair and three patients were poor. Four of the ten patients suffered from functional problems in daily life, which are listed in [Table 2]. The most frequent problems were a decrease of grip strength in four patients, difficulties with fine movements in three patients, pain in two, cold intolerance in two patients. Two patients who have poor results and one patient that had good result according to Strickland scores were considered for further operation.
| Discussion|| |
Restoration of a flexor tendon function in a badly scarred finger is a challenge and much effort is required from both the surgeon and the patient to achieve a good result. Main problems with primary and secondary flexor tendon repairs after ruptures are due to extensive scar formation and tendon adhesion, especially for zone 2 injuries. When the flexor tendon sheath is considerably scarred, such that single-stage reconstruction is undesirable, a two-stage method is preferred. To improve the biologic environment for the subsequent tendon grafts, celloidin, glass, and metal were historically used in an attempt to create a preformed gliding channel. These materials did not allow passive joint movement due to their hard structure so that pseudo sheath around the implant has not been formed.
Basset and Carrol used flexible silicone rubber rods to create pseudo sheaths, which led to the two-stage reconstruction introduced by Hunter and Salisbury., Placing the silicone or Dacron-reinforced silicone implant into the scar tendon bed form a false sheath that is covered with mesothelial cells around the implant thereby lubricating with a synovial fluid. Two-stage flexor tendon reconstruction is still performed according to the original technique used by Hunter and Salisbury, also silicone urinary catheter and feeding tube are used instead of silicon Hunter rod., We used silicon Hunter rod for all of our patients. Advances in hand surgery have been led to a reduction in the need to use the Hunter's technique over time. This was gradually reflected in the number of patients in two-stage tendon reconstruction studies. Wehbe reported a series of 150 patients in 1986, the recent series by Naam, Beris, Ciloglu, Atik or Abdul-Kader, are all smaller (between 12 and 47 patients).,,,,, In our study, we also have limited a small number of patients (10 patients).
Djerbi et al. stated that studies of two-stage tendon reconstruction has had certain methodological limits (heterogenous injuries, multiple surgeons small number of cases) as all are retrospective studies of relatively uncommon disorders. Heterogenous injuries and small number of patients were also methodological limitation for our study.
Our results are similar to other series in the literature. In our series, the rate of excellent and good results was 60% according to the Strickland classification. The frequency of good and excellent results is fairly similar in the literature from 54% to 64%.,,,, When our assessment of power grip was comparing with other studies. Our results were similar to other series in the literature. In the Wehbe et al. reported that (with 81% of the injuries in zone II) mean grip strength was 79% compared with the uninjured hand. In other studies,,, the mean grip strength was found between 73% and 82% compared with the uninjured hand and we found a mean value of 74% in our study.
Amadio and Frakking, found that significant disagreement between the examiners and patients as to the quality of the results in their studies. We did not find a significant disagreement between the examiners and patients as to the quality of the results [Table 2]. In our series, the rate of excellent and good results was 60% according to the Strickland classification. When the patients graded on their end-results, six patients were good, one patient was fair and three patients were poor. Amadio et al. stated that the apparent paradoxical responses, when the patient was more positive than the examiner, could possibly be explained by the reluctance of patients to admit failure of a complicated and protracted treatment regimen.
Fracking et al. stated that, the Buck-Gramcko score is very useful in evaluating finger motion but it is unable to express the patient's subjective assessment of the end result, which ultimately determines the success of the procedure. They thought that the patients, who were more negative about their result than the examiner, had higher expectations beforehand and became disappointed because of the imbalance between the amount of surgical treatment and physiotherapy and the final outcome. Careful selection of patients is mandatory to achieve an acceptable outcome and satisfaction. The timing of stage I tendon surgery should combine the judgments of the surgeon and hand therapist, for patient input and motivation are the keys to a successful result. In the presence of a digit that has borderline nutrition, bilateral digital nerve injuries, and severe joint stiffness, easier solutions such as arthrodesis or even amputation should be considered as alternatives to this exhausting treatment in all cases before treatment is begun.,, The patients should be fully informed about the complexity of the problem and their chances of a good final result, as well as mentioning the possible need for additional operations.
