Clinical Example: Staged Flexor Tendon Reconstruction

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.

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.

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.

A strip of extensor retinaculum was used as a  graft for pulley reconstruction.

The retinacular graft was passed twice around the proximal phalanx in an effort to recreate the entire A2 pulley.

The A4 pulley was reconstructed by bridging the graft to the remaining attachments of the A4 pulley.

Radiographs demonstrating proper tendon spacer position and no bowstringing.

Second stage, three months later. The tendon spacer and the tendon-tendon juncture are exposed:

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.

Tension was adjusted to match the cascade of the adjacent fingers.

The distal tendon graft was brought out the fingertip, and sutured to the old FDP stump.

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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