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Flexor Tendon Injuries: I.

Foundations of Treatment

James W. Strickland, MD

Abstract

During the past 20 years, the difficult process of reestablishing satisfactory function face usually has a layer of uniform col-
after primary repair of flexor tendons has evolved from scientifically unsupported lagen fibers, and elastin and individ-
trial-and-error efforts to protocols based on sound laboratory and clinical investiga- ual fascicles are capable of sliding past
tions. Enhanced appreciation of tendon structure, nutrition, and biomechanical each other with no apparent direct
properties and investigation of factors involved in tendon healing and adhesion for- attachments or cellular communica-
mation have had significant clinical applications. In particular, it has been found that tions. The surface of the individual
repaired tendons subjected to early motion stress will increase in strength more bundles of collagen is covered by the
rapidly and develop fewer adhesions than immobilized repairs. As a result, new and endotenon and a fine fibrous and cel-
stronger tendon repair techniques have evolved, permitting the application of early lular outer layer, the epitenon, which
passive and even light active forces. The author reviews the most recent and clini- is continuous with the endotenon. In
cally pertinent research in flexor tendon surgery and discusses repair techniques and the hand, flexor tendon fascicles are
rehabilitation protocols based on the information provided by these studies. covered by a thin visceral and parietal
J Am Acad Orthop Surg 1995;3:44-54 adventitia called the paratenon, which
contains fluid similar to synovial fluid.
In the digits, the flexor tendons are
enclosed in sheaths lined by visceral
The return of satisfactory digital dons, their function, the biomechanics and parietal synovial layers.1 The A2
motion after severance of the flexor of their action at the joints they move, and A4 annular pulleys arise from the
tendons has long challenged sur- and their biologic response to injury periosteum of the proximal half of the
geons dealing with upper extremity and repair. These investigative efforts proximal phalanx and the midportion
trauma. Flexor lacerations in the fin- have given rise to improved methods of the middle phalanx, respectively
ger were once found to perform so of tendon repair, a greater emphasis on (Fig. 1). The A1, A3, and A5 pulleys are
poorly after primary repair that the flexor sheath preservation and restora- joint pulleys that arise successively
digital sheath was referred to as a sur- tion, and an emphasis on the early from the palmar plates of the metacar-
gical no-man’s-land. Surgeons were application of stress as a means of pophalangeal, proximal interpha-
advised not to repair tendon injuries more rapidly increasing the strength langeal, and distal interphalangeal
in this zone and to resort to free-ten- and gliding capacity of repaired ten- joints. The palmar aponeurosis pulley
don grafting at a later date to achieve dons. This article will review some of is composed of the transverse and ver-
the best results. While that advice has the most recent and relevant research
now been discredited and primary and discuss the current clinical
flexor tendon repair has been the approaches to flexor tendon repair that Dr. Strickland is Clinical Professor of
accepted procedure for over two have resulted from these efforts. Orthopaedic Surgery, Indiana University School
of Medicine, Indianapolis; Chairman, Depart-
decades, the techniques for repair
ment of Hand Surgery, St. Vincent Hospital,
and the postoperative management Indianapolis; and Senior Staff Surgeon, Indiana
programs have varied greatly from Basic Science of Flexor Hand Center, Indianapolis.
surgeon to surgeon. Most clinical Tendons
approaches have been based to a Reprint requests: Dr. Strickland, PO Box 80434,
8501 Harcourt Road, Indianapolis, IN 46280-
large extent on individual experience Structure and Anatomy
0434.
with little or no scientific support. Tendons are composed of fascicles
Considerable research has been con- of long, narrow, spiraling bundles of Copyright 1995 by the American Academy of
ducted in recent years in an effort to mature fibroblasts (tenocytes) and Orthopaedic Surgeons.
better understand the structure of ten- type I collagen fibers. The fascicle sur-

