Flexor tendon surgery & it's anatomical basis

1. 2012.4.27
서울 현대병원 정 순영

2. Anatomy of Flexor Tendon

3. *Origin
2 muscle bellies
- medial epicondyle
- radial shaft
* tendons arise form separated muscle bundles
act independently

4. * Origin
ulna & interosseous membrane
* commom muscle origin for several tendons
act
simultaneous flexion of multiple digits

8. 1. Synovial fluid
:produced within tenosynovial
sheath
2. Blood supply
provide by vincular circulation
Vascular supply to flexor tendon

9. Suprative tenosyovitis
Kanavel’s 4 cardinal sign

10. system
 Nutrition of tendon
 Suspensory ligament of tendon
 Stabilization of tendon

12. 9cm : wrist & digital flexion
2.5cm : full digital flexion with wrist neutral position
DIP ( FDP ) & PIP ( FDS,FDP ) joint motion 10 degrees : 1.5mm excursion
MP motion : no flexor tendon excursion

13. Welcome to Real World !

17. Is it necessary ?

22. * 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
Myofibrosis
Prefer tondon graft

23. How ?
( suture technique )

25. Sourmelis and McGrouther’s Method

26. A. Conventional Bunnel stich
B. Crisscross stich
C. Mason-Allen( Chicago )
stich
D. Kessler grasping stich
E. Modified Kessler stitch with
single knot at repair
F. Tajima modification of
Kessler stitch with double
knots at repair site

27. - Tajima core sutures in place
- Back wall running-lock peripheral epitendinous stitch
- Mattress core suture
- Completion of running-lock peripheral epitendinous suture

28. *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 formation
• May not be necessary for forces of early active
motion

30. Inner side
Outer side
: interference with healing
: interference with tendon gliding

31. *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

32. *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 Message !!

33. * 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 Message !!

34. Zone I : distance < 1cm
 direct insertion into distal phalanx
( Advancement repair )

35. Uneven tension : too tight
 lengthen of tendon at wrist
tendon graft

36. • Can be advanced without disturbing its blood supply
( does not have vinculum )
• Lengthening of tendon at writ by Z plasty may be required

37. Post-Operative Rehabilitation

38. * Heal faster
* Gain tensile strength faster
* Have fewer adhesions
* Better excursions
Take Home Message !!

39. * Kleinert : Active extension,
Passive flexion by rubber bands
* Duran : controlled passive motion
* Strickland : early active ROM
Goal : Full active ROM at 10 ~ 12 weeks

40. Duran protocol
Wrist 30 flexion
MP joint 50~70 flexion
IP joint allow to extension

41. Kleinert Protocol
Wrist 35 flexion
MP joint 60~70 flexion
IP joint full extension
Elastic band : proximal 8~10cm from wrist joint

42. The ideal treatment
of flexor tendon
injuries under almost
every circumstance
is primary repair

43. Hope the Best
Prepare the Worst

44. Too little motion Too much motion
Stiffness Rupture

45. *Severe injury
*Make excessive amounts of scar tissue
*Have not co-operated with therapy
: low pain thresholds
social circumstances
stupidity
Mostly complication of primary repair
: ruptured & adherent primary repairs
Healings of either “ bad injuries ” or “ bad
patients ”

46. One stage

47. By 4 ~ 6 weeks, pseudosheath formation
two stage

49. *The skin is pliable
*Any wounds are well healed
*Edema has subsided
*The joints allow a full passive range of motion
*Sensation in finger is normal ( at least one )
A2 & A4 pulley systems also should be intact

50. * palmaris longus
* plantaris tendon
* long extensors of toes

51. Take Home Message !!

52. cascading
Determining tension

53. Thumb located In front of index
IP joint : 30 degree flexion
Wrist neutral position

54. Tendon reconstruction risks worsening finger function
Tenodesis
Arthrodesis

55. *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

56. * at least 3 months pass
* some situations 4 ~ 6 months may be required to
make an accurate assessment of patient’s progress
Take Home Message !!

59. Extensive shortage of skin

60. Do you know ?

63. What I want to be