Complications of staged tendon reconstruction include synovitis around the implant, infection or wound breakdown, and disruption of the distal implant juncture after stage one. Stage two complications include rupture of the graft, a graft that is too loose or too tight, the development of an intrinsic plus phenomenon, reflex dystrophy, bowstringing, decreased strength, pain, nail deformity, scar sensitivity, triggering, and flexion deformities of the proximal or distal interphalangeal joints. Finally, and most common, adhesions of the graft may prevent a successful recovery of digital motion and may require tenolysis.,,,, Adhesion formation with restriction of tendon excursion and the need for tenolysis has reported rates from 12% to 47%., Tenolysis is indicated in case of unsuccessful recovery of range of motion following appropriate physical therapy, after a delay that all authors agree should be between 3 and 6 months after the second stage of surgery. Our rate of tenolysis was 10% (one patient), which is similar to the result in the literature. In an analysis of 43 two-stage reconstructions by LaSalle and Strickland all of the digits had some flexion deformity at either the PIP or DIP joint or both and had a rate of tenolysis of 47%. In a report by Naam 88% of patients had postoperative persistent flexion contractures ranging from 8° to 55° after staged flexor tendon reconstruction.
A reported incidence of proximal rupture has been found in 7% of Hunter reconstructions. After stage II, we did not record the distal disruption of the graft. Pulley preservation and reconstruction is of pivotal importance for a good outcome. Every effort should be made to preserve or reconstruct at least the A-2 and the A-4 pulleys., Several authors recommended preservation or reconstruction of at least three or more pulleys.,,, The pulley system is not only important to prevent bowstringing and improve the effective excursion of the tendon but also to decrease the degree of flexion contractures. Wehbe et al. identified a clear association between the number of intact pulleys and the final flexion contractures. In our series, we encountered bowstringing deformity in one patient's middle finger [Figure 3]b. A closely supervised hand therapy program would reduce the incidence of bowstringing owing to pulley rupture. The extra periosteal wraparound technique for pulley reconstruction should be considered for crucial pulley reconstruction. The complications of either stage of this complex reconstructive process may compromise severely the end result and must be dealt with promptly and appropriately.
Two patients in this series were children who less than 14 years of age at the time of surgery (one child was operated on at 4 years of age). Both of Hunter and with modified Paneva-Holevich method have been achieved better results in young adults.,, The results of these two young patients were one good and one fair according to Strickland classification. Wehbe et al. thought that cause of best results obtained in younger patients must have been associated less severe injuries. Crush injuries and occupational accidents are less likely to occur in children and young adolescents. The pre-operative status of the finger according to the Boyes grading system is a better determinant of the final result.,,, The results in fingers with a Grade 1 or 2 injury are better than in fingers with a Grade-3, 4, or 5 injury, and they are better in patients with one involved ray than in those with multiple injured rays. If the lumbrical muscle or superficialis tendon, or both, are intact, there will be less flexion contracture and more motion at follow-up. In our series, results in fingers with a Grade 1 or 2 injury were better than in fingers with a Grade 4 or 5 injury.
Our study is limited by several factors, which include our small number of patients, diversity of injury mechanisms, and different delays between injury and surgery. Because of the retrospective design of this study, we do not have the passive range of motion for all patients before the first stage of surgery however, patients all went to physical therapy and had full passive range of motion of the finger before stage II.
| Conclusion|| |
The main purposes of this study were to review our results in staged flexor tendon reconstruction and to compare them with the results in the literature, and to try to identify the characteristics of the injury or those injured that could predict the outcome of staged flexor tendon reconstruction. Flexor tendon reconstruction remains one of the most challenging problems in hand surgery, but advances in surgical techniques and postoperative rehabilitation strategies have improved results. Hunter technique is the reference surgical procedure for reconstruction of the flexor tendon. In some patients, it is clear that the extend of the initial injury is a better determinant of the final result. In general, maximum passive motion before stage II is the goal of the hand therapy program. In addition, the patient should be well motivated and the possibility of a prolonged rehabilitation period and less than perfect result should be explained carefully.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]