44 Journal of the American Academy of Orthopaedic Surgeons


James W. Strickland, MD

tendon through small ridges, or con-


Fig. 1 Lateral (top) and duits, in the tendon surface as the
dorsal (bottom) views of a
finger depict the compo- digit is flexed and extended.
nents of the digital flexor
sheath. The sturdy annular Biomechanical Properties
pulleys (A1, A2, A3, A4, and
A 5 ) are important biome- As much as 9 cm of flexor tendon
chanically in keeping the excursion may be required to pro-
tendons closely applied to duce composite wrist and digital
the phalanges. The thin, pli-
able cruciate pulleys (C1, C2, flexion, while only about 2.5 cm of
and C3) collapse to allow full excursion is required for full digital
digital flexion. A recent flexion with the wrist stabilized in a
addition is the palmar
aponeurosis pulley (PA), neutral position (Fig. 4). The greater
which adds to the biome- the distance a tendon is from the
chanical efficiency of the axis of joint rotation, the greater the
sheath system.
moment arm and the less motion
that a given muscle contraction will
generate at that joint. Conversely, a
tical fibers of the palmar fascia and is The FDP muscle acts as the pri- shorter moment arm will result in
clinically important when other prox- mary digital flexor, while the FDS more joint rotation from the same
imal components of the sheath have and intrinsic muscles combine for tendon excursion. The moment
been lost. The thin, condensable cru- forceful flexion. Digital balance and arm, excursion, and joint rotation
ciate sections of the sheath—C 1 equilibrium during flexion and produced by the flexor tendons are
(between A2 and A3 ), C2 (between A3 extension require a complex integra- governed by the constraint of the
and A 4), and C 3 (between A 4 and tion of extrinsic and intrinsic activ- pulley system. Loss of portions of
A5)—collapse to permit the annular ity. Forces of 200 N can be achieved the digital pulleys may significantly
pulleys to approximate each other during power grip. alter the normal integrated balance
during digital flexion. The flexor ten- between the flexor, intrinsic, and
dons are weakly attached to the sheath Nutrition extensor tendons. The A2 and A4
by filmy mesenteries composed of The vascular perfusion of the pulleys are the most important to
vincula. flexor tendons includes longitudinal these mechanical functions; the loss
Flexor tendons are oval. The vessels, which enter in the palm and of a substantial portion of either
flexor digitorum superficialis (FDS) extend down intratendinous chan- may diminish digital motion and
tendons usually arise from single nels; vessels that enter at the level of power or lead to flexion contrac-
muscle bundles and act indepen- the proximal synovial fold in the tures of the interphalangeal joints
dently. There is often a common palm; segmental branches from the (Fig. 5).2,3
muscle origin for several flexor digi- paired digital arteries, which enter Several studies have been carried
torum profundus (FDP) tendons, in the tendon sheaths by means of out to determine the tendon forces
with the result that there is simulta- the long and short vincula; and ves- generated by various active and pas-
neous flexion of multiple digits. The sels that enter the FDS and FDP ten- sive functions. Despite variation in
FDS tendons lie on the palmar side dons at their osseous insertions (Fig. the methodology used in these inves-
of the FDP tendons until they enter 3). Both tendons have relatively
the A1 entrance of the digital sheath. avascular segments over the proxi-
Within the proximal sheath, the FDS mal phalanx. The FDP tendon has
tendon divides into two slips that an additional short avascular zone
wrap around the FDP tendons; over the middle phalanx. Fortu-
rejoin dorsally by means of fibers nately, synovial fluid diffusion pro-
referred to as the chiasma tendinum, vides an effective alternative
or Camper’s chiasma; and terminate nutritional and lubricating pathway
as they insert along the proximal half for flexor tendons. The rapid deliv-
of the middle phalanx (Fig. 2). The ery of nutrients is apparently accom- Fig. 2 Early in the flexor sheath, the FDS
tendon divides and passes around the FDP
FDP tendons pass through the FDS plished by a pumping mechanism tendon. The two portions of the FDS tendon
bifurcation to insert into the proxi- known as imbibition, in which fluid reunite at Camper’s chiasma.
mal aspect of the distal phalanges. is forced into the interstices of the

