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Flexor tendon surgery & it's anatomical basis
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2012.4.27
서울 현대병원 정 순영
Flexor Tendon In-jury
Anatomy of Flexor Tendon
Hand Anatomy
*Origin
2 muscle bellies
- medial epicondyle
- radial shaft
* tendons arise form separated muscle bundles
act independently
FDS
FDP
* Origin
ulna & interosseous membrane
* commom muscle origin for several tendons
Hand Anatomy
act simultaneous flexion of multiple digits
ZonesHand Anatomy
Pulley SystemHand Anatomy
Hand Anatomy
Tendon Nutrition
1. Synovial fluid :produced within tenosyn-ovial sheath2. Blood supply provide by vincular circula-tion
Hand Anatomy
Vascular supply to flexor tendon
Tendon sheath
Suprative tenosy-ovitis Kanavel’s 4 cardinal sign
Hand Anatomy
Vincular system
Nutrition of tendon
Suspensory ligament of ten-
don
Stabilization of tendon
Flexor Tendon Excursion
9cm : wrist & digital flexion 2.5cm : full digital flexion with wrist neutral posi-tion
DIP ( FDP ) & PIP ( FDS,FDP ) joint motion 10 degrees : 1.5mm ex-cursion MP motion : no flexor tendon excursion
Welcome to Real World !
What can I do for you?
Physical Examina-tion
Is it necessary ?
FDS intact
FDS + FDP severance
Timing of Flexor Tendon Re-pair
* primary tendon repair : < 12 hrs
( 24 hrs )
* delayed primary repair : 24 hrs ~
10 days
* early secondary repair : 10 days ~
4 weeks
* late secondary repair : > 4 weeks
MyofibrosisPrefer tondon graft
How ?
( suture technique )
To obtain exposure
Flexor tendon retrieval
Sourmelis and McGrouther’s Method
A. Conventional Bunnel stich
B. Crisscross stich C. Mason-Allen( Chicago )
stich D. Kessler grasping stich E. Modified Kessler stitch
with single knot at re-pair
F. Tajima modification of Kessler stitch with dou-ble knots at repair site
- Tajima core sutures in place- Back wall running-lock peripheral epitendinous stitch- Mattress core suture- Completion of running-lock peripheral epitendinous suture
Ultimate Strength and Repair Tech-nique*Proportional to number of strands
- 6 and 8 strand repairs
strongest
steep learning curve
4-strand repair adequate strength without complexity of 6 ~ 8
strands
• increased bulk and resistance to glide• increased tendon healing and adhesion for-
mation• May not be necessary for forces of early ac-
tive motion
Flexor tendon repair : strength vs force
Suture knot location
Inner side
Outer side
: interference with healing
: interference with tendon gliding
Repairing the sheath ?
*Providing a barrier for adhesion formation
*Restoring synovial fluid nutrition
*Restoring the sheath mechanics
Technically difficult
Increased foreign material at repair
site
May narrow sheath and restrict
glide
VS
Tendon Healing
*Intrinsic tendon healing
: differentiation of fibroblasts from epitenon ( tenocyte )
: collagen synthesis occurred primarily within the endotenon cells
: vascularity of tendon bed - important
*Extrinsic tendon healing
: activity of peripheral fibroblast
: peripheral adhesions
No Adhesion
Take Home Mes-sage !!
Phases of tendon healing
* Inflammatory phase
: phagocytosis
3 ~ 5 days
* Fibroblastic or collagen-producing phase
: neovascularization, peripheral adhesion
5 ~ 3-6 weeks
* Remodeling or maturation phase
: arrangement of fiber
6 ~ 9monts
Tendon weakest at 10 ~ 14 days Take Home Mes-
sage !!
Something SpecialZone I : distance < 1cm direct insertion into distal phalanx ( Advancement repair )
Uneven tension : too tight
lengthen of tendon at wrist tendon graft
Quadriga effect
Something Special : FPL
• Can be advanced without disturbing its blood supply ( does not have vinculum )
• Lengthening of tendon at writ by Z plasty may be re-quired
Post-Operative Rehabili-tation
Stressed tendons
* Heal faster
* Gain tensile strength faster
* Have fewer adhesions
* Better excursions
Take Home Mes-sage !!
Post OP Protocols
* Kleinert : Active extension,
Passive flexion by rubber bands
* Duran : controlled passive motion
* Strickland : early active ROM
Goal : Full active ROM at 10 ~ 12 weeks
Duran proto-col Wrist 30 flexion
MP joint 50~70 flexion IP joint allow to exten-sion
Kleinert Protocol
Wrist 35 flexionMP joint 60~70 flexion IP joint full extension Elastic band : proximal 8~10cm from wrist joint
The ideal treatment
of flexor tendon in-
juries under almost
every circumstance is
primary repair
Hope the Best Prepare the Worst
Too little motion Too much motion
Stiffness Rupture
Secondary Surgery
*Severe injury
*Make excessive amounts of scar tissue
*Have not co-operated with therapy
: low pain thresholds
social circumstances
stupidity
Mostly complication of primary re-pair : ruptured & adherent primary re-pairs
Healings of either “ bad injuries ” or “ bad patients ”
Reconstruction of Flexor Ten-dons
One stage
Universal tendon spacer
By 4 ~ 6 weeks, pseudosheath forma-tion
two stage
Pulley reconstruc-tion
*The skin is pliable
*Any wounds are well healed
*Edema has subsided
*The joints allow a full passive range of mo-
tion
*Sensation in finger is normal ( at least
one )A2 & A4 pulley systems also should be intact
Prerequisites
Donor tendons for Graft-ing* palmaris longus
* plantaris tendon
* long extensors of toes
Pulvertaft interlace su-ture
Take Home Mes-sage !!
cascading
Determining tension in a reconstructed flexor sys-
tem
Thumb located In front of indexIP joint : 30 degree flexion
FPL tension adjustment
Wrist neutral position
Isolated FDP loss but good retention of FDS function
Tendon reconstruction risks worsening finger function
Tenodesis Arthrode-sis
Lumbrical plus finger
*Paradoxical extension of the IP joints while attempting to flex the fingers
*Most commonly caused by FDP laceration distal to the origin of limbricals
3rd finger m/c involve
Tenodesis of FDP to terminal tendon Reinsertion to distal phalanx Lumbrical release
Tx
Flexor tenolysis after repair and grafting
* at least 3 months pass
* some situations 4 ~ 6 months may be re-quired to make an accurate assessment of pa-tient’s progress
Take Home Mes-sage !!
Extensive shortage of skin
Do you know ?
What I want to be
Thank you for your at-tention