Clinical Example: Staged Flexor Tendon Reconstruction

The results of repair or reconstruction of flexor tendon injuries remains frustratingly unpredictable. This series demonstrates a technique for flexor tendon and tendon sheath reconstruction.
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This patient had undergone two prior procedures elsewhere for flexor tendon injuries  from a laceration in the proximal phalanx of the middle finger. There was full passive but no active flexion and fixed flexion contractures of both the proximal and distal interphalangeal joints.
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At exploration, neither A2 nor A4 pulleys could be identified. PIP and DIP capsulotomies were required to restore passive extension. Reconstruction was undertaken with a silicone tendon spacer, pulley reconstruction and preliminary flexor digitorum profundus to superficialis tendon juncture.
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The deep needle is delivering the tendons into the field. The superficial needle is maintaining an end to end orientation so that the tendon ends were approximated without angulation.
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A strip of extensor retinaculum was used as a  graft for pulley reconstruction.
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The retinacular graft was passed twice around the proximal phalanx in an effort to recreate the entire A2 pulley.
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The A4 pulley was reconstructed by bridging the graft to the remaining attachments of the A4 pulley.
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Radiographs demonstrating proper tendon spacer position and no bowstringing.
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Second stage, three months later. The tendon spacer and the tendon-tendon juncture are exposed:
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The FDS tendon was divided in the forearm. The proximal stump was  delivered into the palm wound, sutured to the tendon spacer and pulled out the fingertip.
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Tension was adjusted to match the cascade of the adjacent fingers.
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The distal tendon graft was brought out the fingertip, and sutured to the old FDP stump.
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That's the easy part! Now it's up to a motivated patient and a dedicated therapist to make it work.

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Flexor tendon reconstruction
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