Vol 3, No 1, Jan/Feb 1995 45


Flexor Tendon Injuries: Treatment Principles

on factors that relate to the injury and


the surgical repair. In the clinical set-
ting, it is impossible to isolate the two
types of healing, and the cellular
events can be viewed as similar for all
flexor tendons. After repair, tendon
healing involves an inflammatory
phase that lasts 48 to 72 hours, a
fibroblast- or collagen-producing
phase that lasts from 5 days to 4
weeks, and a remodeling phase that
continues for about 112 days. During
the inflammatory phase of tendon
healing, the strength of the repair is
almost entirely reliant on the strength
of the suture itself, with a modest con-
Fig. 3 Blood supply to the flexor tendons within the digital sheath. The segmental vascu- tribution from the fibrin and the clot
lar supply to the flexor tendons is by means of long and short vincular connections. The vin- between the tendon ends. Strength
culum brevis superficialis (VBS) and the vinculum brevis profundus (VBP) consist of small
triangular mesenteries near the insertion of the FDS and FDP tendons. The vinculum increases rapidly during the fibro-
longum to the superficialis tendon (VLS) arises from the floor of the digital sheath and the blast- and collagen-producing phase,
proximal phalanx. The vinculum longum to the profundus tendon (VLP) arises from the when granulation tissue is forming in
superficialis at the level of the proximal interphalangeal joint. The cutaway view depicts the
relative avascularity of the palmar side of the flexor tendons in zones I and II compared with the defect. When extrinsic healing
the richer blood supply on the dorsal side, which connects with the vincula. predominates, adhesions between the
tendon and its surrounding tissues
are inevitable. Healing that is largely
based on intrinsic cellular activity will
tigations, it appears that during Tendon Healing result in fewer, less dense adhesions.
unresisted passive flexion, flexor ten- After much debate, almost all In a series of definitive laboratory
dons are subjected to 2 to 4 N of force. investigators now believe that ten- experiments, Gelberman et al 6
Active flexion with mild resistance dons have both an intrinsic and an demonstrated that, compared with
may result in up to 10 N of force; extrinsic capability to heal. The rela- immobilization, the application of
moderate resisted flexion, up to 17 N; tive contribution of each will depend early passive motion stress to
and strong composite grasp, up to 70
N. Firm tip pinch can apparently
generate as much as 120 N of tensile
load on the index FDP tendon. 4,5
Forces produced by the FDS tendon
have been shown to be considerably
less than those produced by the FDP
tendon during grasp and pinch.
From a clinical perspective, it should
be remembered that these loads are
substantially increased by the resis-
tance created by stiffness and swelling
of the finger and by the increased drag
that a healing tendon may experience
within its sheath. Pressure between
the pulleys and the flexor tendons may
reach as high as 700 mg Hg during
active flexion, which perhaps explains
Fig. 4 Approximate flexor tendon excursion (measured in millimeters) necessary to pro-
the histologic alterations to the fibro- duce full flexion of digital joints at the forearm, wrist, hand, and digital levels. P = profun-
cartilagelike tissue in tendons beneath dus; S = superficialis.
annular digital pulleys.

46 Journal of the American Academy of Orthopaedic Surgeons


James W. Strickland, MD

tendons include trauma to the ten-


don and its sheath from the initial
injury and the reparative surgery,
tendon ischemia, tendon immobi-
Fig. 5 Function of the fin-
ger flexor tendon pulley sys-
lization, gapping at the repair site,
tem. Top, The arrangement and excision of components of the
of the annular (A1, A2, A3, tendon sheath. Quantitative mea-
A4, and A5) and cruciate (C1,
C2, and C3) synovial pulleys
sures have shown that adhesions
of the finger flexor tendon form in proportion to the amount of
sheath within the intact tissue crushing and the number of
fibro-osseous canal and the
normal moment arm (MA)
surface injuries to the tendon. Dis-
and FDP tendon excursion ruption of the vincula also has been
as the proximal interpha- associated with a decrease in the
langeal joint is flexed to 90
degrees. Bottom, The bio-
recovery of tendon excursion. There
mechanical alteration that continues to be considerable debate
results from excision of the about whether primary repair of the
distal half of the A2 pulley;
the C1, A3, and C2 pulleys;
digital sheath is favorable for adhe-
and the proximal portion of sion reduction.8,9
the A4 pulley. The distance Various biochemical agents have
between the distal edge of
the A2 pulley and the proxi-
been studied in an attempt to modify
mal edge of the A4 pulley is adhesion formation around tendon
the intra-annular pulley dis- repairs. Anabolic steroids, antihista-
tance (IAPD). The moment
arm is increased and a
mines, and nonsteroidal anti-inflam-
greater FDP tendon excur- matory drugs have been subjected to
sion is required to produce recent laboratory investigations, and
90 degrees of flexion
because of the bowstringing
there has been some evidence that
that results from the loss of ibuprofen 10 and indomethacin 11
pulley support. may improve tendon excursion by
blocking prostaglandin synthesis
through the inhibition of the enzyme
cyclo-oxygenase at the cellular level.
While hyaluronate appears to
reduce adhesions around healing
tendons, it was found to have no sta-
repaired canine tendons led to a the influence that soluble polypep- tistically significant effect on digital
more rapid recovery of tensile tides, including mitogens (growth motion in one double-blind study.
strength, fewer adhesions, improved factors and hormones) and chemo-
excursion, better nutrition, and min- tactic and differentiating factors
imal repair-site deformation. They (e.g., fibronectin), exert on the cellu- Flexor Tendon Repair
concluded that passive mobilization lar sequence of tendon repair. These
enhances healing by simultaneously factors have been shown to play a Indications and
stimulating maturation of the tendon role in both normal and pathologic Contraindications
wound and remodeling of the ten- processes. Continuing investiga- Primary repair of flexor tendons
don scar. From these studies and the tions may, in time, modify current severed in the digital sheath has now
work of many others, it appears that repair methods and postrepair universally replaced the “no-man’s-
the most effective method of restor- motion protocols for severed flexor land” concept, which favored sec-
ing strength and excursion to tendons.6,7 ondary grafting. The concept that
repaired tendons involves the use of flexor tendon repair should be con-
a strong, gap-resistant suture tech- Adhesion Formation and sidered a surgical emergency has
nique followed by the application of Control also been effectively discredited by
controlled-motion stress. Factors that influence the for- several studies that demonstrate
Considerable research is being mation of excursion-restricting that equal or better results can usu-
conducted in an effort to understand adhesions around repaired flexor ally be achieved by delayed primary

Vol 3, No 1, Jan/Feb 1995 47


Flexor Tendon Injuries: Treatment Principles

flexor tendon suture. It has also lanx will allow the identification of gest that there is a 10% to 50% loss of
been shown that it is better to repair injuries to the digital nerves and will the initial repair strength during the
both the FDP and the FDS tendons provide important information for first 5 to 21 days following injury, it
rather than the FDP tendon alone, planning incisions for their exposure should be recognized that these
which was once the preferred and repair. A deep wound with lac- studies were carried out on immobi-
option. erations of both digital nerves lized tendons. Some recent investi-
There are a number of important almost surely indicates division of gations of tendon repairs in which
contraindications to primary suture the digital arteries as well. While the controlled passive motion was used
of severed flexor tendons, including digit will probably survive the loss indicate that this drop may be sub-
severe multiple tissue injuries to the of both vessels, the viability of the stantially lessened by early stress
fingers or palm, wound contamina- skin flaps used for exposure may be application. By converting newtons
tion by potentially infecting materi- in jeopardy. In addition, digital to grams, it is possible to establish
als, and significant skin loss over the ischemia may impair tendon and some working numbers that allow
flexor system. Concomitant frac- nerve healing and result in severe the determination of the strength of
tures and neurovascular injuries are cold intolerance. It is important that various tendon repairs at the time of
not necessarily contraindications to one or both digital arteries be surgery and throughout the healing
primary or delayed primary suture. repaired in these complex injuries. period. These data can then be
If the fracture can be anatomically matched with the stress forces of
reduced and adequately stabilized, Surgical Considerations postrepair motion protocols to
it is almost always better to proceed The techniques of flexor tendon determine the relative risk of tendon
with flexor tendon repair and repair and the protocols for postoper- rupture with each. Conservative
microscopic nerve and vessel ative mobilization of the repaired ten- working numbers for tensile
suture, recognizing that the ultimate don were, for many years, based on demands on a normal tendon in an
results after combined tissue anecdotes and hearsay. In retrospect, unswollen finger can be estimated
injuries are not as good as those fol- publications on this topic often had as follows: passive motion, 500 g;
lowing tendon severance with no deficiencies in scientific methodol- light grip, 1,500 g; strong grip, 5,000
associated injuries. Rejoining the ogy. In recent years, various hand, g; and index finger tip pinch (FDP
tendon at its normal length acutely orthopaedic, and plastic surgery jour- tendon), 9,000 g. Corresponding
or subacutely is usually preferable nals have published a plethora of lab- values for a finger that has under-
to delaying the repair for several oratory and clinical information gone an FDS repair can be calcu-
weeks, because of the inevitable about methods of flexor tendon repair lated as 15% to 30% of these normal
deterioration of the tendon ends and and postrepair motion protocols. values.
shortening of the extrinsic muscle- These investigations stem from the
tendon system. consensus that the greater the incre-
ments of repair-site stress and tendon Suture Techniques
Examination and Preparation excursion, the faster the tendon will
The surgeon must carefully exam- achieve normal tensile strength with Core Sutures
ine the patient’s hand to determine fewer motion-restricting adhesions. Numerous methods of tendon
the total extent of the injury. Alter- Trying to interpret these reports and suture (Fig. 6) have been advocated
ations in the normal resting posture compare them with those from other in an effort to satisfy the six charac-
of the digits will help identify the loss studies is almost impossible given the teristics of an ideal repair: (1) easy
of continuity of one or both flexor different laboratory models used placement of sutures in the tendon,
tendons, and well-known functional (e.g., in vivo versus in vitro), different (2) secure suture knots, (3) smooth
tests will confirm the loss of FDP testing methods, and diverse defini- juncture of tendon ends, (4) minimal
and/or FDS action. Lacerations on tions of failure. A thorough review of gapping at the repair site, (5) mini-
the palmar aspect of the fingers will this information does, however, per- mal interference with tendon vascu-
almost always injure the FDP tendon mit a few reasonably supportable larity, and (6) sufficient strength
before severing the FDS tendon, but conclusions on which to base a clinical throughout healing to permit the
the absence of FDP function alone protocol designed to attain the best application of early motion stress to
does not rule out the possibility of a possible digital performance after the tendon.
near-complete FDS division. flexor tendon division. A comparison of a number of pub-
A careful sensory evaluation of While most in vivo studies of lab- lished investigations of the charac-
the palmar aspect of the distal pha- oratory animal tendon repairs sug- teristics and performance of various

48 Journal of the American Academy of Orthopaedic Surgeons


James W. Strickland, MD

flexor tendon repairs leads to the


following general conclusions: (1)
The strength of a flexor tendon
repair is roughly proportional to the
number of suture strands that cross
the repair site. (2) Locking loops
contribute little strength to the
repair and may actually collapse
A
and lead to gapping at moderate
loads. (3) Repairs usually rupture at
the suture knots. (4) Synthetic 3-0 or
4-0 braided sutures are probably the
best for flexor tendon repair.
The observation that the number
E of suture strands crossing the
repair will determine the strength
B of the repair has been best demon-
strated by Savage, 12 who found
that a complex six-strand repair
was three times stronger than a
two-strand repair, and by three
recently published reports,13-15 in
which four-strand repairs (Fig. 7)
were found to have approximately
twice the strength of two-strand
repairs in vitro. From many repair
studies, it is possible to conserva-
tively list the initial strength of
two-, four-, and six-strand flexor
F

Fig. 6 Commonly used techniques for end-to-end tendon suture. A, Conventional Bunnell Fig. 7 Types of four-strand flexor tendon
stitch. B, Crisscross stitch. C, Mason-Allen (Chicago) stitch. D, Becker bevel (overlapped) repairs. Top, Robertson and Al-Qattan
repair. E, Kessler grasping stitch. F, Modified Kessler stitch with single knot at the repair interlock stitch. Bottom, Lee double-loop
site. G, Tajima modification of the Kessler stitch with double knots at the repair site. locking suture.

Vol 3, No 1, Jan/Feb 1995 49


Flexor Tendon Injuries: Treatment Principles

tendon repairs and predict their Peripheral Epitendinous Sutures tendon repair. The running-lock
strength at 1 week (–50%), 3 weeks Several studies have indicated stitch and horizontal-mattress
(–331⁄3%) and 6 weeks (+20%). This that gapping at the repair site epitenon/intrafiber methods have
information, based on results in becomes the weakest part of the been shown to be the strongest of
unstressed in vivo studies, can then tendon, unfavorably alters tendon the peripheral suture techniques
be plotted against the stress forces mechanics, and may attract adhe- (Fig. 9). 16-18 The gap-retarding
of passive-light and moderate- sions, resulting in decreased ten- quality of these peripheral epi-
strong active motion to determine don excursion. The importance of tendinous sutures is particularly
the relative safety of each method the use of a peripheral circumfer- important in light of the finding
(Fig. 8, Table 1). From this assess- ential epitendinous suture at the that gapping of tagged flexor ten-
ment, it appears that only the six- completion of a tendon repair has don repairs is associated with
strand repair can be considered safe been demonstrated by the obser- poorer clinical results.
from rupture throughout the entire vation that such sutures may pro- On the basis of data from pub-
period of unstressed healing. vide a 10% to 50% increase in lished reports,16,17 it appears to be a
Unfortunately, six-strand repairs, flexor tendon repair strength safe assumption that a horizontal-
such as those described by Sav- accompanied by a significant mattress or running-lock peripheral
age,12 are technically difficult and reduction in gapping between the circumferential epitendinous
may damage the tendon excessively tendon ends. These benefits have suture will increase the strength of
or compromise its nutrition or abil- been further confirmed by experi- two-strand repairs by at least 40%,
ity to heal. ments that apply cyclic loads to the or about 700 g of repair strength to
each core suture repair, and that the
improved strength will be main-
tained throughout the healing
period. The addition of this 700 g of
repair strength to the values
already presented for two-, four-,
and six-strand repairs performed
without epitendinous sutures
demonstrates the increased safety
that can be obtained (Fig. 10, Table
2). The safety of a four-strand core-
stitch repair combined with a run-
ning-lock or horizontal-mattress
circumferential epitendinous stitch
should permit even light composite
grip during the entire healing
period.

Fig. 8 Estimated strength to failure (measured in grams) for two-, four-, and six-strand
Sheath Repair
flexor tendon repairs performed without the use of epitendinous sutures. In recent years, many surgeons
have advocated repair of the flexor
tendon sheath after tendon suture.
Table 1 The stated advantages of sheath
Estimated Repair Strength Without Epitendinous Suture repair are that it would serve as a bar-
rier to the formation of extrinsic
Type of 0 1 3 6 adhesions, should provide a quicker
Repair Weeks Week Weeks Weeks return of synovial nutrition, would
act as a mold for the remodeling ten-
Two-strand 1,800 g 900 g 1,200 g 2,200 g don, and should result in better ten-
Four-strand 3,600 g 1,800 g 2,400 g 4,200 g don-sheath biomechanics. Two
Six-strand 5,400 g 2,700 g 3,600 g 6,500 g
disadvantages are that sheath repair
is often technically difficult and that

50 Journal of the American Academy of Orthopaedic Surgeons


James W. Strickland, MD

the repaired sheath may narrow, Rehabilitation further loading results in tendon
restricting tendon gliding. There breakage. Because the strain resulting
have been a number of conflicting Theory of Early Postrepair from the application of a small force to
laboratory and clinical studies Motion Stress a tendon is probably the result of
regarding the biologic and biome- Splints and exercise programs are changes in the restricting scar, it
chanical benefits of sheath repair, and now routinely used early in the appears to be biologically effective to
no clear-cut advantage has yet been postrepair period in an effort to assist impart small but frequent forces in
established. A number of autoge- the functional recovery by influenc- opposite directions in an effort to
nous and synthetic materials have ing the biologic process of collagen modify and elongate restrictive ten-
been employed to restore sheath con- synthesis and degradation.21 Favor- don adhesions.6,22,23 Although some
tinuity, including tendon, fascia, able remodeling of the scar around a excellent research is being carried out,
extensor retinaculum, peritenon, healing tendon is best accomplished there is still inadequate documenta-
veins, silicone sheeting, and polyte- by applying stress to the tendon, tion of how much stress is appropri-
trafluoroethylene, but these methods which in turn transmits stress to the ate, the optimum duration and
are rarely required in the acute set- adjacent scar. Small loads result in frequency of stress application, and
ting. significant elongation of tendons. As the most advantageous methods for
the load increases, the percentage of the delivery of that stress to a finger
Suture Materials elongation rapidly decreases until after a tendon injury.
Efforts have been made to deter-
mine which are the best tendon suture
materials. A polyfilament ensheathed
by caprolactam was found to be the
strongest by one investigator. 19
Absorbable sutures developed for ten-
don repair seem advantageous
because of low long-term foreign-
body tissue reaction and reduction of
the stress-shielding effects of the host
tissue. Unfortunately, the optimal
rates of material absorption and
strength reduction have yet to be
determined. In actual practice, 3-0 and A C
4-0 braided polyester sutures are the
most commonly employed because of
their ease of placement, adequate
strength, and minimal elasticity.

Partial Tendon Lacerations


There has been debate regarding
the appropriate management of par- D
tial tendon lacerations. Initial inves-
tigations created considerable
controversy because they recom-
mended that partial flexor tendon
lacerations should not be repaired.
Recent studies have demonstrated
that partial lacerations of 60% or less
B E
need not be sutured, but that those
greater than 60% should be Fig. 9 Peripheral epitendinous suture techniques. A, Simple running stitch. B, Running-
repaired.20 The possibility of entrap- lock loop (Lin et al). C, Halsted continuous horizontal-mattress suture (Wade). D, Horizon-
tal-mattress intrafiber suture (Mashadi and Amis). E, Running-lock suture (Indiana). The
ment, rupture, and triggering of running-lock loop suture, the Halsted continuous horizontal-mattress suture, and the hori-
unrepaired partial tendon lacera- zontal-mattress intrafiber suture have been shown to be the strongest.
tions has also been reported.

Vol 3, No 1, Jan/Feb 1995 51


Flexor Tendon Injuries: Treatment Principles

Numerous techniques and modifi- imal interphalangeal joint motion added (Fig. 11, Table 3). Differential
cations of techniques have been retained about 1.3 mm (90%) of FDS excursion between the two digital
advanced in an effort to mechanically and FDP excursion per 10 degrees of flexors was also increased dramati-
alter the normal biologic sequence of flexion.24 cally by use of the synergistic splint.
tissue healing and to modify the for- The amount of tendon excursion It has been demonstrated that if an
mation of adhesions around a tendon that should occur for uninjured ten- active motion protocol is selected, the
repair. Applying early postrepair dons in the original Kleinert splint, wrist should be at 45 degrees of
motion stress to flexor tendon repairs modifications of the Kleinert splint extension with the metacarpopha-
has been shown to be beneficial for with a palmar-bar pulley (Brooke langeal joints flexed to 90 degrees in
more rapid recovery of tensile Army Splint), and an experimental order to minimize the force required
strength, fewer adhesions, improved “synergistic” dynamic tenodesis to achieve or hold full active compos-
tendon excursion, and minimal splint that permits wrist extension ite digital flexion.26
repair-site deformation in a canine (Mayo Clinic splint) has also been
model.6 The load at failure of imme- studied.25 The results demonstrate Practical Early Postrepair
diately mobilized tendons tested at 3 that improved excursion can be Motion Stress Protocols
weeks was twice that of immobilized expected from the use of a palmar bar On the basis of this information, the
tendons, while the linear slope was and that even greater excursion can best postoperative flexor tendon repair
almost three times greater and the dif- be expected if wrist extension is protocol probably (1) compensates for
ferences continued at each interval
through 12 weeks. It seems that
greater magnitudes, frequencies, and
durations of motion stress may have
an accelerating effect on tendon heal-
ing and that almost all splinting and
passive/active protocols now permit
greater interdigital motion at more
frequent intervals than was previ-
ously recommended.
Studies also have been conducted
in an effort to determine the normal
amount of flexor tendon excursion
resulting from increments of digital
joint motion and the amount of excur-
sion that may occur with the various
splints that are commonly employed
after tendon repair. It has been
observed that passive metacarpopha-
langeal joint movement produces no
relative motion of the flexor tendons.
Fig. 10 Estimated strength (measured in grams) for two-, four-, and six-strand flexor ten-
Distal interphalangeal joint motion don repairs performed with the use of epitendinous sutures.
produces excursion of the FDP tendon
of 1 to 2 mm per 10 degrees of joint
flexion, while each 10 degrees of prox-
Table 2
imal interphalangeal joint flexion
Estimated Repair Strength With Epitendinous Suture*
results in excursion of both the FDP
and the FDS tendons of about 1.5 mm. Type of 0 1 3 6
Studies measuring the excursion of Repair Weeks Week Weeks Weeks
tagged flexor tendon repairs have
demonstrated that there is a substan- Two-strand 2,500 g 1,200 g 1,700 g 2,700 g
tial decrease in the normal movement Four-strand 4,300 g 2,150 g 2,800 g 5,200 g
of the FDP tendon to an average of 0.3 Six-strand 6,000 g 3,000 g 4,000 g 7,200 g
mm per 10 degrees of distal interpha-
langeal joint flexion (36%), while prox- *Horizontal-mattress or running-lock suture.

52 Journal of the American Academy of Orthopaedic Surgeons


James W. Strickland, MD

mits active maintenance of passively


achieved digital flexion with the wrist
extended, and (6) utilizes frequent
application of motion stress.
Several programs combining a
strong four-strand repair or its
equivalent with a running-lock
loop, horizontal-mattress, or
intrafiber circumferential epi -
tendinous repair and employing
early protected passive and active
motion have now been developed,
and the results are clearly better
than with previous, more conserv-
ative techniques. 27,28

Summary
Fig. 11 Tendon excursion (measured in millimeters) with three types of mobilization
splints: the Kleinert splint (with no palmar bar), the Brooke Army splint (a modification of
Current information supports
the Kleinert splint with a palmar-bar pulley), and the Mayo Clinic “synergistic” dynamic ten- the use of a four-strand core
odesis splint (which permits wrist extension).25 stitch or its equivalent for flexor
tendon repair combined with a
strong continuous peripheral
Table 3 epitendinous suture. This suture
Tendon Excursion (Zone II) With Three Types of Mobilization Splint method should impart sufficient
strength to the repair to permit a
Tendon Excursion, mm vigorous postrepair motion pro-
tocol, which appears to maxi -
Type of Splint FDS FDP Differential mize the excursion of the
repaired tendon while minimiz-
Kleinert (no palmar bar) 8 10 2.3 ing the possibility of rupture.
Brooke (palmar bar) 13 15 2.0
Although the results of these
Mayo Synergistic 15 20 4.6
techniques are encouraging,
rapid advances continue to occur
in many areas of flexor tendon
swelling of the finger, (2) keeps the distal interphalangeal joints extended surgery, and even better tech-
wrist and metacarpophalangeal joints at rest, (4) passively flexes all digital niques will lead to improved
flexed at rest, (3) keeps proximal and joints before wrist extension, (5) per- results in the future.

References
1. Doyle JR: Anatomy of the finger flexor 3. Idler RS: Anatomy and biomechanics of the Analysis of tensile strengths, in Amer-
tendon sheath and pulley system. J digital flexor tendons. Hand Clin 1985;1:3-11. ican Academy of Orthopaedic Surgeons
Hand Surg [Am] 1988;13:473-484. 4. Schuind F, Garcia-Elias M, Cooney WP Symposium on Tendon Surgery in the
2. Brand PW, Hollister A: Overview of III, et al: Flexor tendon forces: In vivo Hand. St Louis: CV Mosby, 1975, pp
mechanics of the hand, in Brand PW, measurements. J Hand Surg [Am] 70-80.
Hollister A (eds): Clinical Mechanics of the 1992;17:291-298. 6. Gelberman R, Goldberg V, An KN, et al:
Hand, 2nd ed. St Louis: Mosby Year 5. Urbaniak JR, Cahill JD Jr, Mortenson Tendon, in Woo SLY, Buckwalter JA
Book, 1993, pp 10-12. RA: Tendon suturing methods: (eds): Injury and Repair of the Muscu-

Vol 3, No 1, Jan/Feb 1995 53


Flexor Tendon Injuries: Treatment Principles

loskeletal Soft Tissues. Park Ridge, Ill: 14. Lee H: Double loop locking suture: A 22. Gelberman RH, Botte MJ, Spiegelman JJ,
American Academy of Orthopaedic technique of tendon repair for early et al: The excursion and deformation of
Surgeons, 1988, pp 5-40. active mobilization: Part I. Evolution of repaired flexor tendons treated with
7. Gelberman RH, Steinberg D, Amiel D, et technique and experimental study. J protected early motion. J Hand Surg
al: Fibroblast chemotaxis after tendon Hand Surg [Am] 1990;15:945-952. [Am] 1986;11:106-110.
repair. J Hand Surg [Am] 1991;16: 15. Lee H: Double loop locking suture: A tech- 23. Gelberman RH, Woo SLY, Lothringer K,
686-693. nique of tendon repair for early active et al: Effects of early intermittent pas-
8. Gelberman RH, Woo SLY, Amiel D, et mobilization: Part II. Clinical experience. J sive mobilization on healing canine
al: Influences of flexor sheath continu- Hand Surg [Am] 1990;15:953-958. flexor tendons. J Hand Surg [Am] 1982;
ity and early motion on tendon healing 16. Lin GT, An KN, Amadio PC, et al: Bio- 7:170-175.
in dogs. J Hand Surg [Am] 1990;15: mechanical studies of running suture 24. Silfverskiöld KL, May EJ, Törnvall
69-77. for flexor tendon repair in dogs. J Hand AH: Flexor digitorum profundus
9. Peterson WW, Manske PR, Dunlap J, et Surg [Am] 1988;13:553-558. tendon excursions during con-
al: Effect of various methods of restor- 17. Wade PJF, Wetherell RG, Amis AA: trolled motion after flexor tendon
ing flexor sheath integrity on the forma- Flexor tendon repair: Significant gain in repair in zone II: A prospective clin-
tion of adhesions after tendon injury. J strength from the Halsted peripheral ical study. J Hand Surg [Am] 1992;17:
Hand Surg [Am] 1990;15:48-56. suture technique. J Hand Surg [Br] 122-131.
10. Kulick MI, Smith S, Hadler K: Oral 1989;14:232-235. 25. Cooney WP, Lin GT, An KN:
ibuprofen: Evaluation of its effect on 18. Mashadi ZB, Amis AA: Strength of the Improved tendon excursion following
peritendinous adhesions and the break- suture in the epitenon and within the flexor tendon repair. J Hand Ther
ing strength of a tenorrhaphy. J Hand tendon fibres: Development of stronger 1989;2:102-106.
Surg [Am] 1986;11:110-120. peripheral suture technique. J Hand 26. Savage R: The influence of wrist posi-
11. Carlstedt CA, Madsen K, Wredmark T: Surg [Br] 1992;17:172-175. tion on the minimum force required for
The influence of indomethacin on bio- 19. Ketchum LD: Suture materials and active movement of the interpha-
mechanical and biochemical properties suture techniques used in tendon repair. langeal joints. J Hand Surg [Br] 1988;13:
of the plantaris longus tendon in the Hand Clin 1985;1:43-53. 262-268.
rabbit. Arch Orthop Trauma Surg 20. Bishop AT, Cooney WP III, Wood MB: 27. Strickland JW: Flexor tendon repair:
1987;106:157-160. Treatment of partial flexor tendon lacer- Indiana method. Indiana Hand Center
12. Savage R: In vitro studies of a new ations: The effect of tenorrhaphy and Newsletter 1993;1:1-12.
method of flexor tendon repair. J Hand early protected mobilization. J Trauma 28. Silfverskiöld KL, May EJ: Flexor tendon
Surg [Br] 1985;10:135-141. 1986;26:301-312. repair in zone II with a new suture tech-
13. Robertson GA, Al-Qattan MM: A bio- 21. Strickland JW: Biologic rationale, clini- nique and an early mobilization pro-
mechanical analysis of a new interlock cal application, and results of early gram combining passive and active
suture technique for flexor tendon motion following flexor tendon repair. J flexion. J Hand Surg [Am] 1994;19:
repair. J Hand Surg [Br] 1992;17:92-93. Hand Ther 1989;2:71-83. 53-60.

54 Journal of the American Academy of Orthopaedic Surgeons

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